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THE MEDICAL JOURNAL OF AUSTRALIA. VOL. I.-8TH YEAR. SYDNEY : SATURDAY, MAY 7, 1921. No. 19.

FOCAL INFECTION AND ITS LIMITATIONS.' Lions are active and they have little chance of survival within the body from the action of the acid gastric By Sydney Pern, M.R.C.S., L.R.C.P. (Eng.), Honorary Physician to Out-Patients, St. Vincent's Hospital, secretions. Melbourne. It has been found that if bacteria gain entrance The present subject under review is "Focal In- during the quiescent stage of the stomach, such as by fection and its Limitations." This subject is much drinking water containing bacteria on an empty stom- discussed at the present time and a good deal of ach, they pass rapidly into the alkaline or neutral excellent experimental work has been done to bear it duodenum and can thrive and increase below that out, but there are still many points which the clinician point. It requires many thousand times the num- feels to be true but is unable to prove. Results of ber of bacteria to infect an animal by the stomach treatment on certain lines warrant his belief and as by the respiratory tract. To infect an animal under such conditions he should not be considered with cholera by the stomach it is necessary to neu- to have over-stepped the bounds of propriety hi an- tralize the acidity and also arrest all peristaltic move- nouncing them. There are many who hold the same ments. Much infection is also acquired by elderly views as myself ; to them this will be uninteresting females kissing babies and by children putting things reading, but there are many who, from want of oppor- in their mouths to suck. tunity, do not or whose resistance requires overcom- So on the whole the body is fairly well guarded ing by fair argument. In reviewing this subject from infection viâ the alimentary tract. The typhoid from a broad aspect it may be necessary to repeat bacillus is the exception. certain statements which have appeared in a previous Having excluded all other points of entrance we article bearing on this subject and for which I crave are left with the respiratory tract. A healthy nose your tolerance. has been provided by Nature with certain mechanisms I think in dealing with this question it would best to entrap and get rid of bacteria within reason, but be divided into primary and secondary focal infec- any condition which produces mouth breathing, opens tions and their results. a door at which there is only a second line of defence Primary Focal Infections. available. So it comes about that mouth breathers have It is necessary to have a clear idea in one's mind a very much greater chance of bacteria gaining en- of the methods of entry by bacteria into the body trance to their bodies than others. Bacteria which in relationship with primary focal infections and escape being trapped on the nasal mucosa, must im- to differentiate them from secondary focal infections. pinge on the naso-pharyngeal wall which is freely The primary ones are few and well defined. Bac- supplied with lymphoid tissue. Bacteria entering teria have to gain entrance either by the orifices by the mouth must impinge on the fauces and of the body or by the skin or mucous membranes. pharynx, where the second line of defence, the tonsils, is situated. We, therefore, find a strong barrier The skin in. the sound state does not readily permit of invasion and if it does so, the infection remains erected as protection at the entrance of the lungs in localized or is destroyed. The outlets, such as the a mass of lymphoid tissue. This, up to a certain anus and urethra, from their functioning as such point, is capable of dealing with organisms. But are not so likely to be portals of entry as the inlets. there comes a time when this defensive mechanism, The urethra has its special infecting agent—the gono- either as a result of atrophy or of overwhelming in- coccus. The conjunctival mucous membrane has its spe- fection, is no longer of any use and instead of destroy- cial infecting organisms as well as those which may set ing bacteria, it allows of their actually multiplying up generalized infection viâ the lachrymal duct and within the tonsils and adenoid tissue. From this sac. The mouth and nose remain and from their time on they are a source of danger, as from here functioning as inlets, must be responsible for the they gain entrance to the blood and lymphatic stream entry of the great majority of bacteria into the and may cause widespread damage. The mucosa lin- system. The nasal mucous membrane has been ing the trachea and bronchi also have a good protect- adapted to trap bacteria and warm the inspired air. ing mechanism in the ciliated epithelium which sweeps The hairs, the large area of secreting mucous mem- all secretions, etc., upwards. This is the chief prim- brane; the solidifying and drying of the secretion, ary focal infection particularly in the young. Infec- are all Nature 's methods of preventing the access of tion of the nasal mucosa is another and is not so harmful bacteria to the body. The mouth in health frequently recognized as such. It is likely to come is opened to talk and to eat. Of the two, more bac- about when the drainage of the nose and accessory teria are liable to gain entrance during the latter sinuses is in some way interfered with by deflected than the former. In abnormal conditions the mouth septum, etc., and an actual sinusitis occurs. In its is used for breathing and in this condition bacteria uncomplicated condition it is recognized by frequent have no protective mechanism to overcome to gain colds in the head and the result of bacteriological. an entrance. If bacteria gain an entrance by food, examination. Infection of the lachrymal sac may be it is chiefly during such a time as the gastric secre- by the nose or conjunctiva and is a primary. focus, as is middle ear disease. These are the primary in- 1 Read at a Meeting of the Victorian Branch of the British Medical Association on February 2, 1821. fective foci of the young.

378 T>EÍÈ MËt)ÍCAt trOtï>tNAiJ OP AtTST11AIúÌA. [May 7, 1921.

Pyorrhoea and root abscesses are usually those of root of a tooth, gall-bladder infections or a part later years. Prostatitis starting as a Neisserian in- which is injured or subjected to irritation by a for- fection and becoming mixed leads to a focus closely eign body. Bone disease is often metastatic in origin resembling that . of the tonsils in its crypt forma- and may lead to secondary focal points. tion. It is responsible for more trouble than is gen- Secondary Focal Infections. erally recognized. Pyelitis is a secondary focal infection, as bacteria In all primary and secondary foci bacteria are cap- can only gain access to the kidney by the blood or able of multiplying in situ, but the secondary focus lymphatic stream, except in the rare occasion when is not capable of arising without a primary one being it is carried there by a ureteral catheter; even in present, as it is metastatic in origin. If bacteria so-called ascending infection from the bladder, the leaving a primary focus locate themselves in such a infection is carried by lymphatics along the course of

position or on tissue whose vitality is somewhat the ureter and not by the ureter itself. It is . doubtful lowered, they may be able to resist the phylactic pro- if the Bacillus coli is alone responsible for pyelitis perties of the blood and tissues. even in cases where no other organisms can be found. Of this we see an example in chronic cholecystitis, Two cases recently under my care in which it was which may remain active after the primary focus the only organism found, did not clear up till septic which has produced it, has ceased to exist or has been tonsils had been removed. The Bacillus coli is rather removed. The same may be true of chronic appendi- like the jackal and hyena in its habits. It allows citis, but as I have not had the question of appendi- others to go in and do the damage ; then it swarms citis under review until recently, I have not had the in to the feed. It is open to question if it is capable opportunity of reviewing the results of removal of a of gaining a hold in undamaged tissues. Infected primary focus in preventing further attacks. It will, tubes, though usually involved by direct extension however, have to be a point for serious consideration from below, may be involved by metastatis as in in the milder types. tuberculosis. All such secondary . focal points are As has been pointed out these localities are not equally as harmful as the primary foci ; they are easy of infection via the stomach, but are chiefly capable of shedding .bacteria into the blood and lym- metastatic in origin. phatic stream. - With the irritation of a concretion in an appendix When an ec-phylactic focus has been established, it is feasible that the Bacillus coli is capable of caus- what results to the bacteria which are incubated ing appendicitis without a primary focus being within it â This will be governed largely by the state present. of the phylactic properties of the blood and by the About a year ago Sir Almroth Wright published virulence of the bacteria. If some immunity has in The Lancet some views and experiments on infec- been established, the reaction will be moderate. This tion and to make matters easily explainable he coined again may be modified by any factor which tends to some new expressions. He describes the defensive reduce the general vitality, such as fatigue, lack of food, etc.. Take an extreme case, with which all mechanisms of the organism against bacterial " infection as "phylactic power" and the leucocytes and are familiar, a fatal septicæmia following child-birth bacterio-tropic substances in the blood fluids as or abortion. Here the virulence of the infection is "phylactic agents." The provision for the transport overwhelming and the phylactic properties of the of leucocytes and bacterio-tropic • agents is named blood are unable to destroy the invading hosts, which "kata-phylaxis." The reserves held at a distance are then at liberty to multiply in the blood stream. and available as reinforcements are "epi-phylactic In addition to the original ec-phylactic focus, the response" and Wright substitutes the term "apo- uterus, the whole body becomes an ec-phylactic area. phylactic phase" for "negative phase." An "ec- The next stage is seen in pywmia, where there is some phylactic region" is a focus in which bacteria are resisting power of the phylactic agents, as it is only able to multiply within the body by : here and there that an ec-phylactic or secondary focus is formed resulting in temporary abscesses. (a) Radiating out toxins which will (when of sufficient strength) repel leucocytes. This condition, then, offers a great resistance to the invasion which may end either way, by destruction of the (b) By absorbing bacterio-tropic substances from the blood fluid ; and, probably, host or by complete defeat of the invading hordes. (c) By abstracting anti-tryptic power from the The old "laudable pus" indicated that the battle was fairly even and denoted good phylactic powers. blood fluids and so converting these into a congenial culture medium. A further step is seen when the infection is not quite so severe, as in rheumatic fever. Here you do Ec-phylactic foci may become established by exu- not find fresh ec-phylactic areas established, but an dation of fluid, as leucocytes cannot swim, but creep invasion of bacteria with which the phylactic powers along the trellis-work of the tissues. of the body do battle. The fight is fierce and is in This work was done in relation with sepsis during the open; they meet on an equal footing and not under the war, but its application is very suitable to disease the same conditions as when the 'phylactic properties in general as found in civil practice. of the blood are attacking an entrenched or fortified The primary or secondary focus is an ec-phylactic ee-phylactic focus. Here also the phylactic proper- one. These foci are only capable of forming under ties of the tissues as well as the blood can be brought such conditions as Sir Almroth Wright describes, into play. The areas where the bacteria lodge and but locality and environment help • them materially, do battle, can be called machean areas (A 1907, battle). e.g., any part where the circulation is difficult of access, There is evidence to suggest that in these cases they are such as ' a bony cavity, at' the root or even within the not able to multiply and cause further spread of the. con-

May 7, 1921.] THE MEDICAL JOURNAL OF AUSTRALIA. 379

dition, or, if they are able to, it is only for a very been aware that there is anything the matter with brief period, if the patient is going to live. The clini- him If this is the case and we know it to be true, cal evidence in support of this view is as follows: we can dimly realize what may be going on within With a flare up of the ec-phylactic focus there is a the body, when we see pyorrhoea or any other focal corresponding flare up in the joints, if joints are the infection in a patient. tissues involved. With a removal of the ec-phylactic It is well to dwell upon this point because so much focus in the majority of cases the joints clear up and harm is done quietly and insidiously ; nothing worth cease to be involved after a certain period of time. complaining about is noticed until gross damage is Also in the more chronic cases there is the difficulty done. Every tissue of the body is capable of being of cultivating bacteria from these regions. What invaded ; none can claim immunity. This is a big goes on in these "machean" areas is well portrayed statement to make and covers a big field of diseases. by Adami in his work on inflammation. At present it has not been established exactly to There is no pus formation in these cases because what extent there is a bacterial invasion in cer- hordes of white cells have not had to lay down their tain tissues or if the bacterial toxins circulating in lives. Those that are put out of action are quickly the blood possess a selective affinity for these tissues, digested by the connective tissue and endothelial such as is known to exist in several diseases, viz., cells. Only in pyemia where ec-phylactic areas are tetanus, diphtheria and botulism, but the tendency is formed, do we get pus formation. inclining towards the view of direct invasion. The streptococcus in some form or other is respon- Already many have recognized the implication of sible for the majority of complaints of this nature. focal infections in various diseases, arthritis, valvu- Rosenow has shown the transmutability of practically litis, myocarditis, nephritis, neuritis, cholecystitis, all the forms of streptococci up to a pneumococcus appendicitis, herpes, chorea, pancreatitis, erythema from one culture and back again to the origin. In nodosum, spinal myelitis, irido-cyclitis and phlebitis. relationship with this faculty of transmutability an Others besides myself are including goitre in the cate- interesting point arises. If transmutability is pos- gory. Alveolitis of the lung and chronic bronchitis sible in vitro, we can with a fair degree of safety must be added to the list. Certain skin diseases, such assume it equally possible in vivo. Take the case of as eczema, are coming under suspicion Anemia is rheumatic fever, which is caused by a streptococcus. frequently of septic origin. Diabetes has been shown As transmutation takes place through its different so often of late to be associated with gross focal in- phases, no particular harm may occur until it reaches' fections or syphilis and such good results have fol- the stage called Micrococcus rheumaticus, when an lowed the removal of the foci, that the suggestion acute attack of rheumatic fever may occur. When seems to be jixstified that the cause is a focal or specific this is over, it will not occur again till the cycle of infection. No tissues of the body are immune. There transmutability has again come round to the same are cases of epilepsy, often of a Jacksonian type, in point. I explain in this way the failure in the past which an operation has been performed in the hope to find this particular organism in the tonsils, joints, that a removable cause may be found. The finding except during an attack of fever, but not before or is usually a thickened dura. These cases are after. not necessarily specific. There is no other ex- If we apply this story to every tissue of the body, planation than that the thickening is the result of as none can claim immunity, we shall see what an bacterial invasion. There is no reason to assume the cortex cerebri appalling list of diseases are the result of these seem- to be free from bacterial invasion. The ingly harmless factors. question may be asked : What would one expect to find clinically as the result of such invasion ? Epi- To what extent does this warfare go on unknown lepsy suggests itself. In the more acute type of in- to patients and physicians ? Imagine a few bacteria fections cerebritis, abscess and meningitis develope, passing into the blood stream from a tonsil and lodg- while in the milder type symptoms are less severe. ing in the myocardium. They are attacked and A comparison may be drawn between a pyvemic joint beaten. Warfare cannot take place without a cer- and slight rheumatism ; invasion takes place in each tain amount of devastation. A number of muscle condition. Unfortunately once damage is done and cells will be destroyed, but the patient knows nothing fibrous tissue deposited, since this appears to be the of this. Let us suppose that this goes on day after end result of bacterial invasion, removing a septic day and that the patient is suffering from bacterial focus will not cure the disease. In every case of epi- toxemia. He may feel "off colour" and develope lepsy I have seen during the last few years, the blood an extra systole or two. A few may lodge in serum yielded a positive Wassermann reaction or his kidneys and destroy some cells there; he will not there was some gross septic focus. Simple pleurisy experience any discomfort. If this goes on for a is not uncommonly due to metastasis from a focal few years, a few cells destroyed here and there, he infection. Lumbago, sciatica, myalgia, chronic enter- will feel just out of sorts and in need of a holiday, till itis, paralysis agitans, arterio-sclerosis and pos- one day he goes to his medical adviser, who finds he sibly disseminated sclerosis are amongst others. has a leaking valve, a good deal of myocardial damage The deficiencies and excesses of some of the and a high blood pressure. An organ must be very internal secreting glands may owe their origin to grossly damaged before it shows signs of failing All the same cause. It is only a matter of the bacteria this takes place quietly and unknown to the patient having a selective affinity for such tissues. It is not until signs of its failure make him seek for advice. Over half of each of his kidneys may be put out of enough to say that the diseases may be due to a focal action and infection, but we have to accept the fact that in the yet neither he nor his doctor may have great majority they cannot exist without one. If

380 THE MEDICAL JOURNAL OF AUSTRALIA [May 7, 1921.

focal infections could be eradicated, suffering human- is not too soon to put these views into practice and ity would be relieved of half the ills to which flesh save the growing generation from wreckage of body is heir. If venereal diseases, tuberculosis and focal which we now know will eventuate if focal infections infections were eradicated, there would be compara- are allowed to remain. tively few diseases left to plague people living in tem- Ala perate climates. It is on these lines that preventive EMBRYOLOGICAL SPECIMENS OF CLINICAL medicine would accomplish most good. Only a few INTEREST. adult people of the world are free from some primary or secondary focus; their bodies are slowly undergo- I. ing some degenerative changes which might have A CASE OF TWIN TISBAL PRE(NANCY. been or still are preventible. The eradication of some focal infections is simple, of others it is difficult or By John I. Hunter, M.B., Ch.M.. it may be impossible. Sinusitis is often disappoint- Associate Professor of Anatomy, Sydney University. ing, but if free drainage is established and the pa- Though twins and even triplets have been definitely tient put under the best conditions, time and patience established to occur in tubal pregnancies, nevertheless may establish a cure. There is a brighter outlook the following case of twin tubal pregnancy is worthy for the future generation than the last. Many of of record on account of the comparative rarity of the the diseases with which we are so familiar, will cease condition and because of certain associated embryo- to exist. There will be no more rheumatoid arthritis, logical features of clinical interest. no more heart disease except specific cases and we I wish to express my indebtedness to Dr. R. Gordon hope in time these will also soon cease and so along Craig, Sydney, who forwarded the specimen to the the line, if these views are established and acted on. Medical School, Sydney University. It was removed It is only necessary tq apply these views to a large by him at operation, the note accompanying the spe- hospital medical clinic and the results will be cimen stating that it was "a six weeks' abdominal I1 astounding. pregnancy which had ruptured through the Fal- { I found 58% of people seeking medical treatment lopian tube 1.8 cm. from the right cornu of the are suffering from diseases due to obvious focal in- uterus." On further inquiry, it was ascertained that, fections and many more from diseases concerning clinically, the case was one of ectopic pregnancy with which I am hesitating about including in the same no unusual features. On examination of the mass re- category. Let this always be in your mind • These moved at operation, it was found to consist of a uter- things cannot exist without a focal infection being ine tube and two distinct chorionie vesicles of un- present. It is futile to try to treat a patient with the equal size. focal infection remaining, if it is removable. Who Tuba Uterina. can look lightly on a focal infection when such de- The tube, 6.8 cm. in length, was extremely tortuous. vastation and wreckage follows in its wake ? Why The fimbriated extremity was apparently healthy and look outside for the raiders when we are housing the ostium abdominale patent. At its uterine end the them all the time ? Why look for mythical causes tube was ragged and incomplete ; it was found at which have been handed down to us, when we have the operation that the rupture had taken place at such a concrete one and one which is so simple and this site. Elsewhere the wall of the tube was intact. easily understood I Are not most causes of disease This rupture was quite unlike that found in Cam- simple when found out ? These views are more or eron's case (1) of twin tubal pregnancy, where there less accepted.. by many, but to many they are only was only a slight perforation, which was the source partly known - and there are many who openly scoff of profuse haemorrhage. Through this the villi could at them. Let all look for themselves and what they be seen projecting. In the case reported by Child (2) will find will surprise them, for it is written in large there were two distinct perforations in the tube. type that he who runs, may read. The proof will be Sections of the tube taken from the site of rupture in the results obtained. What are the limitations of were examined and the lumen was found to be intact. these views? They cover all the tissues of the body. The outer aspect of the wall was ragged over a con- There are few things which can damage body cells siderable area, indicating that the vesicles had become but bacteria. What are the limitations of treatment ? embedded and had then passed outwards through the Where it is possible to remove the ec-phylactic focus, wall to the peritoneal cavity. results are good ; where not, doubtful. The Twin Chorionic Vesicles. Vaccines have been used indiscriminately in the As already stated, there were found two distinct past and consequently with varying success. Where chorionie vesicles. Cameron made an opening through it is possible to remove the focal infections, vaccines the tube in his case and in doing so separated two are very useful to hasten recovery and may just turn embryos from one another. These had separate am- the balance in the patient's favour. But, against niotic vesicles, but the umbilical cords were united the entrenched focus itself vaccines are of little avail where they entered the placental region. The twins and will only help to alleviate the symptoms of the were evidently uniovular, whereas in the case being patient. There is hope ahead of being able to get more described, the vesicles represented the products of potent vaccines by detoxication and other methods fertilization of two separate ova. which may be able to eradicate the infective focus It has been noted that the ehorionic vesicles were itself. of unequal size. The larger vesicle (H233, Sydney This subject has been dealt with on broad lines. University collection) measured 3.8 X 2.8 X 1.7 cm.. I realize that there is yet much to be done, but it These measurements included the villi, which coin- May .7, 1921.] THE MEDICAL JOURNAL OF AUSTRALIA. 381

pletely surrounded the external surface of the vesicle is an example of an ovum from an ovary of one side (Figure I.B.). The villi varied in length from 3 mm. passing after fertilization to the opposite tube in order to 7 mm. and were freely branching. The dimensions to reach the uterus ; in this instance, the tube on one side and the ovary on the other had been previously removed. Williams (loc. cit.) states 'that in a considerable number of cases examined by him, the corpus luteum was placed, not in the ovary corresponding to the pregnant tube, but in the opposite one. Shattock (5) , in commenting upon Robson's case of primary ovarian pregnancy, declared that the tube on the same side as the pregnancy was in such a condition that the sperm must have travelled to the ovary through the opposite tube. The true explanation of the apparent difference in the age of the vesicles in this ease of twin tubal pregnancy was, however, forthcoming on examination of the embryos after incision of the chorionic vesicles. The larger chorionic vesicle (H 2 ) presented the usual smooth glistening interior. Attached by an umbilical cord, 7 mm. in length, was an embryo of normal external form (Figure II.a.) . A small FIGURE I.. The Chorionic Vesicles from a Case of Twin 'finial Pregnancy : (a) Left yolk sac and a slender yolk stalk were present. the H 4, (b) Right HZS3. latter being partly incorporated in the umbilical cord. When first exposed, the amnion was closely of the vesicle indicated a period of gestation of prob- investing the embryo. The sitting height (vertex- ably six weeks' duration. breech length) of this embryo was found to be 14 mm., The smaller specimen (H234) would have been con- again indicating a period of gestation between the sidered to have been of a shorter period of develop- sixth and seventh week. Combined with the clinical ment than H, if calcu- lations had been confined to the external dimensions of the chorionic .vesicle (1.8 X 1.6 X 0.7 cm.). These measurements correspond to those of a period of gestation of four weeks' duration. Branching villi (maximum length, 3.25 mm.) occurred in patches on the surface of the vesicle and, though sparse, they were developed on all its aspects. An explanation of the disparity of size, which suggested itself at this stage of the examination, was that the two ova had been fertilized at different times, one a fortnight later than the other. This could occur even in the event of the already pregnant tube becoming im- passable to spermatozoa. FIGURE II.. Whitridge Williams (3), Interior of the Chorionic Vesicles of (a) Left H. 4 and (b) Right 11.4. for instance, has described a case in which there was a lithopædion at the uterine diagnosis, these facts appear to indicate that the rate end of the right tube. A twin pregnancy developed of development of both chorionic vesicle and embryo in this tube as the result of the addition of another in this case had been normal. fertilized ovum in the following manner : A sper- The interior of the smaller chorionic vesicle (11 224 ) matozoon passing through the left tube fertilized an presented an appearance in marked contrast to that ovum from the left ovary in which the corpus luteum seen in 11233. The surface was dull and discoloured was found. The fertilized ovum then passed to the and strands of fibrinoid material (probably diseased right side, entered the tube and developed on the magma reticulare) bridged the wall and formed proximal side of the lithopædion. Fransden's case (4) trabeculœ upon it. A careful search failed to reveal 382 THE MEDICAL JOURNAL OF AUSTRALIA. [May 7, 1921.

an embryo; it would have been, if normally devel- (5) Shattock, S. G.: Brit. Med. Journ., Pt. 2, 1902, p. 1447. oped, of 2 mm. to 3 mm. vertex-breech length. This (6) Mall, F. P.: Quoted by Williams (loc. cit.). (7) Mall, F. P.: Keibel and Mall's "Manual of Human indicates that the chorionic vesicle in the case of 11 234 Embryology: The Pathology of the Ovum,"' Pt. 1. was in a state of arrested development and that the (8) Giacomini: Quoted by Mall (7). embryo had 'already become converted into an un- recognizable mass or had been absorbed. It is most

probable that both 11 233 and 11 234 are the result of Reports of eases. the fertilization of two ova at the same time, that A CASE OF MALARIA INFECTED IN THE RIVERINA, they are, in effect, of the same age. It is natural to NEW SOUTH WALES. expect that abnormal and arrested development is more common in tubal than in uterine pregnancies. By Harry J. Clayton, M.B., Ch.M., The complication of twins would tend to increase this Honorary Assistant Physician, Royal Prince Alfred Hospital, tendency, as in this case. Sydney. In Mall's series (6) of 117 extra-uterine preg- PATHOLOGICAL INVESTIGATION. nancies, 86% were abnormal. Moreover, a certain percentage of all specimens consist of an ovum with- By Leslie Utz, M.B., Ch.M., out an embryo. His, however, did not recognize a Sydney. class of pathological ovum in which the embryo was We beg to report having investigated and established the destroyed entirely, for, as Mall (7) states, he had diagnosis in a case of malaria in which the only possible "never seen a human ovum without an embryo." district of infection can have been the Riverina. Giacomini (8) and Mall (7) had a different experi- For the earlier portion of the clinical history, for the ence. The former based his classification upon the opportunity of seeing the patient and for a suggestion of the diagnosis we are indebted to Dr. Weedon, of Wagga, New absence or presence of an embryo, while the latter South Wales. The history and clinical notes are as follow: found that 28% of his pathological ova contained Mrs. M., aged 33, domestic duties, married to a farmer at no embryo. Rosewood, • 20 miles from Tumbarumba, vici Wagga. The of our series, a specimen received from Dr. patient has never been farther north than Sydney. For six 11222 years she has not been farther north than Narrandera, in L. J. Shortland, Sydney, illustrates clearly such an the Riverina district, where she äspent some months prior occurrence in uterine pregnancy. When received, the to her illness; returning home two months before its onset. She has lived the greater part of her life in Wagga and the surrounding district. On her return to Tumbarumba two months before her illness she and her husband became on friendly terms with carpenter and his wife working on railway construction and these two constantly came to her house. Both the carpenter and his wife had been infected with and suffered from malaria in "The Islands." During the two months the carpenter's wife suffered from a recurrence of her malaria and was ill for some days. Alongside the residence of the patient whose case is being reported, is, she states, some swampy ground and mosquitoes are very numerous. Six weeks ago the patient suddenly became ill with "fever," rigors and persistent vomiting. There was no headache, no cough, no epistaxis and no diarrhoea (until two weeks after onset, when there occurred some slight diarrhoea lasting about a week). Occasional pain was felt, not severe, in the left hypochondrium. There were no urinary symptoms and no hm:naturia. The condition continued for some days, with irregular fever, rigors and persistent vomiting, when she was sent to a hospital in Wagga. In spite of treatment on general lines, the condition did not abate; rigors occurred as shown in the chart, as well as vomiting and pain in the left hypochondrium. The spleen was noticed to be enlarged and the patient had an enlarged thyreoid gland. FIGURE III.. 'After some ten days in hospital the symptoms subsided, Decidual Cast from Uterus Containing Human Ovum (H y ) in Which no Embryo was to be Found. the enlargement of the spleen disappeared and the patient rapidly improved. She was convalescent and was about to get up on the next day, when the condition recurred, with specimen consisted of a decidual cast containing a all the previous symptoms. After a couplé of days there chorionic vesicle in situ (Figure III.) . The decidua occurred sudden enlargement of the spleen, which could be capsularis had been reflected and the villi were vis- felt about 2.5 cm. below the costal margin. • ible. On clearing this specimen in cedar oil, no em- One week after the recurrence she was sent to Sydney for further investigation. bryo was discoverable and a microscopic examina- The case, so far, clinically fitteiYÏn with malaria and this tion confirmed the absence of embryonic structures. diagnosis had suggested itself to Dr. Weedon, who, in his notes, forwarded at the time, states "has lived in Wagga References. all her life. No malaria here, except returned soldiers." The (1) Cameron, S. J.: "Twin Tubal Pregnancy," Proc. Roy. diagnosis would, in the ordinary course of events, be natu- Soc. Med., Vol. 4, Pt. 2, 1910-11. rally excluded on geographical grounds. (2) Child, C. G.: "Twin Ectopic Pregnancy," Amer. Journ. On examination on her arrival in Sydney, the patient's Obstetrics, January, 1907. condition was very alarming. (3) Williams, Whitridge: "Obstetrics" (text-book), 1917. Her temperature was 36.6 ° C.; pulse-rate 156, small volume (4) Fransden: Quoted by Chiene, Obstet, Trans., Edin., and very feeble, of low tension; respirations 24. She looked 1913, 38. desperately ill and was in the "typhoid state." Her face -_.—_-- -^

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^ a3 sz ^ m H ^.^ q ^ ° 9 + Cz ^^ ^ ^ A a^ ^ â 4 ii■I[ III./iiiiiiii 01 ^^ ^^^, ^ ^^^^^^ ^ Cg a^ cd wa^ q^ ^^m^R O O cd z4v 1111111•111111111111111M1 O O ■Ci3IIDL■1I I11111111■1 ^^ ^^ ° ó ^ 3,xt ^ *'^ sR I ■ ?)..E,90. a ° ■■■IÎt ìü=^!^ III1i 1 I R, ° i s°. ° t ^ cd ^ m —C a° ■■1111^ I1I °v ^^ on ^ ^ 3 ^ ^^ ^ •^ ^^ w Hp° pLa,-.^ ° >° ^^° o c m ìlllllll lll Ilüî^^.^. d id. E ^;^ ^.^ a, o l v +,". Etìii111^C1'L^1'^11111/^ m a) âi c°d E ^ D m+'H c, ai• ^ a>+-' ^W _1^^v^ c a^ °H âz Ó 0. Ii+CI WilizsgCInamoiúlllCa1 ^ HH c^d+^ m éi Â v;ÓH ß, ?^ ^ o g 4T 384 THE MEDICAL JOURNAL OF AUSTRALIA. [May 7, 1921. hospital in Sydney that she was immediately given intra- in that district. The position seems to us to be most serious, venous injections of bicarbonate of soda in saline solution, to demand an immediate mosquito survey first of all in this stimulant treatment, morphine hypodermically and feeding district and later throughout other areas with the object of per rectum. Her condition was so bad that, in spite of the dealing scientifically with the mosquito and its breeding . persistent vomiting, washing out the stomach could not be places. The situation also demands immediate search for considered on account of the distress it would cause. and thorough treatment of all cases of malaria in Australia. The following day her general condition was slightly im- We hasten to report this case hoping that early steps may proved. though she was still alarmingly ill. The treatment prevent the spread of this danger to the community. was repeated. Acetone disappeared from the urine and she It is probable in these post-war days that there are and improved perceptibly. have been other cases of unexplained irregular fever, diag- Having in view the fact that the ordinary causes of nozed provisionally perhaps as enteric fever, influenza, etc., toxæmia had been clinically excluded. the cause of the con- in which the malarial parasite has been at work unrecog- dition was pathologically investigated. Blood examinations nized. We ourselves have at present under observation an were made to exclude pernicious anæmia, typhoid and para- obscure case of irregular fever which was under the care of typhoid fevers and malaria Subacute yellow atrophy of the one of us some time ago. liver was also considered a possible diagnosis (though no This patient presented most perplexing symptoms and convulsions and no jaundice had occurred) and the urine was seen in consultation by many other medical men. Un- was examined for leucin and tyrosin, which were absent. fortunately during the pyrexia no investigation with the No Widal reaction was obtained with Bacillus typhosus or specific object of discovering malarial parasites was sug- Bacilli paratyphosus A and B. gested, that provisional diagnosis having very naturally been A blood count showed: excluded on account of her residence in the western district Total Red Cells .. 4,200,000 per c.mm. of New South Wales and of the fact that she had not been Hemoglobin 60 farther north than Sydney. Colour Index .. .. 0.7 In view of the findings in the case now reported, we are Total Leucocytes 6,300 per c.mm. again in touch with this patient. On reviewing her case, it Differential count: seems that the clinical history and features correspond re- Polymorpho-nuclear cells . .. 68 markably with malaria. The disease, if present, is however Lymphocytes .. . 30% now quiescent, but a prolonged search or a recurrent attack Monocytes . .. 2% may reward us in finding the parasite. Another impressive feature about this case is the fact No eosinophile cells were seen. The red cells were practically that in the stage of fever when there was a leucopenia normal in size and shape. (again fitting in with malaria) and relatively slow pulse, Malarial parasites were present in large numbers, includ- a provisional diagnosis of enteric fever was made and the ing trophozoites, macrogametocytes and microgametocytes of patient was given, as she was constipated, a daily enema of the tertian type. No crescents were seen. sulphate of quinine. On defervescence her anmic con- The case was, undoubtedly, on the pathological findings, dition was treated with arsenic. The "accidental" adminis- one of malaria. tration of quinine and arsenic may have had some influence With the discovery of the parasite and in view of the should the case have been one of malaria. clinical history and signs, the diagnosis of tertian malaria Should the investigation reveal a malarial infection, the was obvious. case will be reported later. On the day while waiting for the pathological report, the This article may draw attention to the necessity of in- patient complained of pain in the left hypochondrium and cluding malaria in the provisional diagnosis of any case of the spleen, which in the two days she had been under obser- irregular fever, in addition to urging the adoption of vation had not been palpable, was found to be distinctly measures necessary for the preservation of the public health. enlarged to 2.5 cm. below the costal margin. This enlarge- We again beg to acknowledge our indebtedness to Dr. ment is now subsiding. Weedon, of Wagga, and to Dr. Frank Tidswell for his With appropriate specific treatment the patient is rapidly interest in the pathological work and for information from improving. There is no vomiting; the pulse is almost normal. his own practical experience of the previous history of

• The cardiac oondition has improved. The liver dulness, malaria in Australia. diminution of which was probably due to hyperemesis, causing a temporary atrophy of glycogenic cells, is now in- . Addendum. creasing towards normal. The patient's general condition Since the foregoing article was written we have investi- is good and she is well on the way to recovery. gated another case from Barraba near Tamworth, New The only difficulty in treatment lay in the grave hyper- South Wales, in which we have established the 1iagnosis of emesis; but quinine was given at first intravenously and by aboriginal malarial infection by the discovery of the parasite. the high rectal method. Now that the vomiting has subsided, In addition the "obscure" case mentioned in the article quinine is being given by the mouth and novarsenobillon has, on repeated examinations, revealed intra-corpuscular intramuscularly. The intravenous injections of bicarbonate chromatin bodies in great numbers. Though no typical of soda in saline solution and of quinine have now rendered parasites have been found, these bodies are so numerous as the veins useless. They were originally "poor ones" and definitely to indicate that they are degenerated forms of the were made more so by her condition. amoeba; this degeneration had no doubt occurred in consequence of the patient now being convalescent and in conse- Comment. quence of the small doses of quinine and arsenic which We consider that the discovery of this case is of the she has received. Taking these findings together with the utmost importance to the public health. It has been recog- clinical history and signs, we do not hesitate to make a nized that the return of great numbers of men suffering final diagnosis of malaria. from malaria from Palestine and New Guinea after active This case is also an indigenous infection, the patient service would provide a source of spread of this disease in coming from Forbes, New South Wales. Australia. Anophelines are authoritatively stated to exist These three cases (from the Riverina, from the western throughout Australia. We now have a case, the first we district and from New England) emphasize the fact that believe to have been actually reported south of Sydney, the disease has certainly gained a foothold in widely where aboriginal infection has occurred, where a patient scattered centres in New South Wales. as a source of infection 'is * known definitely to have been present within "mosquito distance" of the patient infected, where the essential condition (swampy ground) for the Corrigendum. breeding of mosquitoes has also been present within mos- Our attention has been directed to an error in an an- quito distance of both the "carrier" and the new host, nouncement made in our issue of April 16, 1921 (page 314). where we can exclude previous infection from other known Dr. E. W. Chenoweth has been appointed Stewart Lecturer malarial districts and where the actual parasite has been in Anatomy at the Melbourne University. The Stewart Lec- found in the blood of the infected patient. The whole chain turer in Medicine to succeed Sir Henry Maudsley has not is complete except the actual discovery of infected mosquito yet been appointed. May 7, 1921.] THE MEDICAL JOURNAL OF AUSTRALIA. 385

host of the plasmodium. It is assumed, but not proven, that the sub-family Anophelinco alone can transit the Che medical Journal of 3iustralía. disease. In science guesses are inadmissible. It is essential that someone should determine the actual

SATURDAY, MAY 7, 1921. mosquito which transmits the parasite in those districts of Australia where malaria is prevalent. Che malaria Danger. Mr. Taylor found Nyssorhynchus annulipes in practically every district investigated from Pompoota, a On January 5, 1915, a patient was admitted to the township not far from the mouth of the Murray River, Sydney Hospital under the charge of Dr. Sydney to Kyabram. In the eastern areas there were many Jamieson suffering from malaria. This man had not varieties of mosquitoes, including Anophel nce and been outside the State of New South Wales for a Culicinw. The survey was not extended to the north period of 21 years and for five years he had not left into the Murrumbidgee irrigation area, nor eastward the Gosford district. He had not previously been up to the Snowy Mountains. The information, how- affected with the disease. It thus appears that the ever, contained in his report was most disquieting. infection had taken place locally, probably from some- In some places, there was already a large anopheline one who had returned from New Guinea. The case mosquito population. Apparently but small meteoro- was published in our issue of February 20, 1915, and logical changes and an extension of settlement would at the same time we issued a grave warning to those suffice to render the main water street of three Aus- responsible for the safety of the public. At that tralian States a hot bed of anophelines and thus time it was held by many that the anopheline mosquito presumably a potential source of danger to the population south of the northern portion of Queens- community. land was so small that there was no real danger of a A year later, that is in 1918, Dr. Breini and Mr. spread of malaria. A year later a conference took Taylor published in this journal a report of the sur- place between the military medical authorities, the vey undertaken in Cairns. This report is important Director of Quarantine and others concerned with the in view of the fact that in the definitely infected area malaria problem. As a result of this conference a two anopheline mosquitoes were found in consider- definite course of action was adopted, aiming at the able numbers. They are Nyssorhynchus annulipes control of persons returning from. New Guinea in- and Myzorhynchus bancro f ti. Culicine mosquitoes fected with malaria. It was decided to place these were also abundant. persons under observation and treatment. Further it In the present issue Dr. II. J. Clayton gives a full was determined to segregate all invalided and dis- account of a malarial infection of a person who had charged soldiers then in the Commonwealth, who were not been outside the district of Wagga Wagga. The known to have been infected with malaria. In 1917, chain of evidence is complete, proving that the in- Mr. F. H. Taylor, F.E.S., Entomologist at the Aus- fection was a local one, notwithstanding the fact that tralian Institute of Tropical Medicine, published the the mosquito conveying it was not identified. Dr. results of a malaria mosquito survey of the irrigation Clayton also refers to two other cases in which a local areas in the Murray River district. In order to make infection has occurred. In next week's issue we hope the position amply clear, it must be stated in this to publish a short account by Dr. Gerald Doyle of place—we have called attention to the fact many times another instance of local infection in St. Arnaud, in the past—that we are ignorant concerning the mos- Victoria. The inference that Dr. Jamieson's case, quito vector of the Plasmodium malarice in Australia. Dr. Clayton's three cases and Dr. Doyle's case do not It has been inferred that here as elsewhere the ano- represent the only indigenous infections will scarcely pheline Nyssorhynchus annulipes is the mosquito that be challenged. How many malarial infections have conveys malaria from patient to patient. In other been mistaken from influenza, rheumatic attacks or countries it has been found that not every anopheline other common illnesses, no one can say. It is probable mosquito is capable of acting as the intermediary that malaria has already gaindd a sufficiently firm 386 THE MEDICAL JOURNAL OF AUSTRALIA. [May 7, 1921.

hold in New South Wales—and possibly other States— hold the infection within narrow limits. In these to constitute an immediate, and serious menace to the circumstances we regard the painstaking and extensive study undertaken by Dr. J. P. Greenberg at the community. Very active steps are needed to check Gynecological Clinic of the Johns Hopkins Hospi- its spread. Malaria, like yellow fever, can be stamped tal of a large number of cases of tubercular salpin- • out of any community. The cost is relatively small, gitis as an important and helpful work.' It appears that during the thirty years up to the end of 1919, if the attack be planned and carried out before the tuberculous changes were detected under the micro- intermediary hosts have established themselves in scope in the Fallopian tubes of 200 patients, while there were reasonable grounds for the assumption that the overwhelming numbers and over a large area. It must tubes were involved in a tubercular infection of the be remembered that the price of irrigation includes peritoneum in at least 23 other patients. The 200 the risk of a spread of the mosquito population. If Patients represented 0.83% of all the patients treated for gynecological disorders in the clinic during this we had a map of the Commonwealth, marked with period. Moreover, Dr. Greenberg finds that of every the varieties of mosquitoes in each and every district, 13 tubes removed, one was affected with tuberculosis. While the majority of the patients were of the child- we would be able to gauge the magnitude of the bea ring age, the affection was seen in young girls from task of removing the malaria danger from our midst. the age of 14 years and in women up to the age of 55 years. Approximately 60% of the patients were sterile. The symptoms included pain in the lower TUBERCULOSIS OF THE FALLOPIAN TUBES. segment of the abdomen and in the back, menstrual disturbances (dysmenorrhoea, tmenorrhagia, oligo- There are many pathological processes the signifi- menornccra; and amenorrhoea) and leucorrhoea. It is cance of which is not fully recognized as a result of pointed out that pain in the neighbourhood of the clinical observation. History reveals that these pro- umbilicus, supposed to be characteristic in tubercular cesses have been regarded as rare occurrences until peritonitis, was complained of by Duly 14 patients, an astute investigator has delved deeply into the notwithstanding the fact that no less than 126 of the pathology and has correlated the clinical manifesta- patients had in addition to a tubercular disease of tions with the pathological changes. The attention the tubes a tubercular peritonitis. A definite onset of the profession has then been turned to the condi- was timed on 74 occasions. Fever was considerably tion and it has been found that a supposedly uncom- more common in the patients with peritoneal involve- mon affection has passed undiscovered in every clinic ment. About 25% of the patients had at the same and in every extensive private practice. It appears time a pulmonary tuberculosis. that such a course of events occurred in the case of The data given above reveal that tubercular salpin- tubercular salpingitis. Before 1886, the disease was gitis is by no means a characteristic condition. It is overlooked save when the process had developed to therefore not surprising to learn that a correct pre- so advanced a stage and the changes had become so operative diagnosis was made in only 26 instances, typical that the diagnosis was self-evident. Hegar i.e., in 13%. In this connexion it would seem that was the first to dispute the firmly-rooted belief that the cases dealt with in the Gynæcological Clinic at the this affection was very rare. He showed that in the Johns Hopkins Hospital were sufficiently advanced majority of instances it either passed unnoticed or to demand operative interference. No information was mistaken for other affections of the Fallopian is offered concerning tubercular lesions of the tubes tubes because there were no special or specific char- without extensive implication of adjacent or distant acters that could be discerned by clinical examination tissues or organs. There is some evidence in support or by macroscopic inspection. Even to-day the major- of the contention that a localized tuberculosis of the ity of general practitioners are forced to the conclu- pelvic organs is not rare. Dr. Greenberg's figures sion that tuberculosis of the tubes needs scarcely be are suggestive, for in 43% of the cases either the considered in the differential diagnosis of pelvic dis- tubes alone or the tubes and the pelvic peritoneum orders. Unfortunately this affection is not unique in were involved without any other pelvic lesion. Efforts resisting an accurate diagnosis without the micro- should be made to improve our diagnosis, so that scope. Moreover, it is extremely difficult to form a some, at all events, of the less severe cases might be correct conception of the pathological value of tuber- recognized. The diagnostic failure in 87% of marked cular disease. The diagnosis of tuberculosis based on cases is not creditable to scientific gynecology. That biological reactions is not reliable, since healed or this matter is important in the interests of the pa- latent lesions may be accompanied by antibodies tients, is revealed by the record of the. results. There

' capable of yielding specific reactions. The differentia- were 17 deaths in the hospital among the 200 pation between clinical tuberculosis which endangers tents. Of these 17, seven patients had definite pul- the life of the patient and a tubercular infection monary tuberculosis. While Dr. Greenberg was un- with which the body is capable of dealing, is fraught able to discover the fate of all the 183 patients dis- with difficulty and traps for the unwary. In addi- charged from the clinic, he was able to ascertain that tion it has to be recognized that when the disease is nine out of 90 had died of their tuberculous infec- localized in a special organ or tissue, the clinical tion. We may assume that the tubercular disease • significance to the patient will depend to a consider- robbed at least 26 patients of their lives. It is unable extent on the power of the organ or tissue to ' .Bulletin of the John8 Horokina.HOapital, February. 1921.

May 7, 1921.1 THE MEDICAL JOURNAL OF AUSTRALIA. 387 likely that tubercular salpingitis is as common in of the dogs proved to be more than usually sus- Australia as it seems to be in America, or that it is ceptible to distemper, just as the human diabetic as fatal. It is well known that the coloured people is prone to become infected with tuberculosis. Preg- in America are more susceptible than the white nant bitches often aborted shortly after the operation women. Nevertheless, until it is proved to the con- and died • after the course of a few days. In the trary, we must accept this disease as a real menace next place, Dr. Allen recounts the evidence of an in the Commonwealth and we should direct our intoxication which often followed the chronic in- energies toward its early recognition. flammatory reaction affecting the pancreatic remnant. He also records a series of typical examples of asthenia in dogs and cats rendered "diabetic" by THE PANCREATIC FUNCTION IN DIABETES. operation. This asthenia usually appeared late in the period of advanced emaciation. He found that On several occasions during the past few years the animals with very small remnants suffered from a modern aspect of the relationship of diabetes mellitus more rapid decline than could be attributed to the and pancreatic function has been subjected to a disturbance of digestion. The asthenia at times was critical review in these columns. Care had been taken noted at an early stage after partial pancreatectomy to avoid precipitous acceptance of a final cause argu- and frequently after complete pancreatectomy. That ment when Dr. F. M. Allen introduced his so-called it was not due to mere loss of fat is shown by the fact starvation treatment. In the first place, it was neces- that many of the animals still had a considerable sary to await the final results of this form of treat- amount of adipose tissue at the time of death. He ment applied in a very large number of cases, always is not prepared to admit that the asthenia is an ex- a matter of many years. In the next place, a critical pression of the body reaction to loss of sugar or spirit was needed to distinguish between the advocacy nitrogen. Neither can he accept the suggestion that of enthusiasts and the more reluctant evidence of it is produced by a severe type of diabetes. He established facts. In the third place, there exists a examines the possible explanation of the asthenia as grave danger in assuming full knowledge of a highly a result of nervous influences, indigestion and in- complicated process, when in reality only some of toxication and finds objections to each. He is there- the information is available. That the information fore driven to the conclusion that the asthenia is on which Dr. F. M. Allen bases his conception of produced by an endocrine deficiency. diabetes, depends on the identity of diabetes in the Partially depanereatized dons and cats were found human subject and the condition produced by the to be subject to a form ofq4ngrene, characterized removal of the greater portion of the pancreas in the by superficial infections and ulcerations. Dr. Allen dog, signifies that all doubt as to the truth of this contention must be removed. Dr. Allen recognizes points out that dogs are not liable to arterio-sclerotic the validity of this critical contention, for in his last changes, which form the basis of the dry gangrene contribution to this important study', he states that often associated with human diabetes. On the other hand he claims that the frequency of the ulcerative the evidence brought forward strengthens the claim form is approximately the same in dogs as in human of the similarity of "clinical and experimental diabetes" and justified the "application of results patients. He ascribes this also to a specific endocrine gained with the' one form to the other." More con- deficiency. He cites the histories of dogs who became vincing proof than has yet been adduced must be cachetic in the course of the experimental "dia- demanded, since it would seem to be highly improb- betes." While he admits that this fatal cachexia is able that the essential and initial pathological pro- dependent on some unknown cause, he argues that it cess of diabetes is the inflammation of the pancreas. is probable that metabolic alterations occur which lead to the suppression of the glycosuria and to the Moreover, the. physiological reaction of the functioning remnant of the pancreas, after a greater or lesser appearance of prostration and wasting. In some segment of the pancreatic parenchyma has been de- cases, under-nutrition may play a part. In this stroyed functionally, would be dissimilar to the connexion he wishes to distinguish sharply between physiological reaction of the remnant after removal the suppression of the glycosuria and the results of of a varying amount of healthy pancreas. It is not under-feeding. In the latter the power of the as- unreasonable to seek for a cause of the pancreatitis, similation of food is increased, the general strength which seems to be a condition precedent to the clinical is raised and life is prolonged. All these observa- manifestation of diabetes. If such a primary cause tions provide material for careful consideration. exists, even in a proportion of cases, much of the Everyone will admit that they furnish fresh points hypothesis set up by Dr. Allen would have to be of similarity between human diabetes and the con- ruled out as inadmissible evidence. dition produced by the removal of a portion of the pancreas in a dog or a cat, but convincing proof of In the present cpmmunication Dr. Allen gives de- the identity of the two processes is still lacking. Dr. tails of some important observations made on dogs Allen's work is of the utmost value in illuminating and cats rendered glycosurie by the removal of por- many obscure processes connected with the physiology tion of the pancreas. Death at times occurred after of the pancreas and with the pathology of pan- the operation, especially in old, obese dogs. The creatitis, but further evidence is needed and many fatal issue was preceded by progressive prostration, other channels of study must be traversed before the before any glycosuria or acidosis had appeared. Some aetiology and pathology of diabetes can be fully

1 The dmericgn Jonrngl of the Medical Sciences, March. 1921. appreciated.

388 THE MEDICAL JOURNAL OF AUSTRALIA. f May 7, 1921.

Abstracts from current Medicai the other end tucked into the dome of was normal. No recurrence has oc- the sac. This was removed by way of curred, although eighteen months have Literature. the nose four or five days later. The passed. -' author recommends this method also for chronic cases where an external (159) Melanosarcoma OI'HTHA],MOLUG Y. Conjunctivae incision is permissible. 'The method em- Bulbi. ployed in the chronic cases consisted E. K. Wolff ..and II. T. Deelman re- in uncapping the lachrymal sac in (155) Injuries to the Eyes of Children. port a case of melanosarcoma con- front of the middle turbinate bone, then L. Buchanan considers that injuries iunctivce bulbi which is more uncom- pushing the sac into the nasal cham- to the eyes of children are becoming mon than intra-ocular sarcoma. (Brit. ber by a probe through the punctum, more frequent and that most of them Journ. of Ophthal., January, 1921). The and excising as much of the tent thus are preventible (Brit. Journ. of Oph- patient was a woman of 35 years who produced as could be obtained. A thal., January, 1921). During the years had noticed a small black spot, the special chisel with a s 1917, 1918 and 1919 there were in a , curved end was size of a pin's head,' on the left con- used to "bite" into the bone. The certain series 61 eyes removed from junctiva during the last ten years. opening could be enlarged with a burr children for severe injury. A table of More recently it had become bigger and guarded to prevent injury to the sep- causes shows that stone and glass a red blister had appeared. The tum. It was not easy to obtain a good throwing hold the chief place, being growth was found to be loosely at- hold of the sac tented into the nose responsible for 31 cases. The loss of ' tached to the sub-conjunctival tissue. from the punctum, but a few serra- these eyes is of great economic im- As the eye was otherwise normal it tions on the Hartman forceps facilitated portance. Excision of the injured eye was decided to excise the tumour and this step. The window in the sac was is frequently required as young child- apply X-rays. The histological diag- sometimes cut with a cataract knife. ren are much more liable to sympa- nosis was melanosarcoma. About two Granulations were kept down by thetic ophthalmitis. It is wiser to re- years later there was a patch of pig- cauterization. move a child's eye which is injured in ment beyond the cornea and the eye was excised though It had otherwise the ciliary region. . Injuries by glass (157) Trephining and Aspiration in are especially serious and the same may Retinal Detachment. remained normal. Microscopically there be said of perforation by a fork or E. S. Thomson reports the result of was pigmentary involvement of the pen-knife. Injuries to the lens give 75 operations performed for the relief cornea and the enucleatlon of the eye rise to more serious results than of detached retina (Archives of Oph- was justified. A. year later the patient do 'similar injuries in adults.. As re- thalmology, November, 1920). There returned with a tumour in the temple gards treatment, when an attempt is were seven successful cases and these near the left eye. This was removed made to save the eye, the less the eye are reported in some detail—the others, and the patient so far has remained is touched the better. If the wound is to quote the author, were "flat failures." well. of less than six hours' duration and The operation is performed as follows: the anterior chamber still open, the A conjunctival incision is made and (160) Neuropathic Keratitis. prolapsed iris may be trimmed away. the edges retracted by sutures. k B. Chance reports the case of a man, But if the anterior chamber be closed, 2 mm. trephine button is then re- aged 45, suffeR,ing from keratitis of to cut away a prolapsed part of the moved from the sclera as far back as neuropathie origin. (archives of Oph- iris Is to expose the eye to a second possible over the area of the detach- thalmology,` ovember, 1920). He had risk of infection. The author does not ment and any suprachorioidal fluid is suffered from left-sided trigeminal neu- approve of the procedure known as the allowed to escape. The needle of a ralgia and had had resections of the "conjunctival flap," except in the case hypodermic syringe is introduced supra-orbital and infra-orbital nerves of purely scieral wounds. He has found through the choriold well back into the without relief. He then had alcoholic no advantage in the use of sub-con- middle of the detachment and all the injection into the - Gasserian ganglion junctival injections of mercurial salts. fluid removed. The conjunctival flap and for two years had been entirely He has a preference for atropine, as is then sutured in place. It is useless free from pain, having had ansesthesia against eserine, in all cases. The eye to operate in the presence of a well- of the left side of the face and left should be watched for three months defined retinal rent. All the fluid must cornea. On examination, the cornea and at the first sign of reduced tension be removed at the time of the opera- was found to be oedematous, without should be excised. A double bandage is tion, even if the globe collapses. Ten sparkle and pervaded by fibrillary scars. recommended to prevent the occur- days in bed are sufficient rest. The case is remarkable in view of the rence of squint. long period i tkfhich elapsed before the (158) Uveitis Dependent on Appendi- onset of the keratitis, and of the (156) Naso-lachrymal Surgery. citis. repetition of the intense oedema and The literature describing iritis de- the rapidity of its subsidence. The Clifford B. Walker has written down pendent on focal infections has chiefly patient was under " treatment for five his belief that eventually a naso- been concerned with focal infections in months and ultimately enjoyed a good lachrymal fistula procedure will become the teeth, tonsils and nasal sinuses result. the operation of election which will dis- and with auto-intoxication from th e. place many operations involving extir- intestinal tract. H. H. McGuire sug- (161) Trephine in Chronic Glaucoma. pation of the lachrymal sac. (Archives gests that iritis may also result from T. Harrison Buller confesses that he of Ophthalmology, November, 1920). infections in distant organs, e.g., the has changed his views on the subject Dealing with the acute phlegmonous vermiform appendix (Archives of Oph- of trephine in chronic glaucoma. cases, the author determined to exploit thalmology, September, 1920). Chronic Whereas formerly he opposed the the possibilities of intranasal drainage appendicitis has been referred to by operation, he is now decidedly in by the process of fistulization. Hugging several authors in this connexion -, but favour of it. (Archives of Ophthal- the nasal side carefully, he carried the so far acute suppurative appendicitis mology, January, 1921.) The result of dissection down between the sac and has not been mentioned. The author's iridectomy he found disappointing, re- its nasal wall. A narrow mastoid patient, a girl of 18 years, was treated sulting in only 43 % of success, whereas gouge or chisel was pushed horizont- for acute iritis - and uveitis for two in trephining( r the successes total ally inwards into the nasal cavity In months without relief. The usual 77% or more. He prefers the front of the middle turbinate. The causes had been excluded. She then 2 mm. trephine and if the iris opening was sometimes enlarged by a mentioned that during her attack she does not prolapse, does not "fish" for Kerrison punch or by a burr. A probe had experienced several spasms of pain it. He is convinced of the necessity of was passed into the sac through the in the right side of the abdomen. Her early operation and the more the fixa- dilated punctum and that part re- appendix, which was full of pus and tion point is menaced the more urgent moved which corresponds to the bony almost ready to perforate, was removed is the operation. He reports ten more opening. A "drain" was pushed and her eye condition began at once cases of late infection but regards through the nasal opening and part of to -improve. Tn âix weeks the vision tragedies of this kind as inevitable. THE MEDICAL JOURNAL . OF AUSTRALIA. 389

Painful eyes with absolute glaucoma that frequently follows a sudden loud Med. Assoc., November 15, 1920), for are best treated by removal. noise, precedes in time the reception of the removal of tonsils and adenoids. the sound by consciousness and he sug- The age of the patient need not be gests that it is the result of a sudden considered. In adults, the tonsil may LARNYGOLOGY AND OTOLOGY. and violent stimulation of the canalicu- appear healthy; but local manifesta- lar hair-cells. tions of infection therefrom may be an (162) Chronic Catarrhal Otitis Media. irritable throat, with a muscular sore- The pathological changes in adhesive (164) Chorditis Fibrinosa. ness and stiffness, particularly in the catarrh of the middle ear are stated Forty patients suffering from chord- mornings, a persistent dull red appear- by William Milligan (Proc. Roy. Soc. itis fibrinosa, that rare variety of acute ance of the pillars and surrounding Med., January, 1921) to be, firstly, laryngitis, in which the inflammation mucosa, the ability to express pus from surface epithelial changes; secondly, is limited to the true cords, the liga- the tonsil crypts when there is no connective tissue changes, both hyper- • mentous portions of which suffer acute inflammation and persistent ten- trophic and sclerotic; and, thirdly, mostly, owing to excessive vibratory derness of varying degree when direct atrophic changes. These may occur movements, have been seen by A. pressure is made on the tonsil. Other separately . or collectively. He believes Brown Kelly (Journ. Laryng. and signs of disease are a firmly adherent that the neglected exudative catarrh of Otology, January, 1921). The disease condition of the tonsil, cervical adenitis the nasopharynx of early life is the occurs in the cold season of the year. without general glandular (license and main cause of adhesive catarrh in after Its symptoms are hoarseness or a tendency to stiffness and sorenesC life. He advocates an incision with a aphonia, but no pain. The cords, ex- near the centre of the sterno-cleido- fine galvano-cautery to drain the middle cept in the posterior thirds and near mastoid muscle. This soreness is caused ear in cases of exudative catarrh, fol- the anterior commissure, present a by a nest of deep cervical lymphatics lowed, perhaps, by lavage with a ca- pure white appearance, due to a deposit lying directly under the centre of this theter and douche. He deprecates the of fibrin, which gradually loses its muscle. injecting of fluids into a cul de sac lustre, becomes thin and greyish and whose lining membrane has practically passes off, leaving a red surface. The (167) Septal Deflections in Children. lost its powers of absorption. He re- changes in the two cords generally pro- In a child with pronounced nasal ob- gards the secondary membrane of ceed pari passu. The remainder of the struction due to a badly deflected sep- Scarpa as a structure equal in im- larynx is normal. The average dura- tum, the obstruction should be relieved portance, from the pathological point tion of the fibrinous exudation is from with as little disturbance of the septum of view, to the attachment of the foot- three to four weeks. Erosions are as possible. W. W. Carter (Medical piece of the stapes to the margin of found in about half the cases, usually Record, November, 1920) makes an in- the fenestra ovaLis. Hence middle-ear in the later stages. One or more tiny cision along the entire' septal muco- deafness may exist without paracusis, notches form in the edge of one or cutaneous junction, and extends the cut i.e., the ossicular chain may be mobile, both cords, near the junction of the across the floor of the nose. Through but owing to a formidable barrier of anterior and middle thirds. They gen- this incision the muco - perichondrium fibrous tissue in and about the mem- erally disappear in three or four days. is elevated over the entire septum on braina secundaria, excursions of the The causes assigned in most cases both sides. Working through this in- endolymph are prevented, and the were gas and cold. The chief treat- cision with very small knives of vari- movements of the foot-plate of the ment is rest to the voice. ous shapes and angles devised for the stapes are antagonized. Future pro- purpose, he reduces the septum till it gress in the treatment of chronic ad- (165) The Diploëtic Type of Temporal becomes a fiat surface in a vertical hesive catarrh appears to lie, he thinks, Bone. plane. He then places a paraffin splint in the employment of radio-active sub- Arthur H. Cheatle (Prop. Roy. Soc. on either side of the septum and packs stances, whose rays have the power of Med., June, 1920) states that the dip- both nasal cavities with vaseline gauze. softening and rendering pliable dense loëtic type of temporal bone is char- A tin-lined copper splint, made to fit sclerotic tissue. The ß and y rays of acterized by the presence of diploë the nose, is worn for a week. The nose radium or its emanation probably act running through the outer antral wall must be examined and, if necessary, upon the connective tissue cells by vir- continuously with the diploë of the rest dressed .daily. tue of their power of transforming hard of the bone. The layer runs between and dense mesoblastic tissue into some- the outer compact layer and the cells (168) The Laryngo-Stroboscope. thing approaching embryonic tissu e. which line the inner aspect of the outer E. W. Scripture's laryngo-stroboscope which is soft and pliable, with its antral wall, but is separated from them (Proc. Roy. Soc. Med., J une, 1920) con- fibrils arranged in lines parallel to the by a layer of dense bone of varying sists of a disc with forty slits mounted superimposed skin or mucous mem- thickness. The condition is rare. The on the axle of an electric motor. The brane. Everything depends upon the bones are frequently devoid of cellular light from an arc lamp is concentrated dosage, deviation of exposure and ef- development, or a few cells may be by condenser lenses, so that it passes fective filtration. present in the mastoid. The condition at a focus through the slits. The is not always symmetrical. In an acute beam is caught by another lens; it (163) Vestibular Function. infection of the antrum there is likely falls on a fiat head - mirror and is re- That the vestibular end-organ, in to be a rapidly spreading infection flected by the throat-mirror to a focus addition to its stimulation by waves of throughout the diploë of the bone at the glottis. The singer is told to endolymph, reacts to sound waves, is (osteo-myelitis), with symptoms of sing the same tone as that produced by regarded as probable by Dan McKenzie acute septicemia. On opening the bone blowing through the slits of the disc. (Proc. Roy. Soc. Med., June, 1920). He in such a case congested diploë is His vocal cords then vibrate with the remarks that the scala cochlece and found, with heads of pus scattered same frequency as the flashes. As soon the membranous semi-circular canals through it, and in order to reach as he sings a tone of a slightly differ- share the same endolymph and are healthy parts an extensive operation is ent pitch the cords appear to execute alike exposed to sound vibrations. Fur- usually necessary. slow vibrations, whose character can ther, the footpiece of the stapes, be studied. Scripture finds that for through which sound vibrations pass to (166) Indications for Tonsillectomy. the chest register the vibrations take the endolymph, lies no less near to the In children, obstruction to breathing place along the entire glottis; for the sense-epithelium of the canals than it • or to the passage of food, recurring head register the cartilaginous glottis does to that of the cochlea. It is known attacks of tonsillitis and post-nasal is closed and vibrations take place along that vertigo is sometimes caused by adenitis, frequently recurring or per- the muscular glottis only. He holds loud sounds and it has been shown that sistent cervical adenitis, when not due that the masses of muscle which con- noise-deafness, produced by the habitual to some general glandular disturbance, stitute the vocal cords, act like cushions exposure to, harsh noises, is associated and firm adherence of the tonsils to that yield to compression and not like With a reduction in the responses to the pillars and lateral pharyngeal . membranes. The larynx resembles the vestibular tests. McKenzie has muscles are indications, according to neither a reed pipe nor a membranous noticed that the "start" of the body John W. Cormack (Journ. Indiana State pipe; it is really a cushion pipe, 390 TILE MEDICAL JOURNAL OF AUSTRALIA. [May 7, 1921.

British Medical .ASSOCiatios He did not wish it to be thought that he did not appreciate news. the importance of septic foci, but he was firmly of opinion that in every disease where there might also be a septic SCIENTIFIC. focus, it wàs not right to ascribe the whole condition to such focus. A meeting of the Victorian Branch was held at the Medi- Dr. Davies instanced exophthalmiç goitre. There had been cal Society Hall, East Melbourne, on February 2, 1921, Dr. patients in whom the focal infection theory had been fol- A. V. M. Anderson, in the absence of the President, in the lowed to such an extent as almost to compel them to look chair. upon it as so much humbug. First tonsils were removed, Dr. Sydney Pern read a paper on "Focal Infection and then the different sinuses cleaned out; later all the teeth its Limitations" (see page 377). were extracted, the appendix possibly removed and then the Dr. W. Spalding Laurie, in opening the discussion, said gall bladder inspected. All the time the unfortunate pa- that as a matter of observation certain septic foci were tient was getting rapidly worse, because this theory was found to operate in a regular sphere of influence. He .in- being run to death and a proper outlook was not maintained. stanced the constant association of septic tonsils with rheu- In the same way, some years ago there was a great dis- matic fever. It was not usual to meet with rheumatoid cussion as to. whether cholecystostomy or cholecystectomy arthritis dependent on septic tonsils alone; pyorrhoea was the operation of election. The gall bladder was in alveolaris, on the other hand, was not followed by rheumatic everyone's mind and at times obscured the general outlook. fever, but this condition very commonly preceded the de- He recollected a patient who was admitted to hospital with velopment of rheumatoid arthritis. He had often sought an obvious pyloric obstruction. At the operation it was the explanation of the fact that, while the tonsillitis which found that the gall bladder was contracted down on gall- ushered in acute rheumatism, was frequently of a suppura- stones and the pylorus was drawn up in surrounding ad- tive nature, yet rheumatic fever was in no sense pus-pro- hesions. The gall bladder was removed, the patient conducing. tinued the same obstructive vomiting and died in a few Dr. Pern had differentiated between primary and second- days. He had quoted this case to show how the pre- ary foci of infection, but it was not always easy to make dominant idea might obscure the perception ,of the real such a distinction. condition. Dr. Laurie deprecated the use of such terms as Hodgkin's Mr. W. Kent Hughes expressed himself as in agreement disease, pernicious anemia and rheumatoid arthritis, as con- with the opinions held by the two preceding speakers. His ditions simulating them were frequently found to be associ- practice consisted largely of the removal of seplc foci, but, ated with septic foci. The best success in the amelioration unfortunately, it could not be said that such removals always of such conditions was attained by efforts directed towards cleared away disease. In his opinion all tonsils were the the eradication of the focal infections. It was highly im- site of focal infection and this applied particularly to ton- portant that this fact should be recognized. He was afraid sils that had been only partly removed. With such an omni- that too often the giving of a definite name, such as "Hodg- present source of disease from focal infections, if all that kin's disease," led to relaxation of e fforts in the direction of Dr. Pern claimed were true, it was surprising that anyone cure, because of the hopelessness implied In the name as- retained his health. signed to the condition. Dr. Laurie expressed himself as Dr. fern had instanced sinusitis as a focal infection under- grateful to Dr. Pern for ventilating the subject of focal lying various diseases. In the experience of the speaker, infection, the importance of which was, perhaps, not fully sinusitis, while often related to vague recognized. ill health, was not such a potent factor in the production of serious diseased Dr. Konrad Hiller remarked that, although he was always conditions arising from septic absorption as were septic interested in the subject of focal infections, he did not feel tonsils. that he could allow them the large rôle in the production Mr. Kent Hughes considered that Dr. Pern's claim that of such a diversity of diseases as had been attributed to all cases of epilepsy were due either to syphilis or a focal them by Dr. Pern. Septic foci were potent factors in the infection was extravagant. In a long experience at the etiology of different diseases. He was fully convinced of Children's Hospital he had met with many epileptics in whom their intimate relation to rheumatoid arthritis, for instance, neither of these factors could be shown to be operating. but he found it difficult to accept the conception of epilepsy Others, in whom septic foci had been eradicated, had de- as a septic focus disease. rived no consequent benefit. The frequent dependence of epilepsy on syphilis was to No doubt it was of very great importance to recognize be correlated with the well-known affinity of the spirochete and deal with local septic processes, but he could not recon- for the cerebral vascular system; sufficient evidence was not cile himself to views which seemed to embrace nearly forthcoming to show that streptococci, to which organisms every known disease within the category of focal infections. so many activities were attributed by Dr. Pern, could in- Dr. J. Newman Morris said that the paper and discussion duce the same vascular changes. Further, instances of epi- had reminded him of Sir Arbuthnot Lane's favourite "septic lepsy in which the seizures commenced at 12 months of age focus" and the very radical measures adopted by that sur- and continued throughout life could hardly be laid at the geon for its removal. door of a septic focus. He was very anxious to believe in the probability of Dr. Dr. Pern had also mentioned appendicitis as being re- Pern's forecast; if it were likely to be realized it lated to distant septic foci, but whereas this might be so - would provide a strong argument in favour of nationalization of in some cases, he (Dr. Hiller) thought that in view of the medicine and payment by results. The doctor's duties would proximity of the intestinal organisms, inflammatory changes be narrowed down to the prevention and prompt treatment in the appendix were much more frequently the result of of septic foci. direct infection. In conclusion, Dr. Hiller stated that while There was no doubt that the habit of searching care-. he did not wish to minimize the important part played by fully for focal infections improved the quality of the prac- focal infections, he was not prepared to accept them as titioner's work and tended to prevent that drift towards causal factors in such a wide range of conditions as had "slumming" which was the danger besetting men in busy been claimed for them by Dr: Pern. practices. Dr. Morris expressed disappointment with re- Dr. F. L. Davies observed that the fact that a septic focus gard to the general results after a considerable experience was present along with some definite disease did not necessi of methods of treatment directed towards eradication of tate the disease being due to such focus. Epilepsy had been focal infections; unfortunately, the removal of multiple foci mentioned, but it was to be expected that epileptics would of infection often did not lead to ultimate cure or allevia- have septic tonsils. They usually had adenoids, were mouth tion of systemic disease. breathers, took little exercise and their whole existence It was no doubt a fascinating and stimulating theory to favoured septic infections. Again, the upholders of septic imagine that streptococci gained access to the tissues, settled foci wished to claim as proof of their ideas any case in down and proceeded to elaborate toxins. Such toxins reached which a definite condition was improved by the removal of the blood stream via the lymphatics, led to the destruction a focal infection, whereas if no improvement took place, of a few cells here and a few cells there and after being they said the disease was too far aävançed or gave some withstood by the body generally for perhaps a long period, other reason, attained a climax by precipitating an acute disease. If the May 7, 1921.1 7°IIÉ MtbICAL JOURNAL OV AUSmRALIA. 891

conception of disease in general advocated by Dr. Pern were Dr. Pern did not agree with Dr. Hiller that syphilis of the correct, it should not be a difficult matter to insure longevity brain was only of vascular origin; it also affected the for the next generation. parenchymatous tissue and meninges. If a spirochte was Dr. Morris tendered his thanks to Dr. Pern for the paper .capable of damaging parenchymatous tissue, he saw no he had presented and observed that he had not found the reason why a streptococcus could not do the same. practical results of removal of focal infections sufficiently In response to the remarks made by Dr. Davies on ex- encouraging to enable him to accept Dr. Pern's views with- ophthalmic goitre and sepsis, Dr. Pern stated that he had out reserve. frequently hammered at that old 'question. Because men Dr. A. V. M. Anderson remarked that there was un- did not get quick cures by removal of focal infections, it doubtedly a large element of truth in the doctrine that septic did not prove that septic foci were not the cause of ex- foci were responsible for a certain number of diseases; the ophthalmic goitre. His own experience in some hundreds of cases only fault in Dr. Peru's advocacy of the far-reaching effects had shown that where focal infections could be of focal infections was that of the enthusiast who incurred completely . removed, his patients got •well and that the a risk of obscuring his outlook by too much attention to one disease did not recur unless the focal infection had been idea. Chronic infective or "rheumatoid" arthritis was very incompletely removed or a fresh one had developed. prominent in connexion with focal infections and he recol- Regarding Dr. Kent Hughes's remarks that he thought lected as a student that Dr. P. Maloney used to emphasize people could go about in perfect health with focal infec- the fact that chronic mono-articular arthritis was associ- tions, Dr. Pern voiced his disagreement. He thought there ated with gonorrhoeal prostatitis. were very few adults free from some slight streptococcie infection and that sooner or later it did them harm, although In his fairly recent experience at No. 16 Australian Gen- for years they were unaware of it. eral Hospital Dr. Anderson had met with joint affections of The opinion had been expressed that focal infections should soldiers in whom spirillar infections of the mouth were pre- not be removed unless doing some obvious harm. He could sent. In these cases progress in the amelioration of the not understand the attitude of 'anybody carrying about a joint condition was only achieved after the spirillar foci had virulent strain of streptococcus within his body and main- been successfully treated. Lang, some time ago in the taining the hope that it would do him no harm. They had British Medical Journal, had claimed that a , considerable only to look around them to see how unfounded was such a number of eye diseases were due to septic processes in the view. Medical men were quite willing to recognize that mouth and his own experience was in favour of such ascertain tissues of the body were liable to invasion from sociation. focal infections, but why did they limit these tissues? Dr. Anderson pointed out that the co-existence of a focal Syphilis could invade any tissue of the body. Had they infection and a more or less general morbid condition was any reason to assume that the streptococcus could not do not always to be interpreted as cause and effect. If a local likewise? septic process called for treatment of itself, it should cer- Dr. Anderson had mentioned the subject of vaccines. tainly be dealt with, but it was not safe to tell the patient No vaccine at the present time could eradicate a focal in- that other disease manifestations would thereby be cured. fection, as it was an entrenched position. Its use would Dr. Pern had introduced the question of exophthalmic keep down symptoms and it was of the utmost assistance goitre in relation to focal infections. As bearing on this, when the focal infection had been removed. Dr. Anderson recalled an interesting patient in whom exophthalmic goitre had been accompanied by hyperchlorhydria. One half of the thyreoid gland had been removed, A meeting of practitioners interested in preventive medi- with temporary benefit only; the relapse had been treated cine was held in the Medical Society Hall, East Melbourne, by the resection of a further portion of the gland and on Wednesday, April 20,1921, convened for the purpose of eventually on a third occasion the surgeon had removed considering whether a Section of Preventive Medicine of as much of the thyreoid as he dared. The woman, after the Victorian Branch should be formed. Dr. A. V. M. An- some years of invalidism, had died as the result of peri- derson took the chair. tonitis due to the rupture of a duodenal ulcer. Was this Dr. R. H. Fetherston stated that the Council of the Vic- the septic focus responsible for the thyreoid hypertrophy? torian Branch had signified its approval of the formation of Dr. Anderson commented upon the frequent association a Section of Preventive Medicine and had appointed a sub- of cholecystitis and other infective conditions with myo- committee to take the necessary steps to organize the Sec- cardial trouble and quoted the case of a patient who had tion. The members of the Sub-Committee were Dr. J. W. suffered from gall-stones and who had also been the subject Dunbar Hooper, Dr. J. Ramsay Webb, and Dr. Fetherston. of angina pectoris. Operation had afforded relief from the The project was in accord with the expressed wishes of gall bladder trouble for a period of eight years, during many members of the Branch. It was hoped that all would Which time there had been no anginal attacks. With a be interested and would endeavour to make the Section a recurrence of the gall-stones, the anginal attacks had re- success. turned. Dr. J. W. Dunbar Hooper stated that the Council felt Dr. Anderson concluded with the remark that he had that preventive medicine was the question of the day. It observed a number of instances in which angina and cardiac had been preached assiduously in Great Britain and had irregularities were associated with cholecystitis and chole- been learned and practised during the war. It was the Iithiasis and he regarded the cardiac condition as being in pleasure, privilege and business of the Association to assist some cases due to myocardial disease, the result of a septic in every way in promoting the advancement of preventive focus, while in others there was probably a reflex con- medicine. nexion between the two conditions. Dr. J. H. L. Cumpston, Director General of Health for the Commonwealth, Dr. E. Robertson, Chairman of the Com- In his reply Dr. Pern said that he had not for a moment mission of Public Health of Victoria, and Dr. T. W. Sin- expected them to accept right away what he had read to clair, Medical Officer of Health for Melbourne, spoke in them that evening. It appeared from their remarks that favour of the project. he was quite justified in his premises He could not expect Dr. R. H. J. Fetherston moved on behalf of the Council: them to accept in a few minutes views which had taken That the members present form themselves into a several years to evolve, but he hoped that by giving thought Section to be known as the Section of Preventive Medi- to the subject they would in time see things as he saw cine, in connexion with the Victorian Branch of the them. British Medical Association. With reference to the question raised by Dr. Laurie, as The motion was seconded by Sir J. W. Barrett, K.B.E., to why there should be a pus-forming organism in the ton- C.B., C.M.G., and was carried unanimously. sils in acute rheumatism and yet no suppuration in the The following were elected office-bearers and members of joints involved, Dr. Pern pointed out that if leucocytes were the Committee: destroyed faster than they could be absorbed, they would President: Dr. R. H. J. Fetherston. appear as pus, but if their absorption kept pace with the Vice-President: Dr. J. Ramsay Webb and Dr. J. W. destruction there would be no pus. Dunbar Hooper. 392 InDÌCAL JOÌJRNAL 0P AÜSTItALtA. 1 May 7, 1921.

Members of Committee: Dr. A. V. M. Anderson, Sir balance in the Association's banks on January 1, 1919, £539 James Barrett, K.B.E. ; C.B., C.M.G., Dr. J. H. L. 6s. ld. was fixed deposits which matured during the year, Cumpston, Dr. Constance Ellis, Dr. Jane S. Greig, £170 ls. 2d. was interest received and £46 14s. 8d. was Dr. J. Newman Morris, Dr. E. Robertson; Dr. T. W. dividends of the Australian Deposit and Mortgage Bank. Sinclair, Dr. Walter Summons, O.B.E., Dr. Vera The disbursements included £594 7s. 6d. invested in 5 °%, War Scantlebury. Loan and Commonwealth Government Inscribed Stock and The Committee was given power to co-opt additional £26 2s. in the form of sundry grants. Of this latter sum, members and to appoint its own Secretary. £24 was granted to one person. The balance in the banks A discussion ensued concerning the methods to be adopted on December 31, 1919, stood at £300 6s. 11d.. to carry out the objects of the Section. On December 31, 1920, the Association had accumulated funds amounting to £4,893 5s. 7d., of which £3,000 was invested as Commonwealth Treasury Bonds or Commonwealth Frank Solomon I#ansman, Esq., M.B., Ch.M., 1920 (Univ. Government Inscribed Stock, £900 as Victorian Government Sydney), of Royal Prince Alfred Hospital, Camperdown, has Debentures or Stock and £103 15s. as shares in the Australian been nominated for election as a member of the New Deposit and Mortgage Bank and £789 10s. 7d. in the accounts South Wales Branch of the British Medical Association. at the banks. The statement of receipts and disbursements during the Notices. period January 1 to December 31, 1920, shows that the total The Scientific Committee of the Victorian Branch has receipts were £1,710 12s. 9d.,, of which £300 6s. lid. was drawn up the following provisional programme for the the balance in the Asssociation's banks on January 1, 1,920, ensuing three months. The Committee reserves itself the £148 14s. 7d. was interest received, £638 ls. 3d. were dividends right to modify the arrangements, but it is hoped that no of the Australian Deposit and Mortgage Bank, £622 10s. was changes will be necessary. The meetings will be held at the amount obtained on the redemption of 415 preference the Medical Society Hall, East Melbourne, unless another shares in the same bank and £1 was a subscription received. place is indicated. The meetings commence at 8.15 p.m.. The disbursements included £1,392 invested in Common- The publication of the 'provisional programme has the wealth Government Peace Loan and Inscribed Stock, £75 object of enabling members to prepare themselves for the 13s. as grants in aid to four persons and the balance in the discussions. Country members will also gain the oppor- banks on December 31, 1920, amounted to £239 14s. 6d.. tunity to make arrangements to attend meetings and take part in discussion on subjects in which they are interested. June 1, 1921.—Dr. K. S. Cross: "On the X-ray Examination MELBOURNE PERMA NENT POST-GRADUATE of the Abdomen Following Inflation of the Peri- COMMITTEE. toneal Cavity." Dr. C. E. Dennis, O.B.E.: "Some Remarks on the At a meeting of the Melbourne Permanent Committee for Radiology of the Thorax." Post-Graduate Work held on April 25, 1921, the arrange- July 6, 1921.—Mr. Victor Hurley, C.M.G., Mr. Alan Newton ments were completed for a course of five lectures on cardiac and Mr. W. D. G. Upjohn, O.B.E.: "Blood Trans- disease to be delivered by Dr. Hume Turnbull on June 8, fusion; Indications for Transfusion; Testing of 1921, and the following days at 8.30 p.m. at the Walter and Donors; Preparations of Patient and Donor; Eliza Hall Institute of Research in Pathology and Medicine, Technique of Operation; After Care." Melbourne Hospital. The first lecture will be on the me- August 3, 1921.—Mr. A. Fay Maclure, O.B.E.: Paper and De- chanism of the heart-beat and circulation. The subject of monstration at the Alfred Hospital: "On the the second lecture will be cardiac irregularities and their Making and - Fitting of Modern 'Splints and clinical diagnosis. The third lecture will be on the normal Fracture Beds, Together with a Display of heart and the heart in acute rheumatism. The fourth lec- Splints." ture will be on cardiac failure and the principles guiding prognosis and the subject of the last lecture will be the Mr. W. E. Hempson, the Solicitor of the British Medical treatment of cardiac failure. Association, has recently paid a short visit to Australia. These lectures will be followed by others on special sub- While he was unfortunately unable to visit every State, the jects in the interval before the commencement of the general Councils of several of the Branches of the British Medical post-graduate course in November, 1921. The fee for each Association were enabled to discuss with him some of the series of lectures will be £1 ls.. Medical practitioners wish- problems connected with the proposed alterations of the ing to attend these lectures can have their names enrolled articles and by-laws to be introduced for the purpose of on application to the Honorary Secretary of the Per- giving the Australian Branches a greater measure of manent Committee for Post-Graduate Work, Medical Society autonomy. Mr. Hempson's intimate knowledge of the con- Hall, East Melbourne. stitution and working of the Association based on an experience of many years rendered his visit peculiarly timely THE NOTIFICATION OF TUBERCULOSIS IN and very valuable. VICTORIA.

VICTORIAN MEDICAL BENEVOLENT ASSOCIATION. The Secretary of the Public Health Department of Vic- toria directs the attention of medical practitioners to the The annual meeting of the Victorian Medical Benevolent provisions of the Health Act, 1919, in respect to the noti- Association was held on February 9, 1921, the President, Dr. fication of tuberculosis. He points out that all forms of W. Moore, in the chair. tuberculosis, including tubercular glands and tubercular The following office-bearers were re-elected for the ' ensu- joints, have to be notified. We appeal to all practitioners in ing year: Victoria to carry out their obligations under the Act as President: Dr. W. Moore. promptly as possible. Honorary Secretary: Dr. E. L. Gault. Air Honorary Treasurer: Dr. G. W. Cuscaden. Members of the Committee: Dr. G. A. Syme, Dr. J. Talbot Correspondence. Brett, Sir Charles Ryan, Dr. F. Hobill Cole. Of the funds invested at December 31, 1919, aggregating NITROUS OXIDE AND OXYGEN IN OBSTETRICS. £4,176 8s., . there were £1,700 in Commonwealth Treasury Bonds or Commonwealth Government Inscribed Stock, £900 Sir: In view of your sub-leader of April 9 the following in Victorian Government Debentures or Stock, £726 5s. in notes may be of interest: Mrs. H. cet. 36, primipara, con- shares in the Australian Deposit and Mortgage Bank and sulted me on 16.7.20. She complained of periodic very acute £850 3s. deposited with the Association's banks. upper abdominal pain, much flatulence, nausea and occa- The statement of receipts and disbursements during the sional vomiting. period January 1 to December 31, 1919, shows that the total In her past history there was nothing apparently per- receipts were £925 Gs. 2d., of which £169 5s. 3d. was the tinent except that in July, 1916, after a curetting, she May 7, 1921. ] THE MEDICAL JOURNAL OF AUSTRALIA. 393

developed severe post-anaesthetic acidosis, requiring intra- is mature. Menstrual history, date of quickening, etc., are venous infusion of glucose and sod. bicarb.. The case was only approximate and often unreliable, and for some un- reported in The Medical Journal of Australia of September known reason the onset of labour is often postponed beyond 14;' 1918: the due date in 6% to 8% of cases (Parvin). But where On examination the abdomen was found to be tender there is such a big discrepancy between the estimated due over the liver and to a less extent in the right iliac region. date and the onset of labour as three or four weeks, a care- Per vaginam the uterus was normally placed and enlarged ful review of the history assisted by external measurements to the size of a two months' pregnancy. by the methods of Ahlfeld, McDonald and Perret, which are The cardiac, respiratory and nervous systems were nor- well described in the American journal, Surgery, Gynecology, mal. There was no jaundice. and Obstetrics, June, 1920, in an article by Reed on "The The blood pressure was systolic 100, diastolic 78. Postmature Child," will assist in determining when labour The urine had an acid reaction, sp. gr . 1,016, no albumin, should be induced. sugar or bile was found; but acetone was present and a Also, in case (2) would not a cleldotomy have been pre- trace of di-acetic acid. The breath, which could not be ferable to a'dislocated shoulder when the shoulders became held for more than 17 seconds, did not smell of acetone. impacted? A mixture of sod. bicarb., syrup of glucose and bismuth Is there any proof that the foetal head is now greater than carb. gave great relief and the acetone disappeared. 100 years ago? From time to time until the end of the seventh month the Yours, etc., symptoms reappeared, but relief was always obtained by use PERCY G. BRETT, the above mixture and trypsogen. of Honorary Surgeon to Out-patients, During the last month trypsogen was taken fairly regu- Women's Hospital, Melbourne. larly. Toorak, It was explained to the patient that her present symptoms April 27, 1921. and past history precluded the use of ether or chloroform at her con finement, but that gas-oxygen might be used if the contractions became too painful. Obituary. Labour commenced on February 16, at 9 a.m.. The patient however, did not arrive at hospital till nearly 2 a.m., owing CHARL1tS SMITH. to the motor car breaking down. The position was right occipito-anterior, the pains regular and fairly frequent. At The long and honourable career of Charles Smith was 8 a.m. a hypodermic injection of morphine 0.016 and scopola, brought to a close on April 12, 1921, to the deep sorrow of mine 0.0006 was given. No complaint of severity of pain a very large circle of friends and acquaintances. He was was made until afternoon. At 4.30 in spite of "good pains" the son of William Joseph Smith, an English farmer and there was no apparent advance. As there was full dilatation, was born in 1842 in London. At an early age he was taken the membranes were ruptured. At 5.15 the contractions to Basingstoke in Hampshire. His early education was were very painful and gas oxygen anaesthesia was induced carried out in a private school at Basingstoke under the for individual pains. This was continued till 5.50, but little guidance of an exceptionally cultured teacher. At the age further advance had occurred so continuous anesthesia was of 17 he passed the matriculation examination of the Lon- begun and forceps applied. At 6.30 a female child weigh- don University and entered Guy's Hospital as a medical ing 81 lbs. was born. It was, somewhat cyanosed, student in the following year. Five years later he dis- but after a few slaps and a whiff of oxygen it cried and tinguished himself by gaining First Class Honours at the breathed normally. M.B. examination. In 1886 he obtained the Gold Medal and The placenta came away at 6.20; there was no perineal the M.D. of the London University. His ability as a student laceration. - was recognized by the great men of those days, including The puerperium was uneventful and no further acetonuria William Gull, Samuel Wilks and John Hilton. Shortly after or abdominal - pain appeared. graduation he served as House Surgeon at the Royal Oph- The child was breast fed and steadily gained weight. thalmic Hospital al Moorfields and at the Metropolitan Free The anesthesia was quite adequate for forceps delivery Hospital. He devoted much time and attention to the study and the patient spoke sensibly less than one minute after of ophthalmology and rendered himself very expert in this the face piece was removed. branch of medical practice. The apparatus was Marshall's, modified to suit the In 1869 he obtained the position of ship's surgeon on the cylinders obtainable here. Though heavy and rather cum- sailing ship Yatala bound for Australia. On December 3, bersome, it may be quite easily carried in a car. 1869, he was registered in the Colony of Victoria. He held The present price of nitrous oxide and oxygen prevent a position on the resident sta ff of the Melbourne Hospital their frequent use. But there are a certain number of for a period of about eighteen months and worked under special cases in which nitrous oxide and oxygen may with Dr. J. Robertson, Dr. Motherwell, Dr. Laurence and Dr. advantage replace chloroform or ether. Cutts. From Melbourne he moved to Clunes, where he was Yours, etc., appointed Medical Officer of the local hospital from its 'in- GILBERT BROWN. ception. He held this position for three years. In 1874 he April 25, 1921, began private practice at Casterton in the western portion Adelaide. of the colony. During the course of 27 years he built up an extensive and valuable practice and endeared himself to a very large number of people by his kindliness, sympa- PRINCIPLES GOVERNING - MODERN MIDWIFERY thetic bearing, professional skill and tact. PRACTICE. In 1902 he returned to Melbourne and was soon appointed Medical Officer to the Railway Department. In this office Sir: The two obstetrical cases reported by Dr. McLorinan his knowledge and skill in ophthalmology stood him in good in The Medical Journal of Australia, April 9, are interesting stead. During the course of eight and a half years he and instructive and provide points for discussion. earned the respect, gratitude and admiration both of the In case (1) I would ask why, in face of the fact that departmental authorities and of their employees. In 1910 he the patient was obviously getting worse under treatment, retired from active work. His chief extra-professional as shown by increase of albumin, oedema, etc., that labour pastime was reading. His knowledge of literature is said to was not induced (when quinine and ol. ricint failed) by the have been profound. He leaves a widow, one son and - two more reliable methods of inserting bougies or packing, which daughters, whose grief must surely be lessened by the procedures would surely not have been as exhausting to the recognition that his long life was full of good deeds. patient as having Caesarian section performed after she had got much worse? In my opinion, if a patient with threatened eclampsia does A CONGRESS OF TROPICAL MEDICINE. not show any response to medical treatment within a reasonable time, induction of labour should be performed. The Fourth Congress of the Far Eastern Association of Case (2)raises the question of when the child in utero Tropical Medicine will be held at Weltevreden, Batavia, in

394 Tilt ; M1 DICAL JOURNAL QF AUSTRALIA. [May 7, 19121..

August, 1921, under the auspices of the Government of the Dutch East Indies. The Consul-General for the Netherlands has extended an invitation from his Government to medical Branch. APPOINTMENTS. men in the Commonwealth to participate in this Congress either by contributing papers or by taking part in the discussion. Further particulars can be obtained at the All Institutes or Medical Dispensaries Consulate-General for the Netherlands, Melbourne. Manchester Unity Independent Orde of Oddfellows. Ancient Order of Foresters. VICTORIA. Hibernian Australian Catholic Benefl Births, Marriages and Deaths. — Society. {Hon Sec., Medi- Grand United Order of Free Gardeners The charge for inserting advertisements of Births, Marriages and Deaths is 5s., which sum should be forwarded in money orders or stamps with cal Society Hall. Sons of Temperance. the notice, not later than the first post on Tuesday morning, in order to East Melbourne.) Order of St. Andrew. ensure insertion in the torrent issue. Australian Prudential Association Pro BIRTH. prietary, Limited. Mutual National Provident Club. BRYDON.—On April 14, 1921, at Armidale, New South National Provident Association. Wales, to Dr. and Mrs. A. G. Brydon, a son.

QUEENSLAND. DEATH. — Australian Natives' Association. (Hon. Sec., B.M.A. Brisbane United Friendly Society In• SMITH.—On April 12, 1921, at "Netralta," Rockley Road. Building, Adelaide statute. South Yarra, Charles Smith, M.D. (London), late of Cas Street, Brisbane) Stannary Hills Hospital. -terton, Victoria, aged 78 years.

SOUTH AUS- Contract TRAITA Practice Appointments al Medicai Appointments. Rentnark. Contract It is announced that Dr. C. G. Godfrey (B.M.A.) has been (Hon. Sec., 3 North Practice Appointments it South Australia. appointed a Member of the Police Medical Board of Vic- Terrace, Adelaide.) toria and an Inspector of places where the study of anatomy is carried out. The appointment of Dr. H. G. Howell (B.M.A.) as Gov- WESTERN AUS- ernment Medical Officer at Werris Creek, New South Wales, TRALIA. has been approved. (Hon. Sec., 6 Bank All Contract Practice Appointments in of New South Western Australia. Medical .Appointments Daunt, tic. Wales Chambers, St. George's Ter- For announcements of medical appointments vtoant, assistants, locum tenentes sought, etc., see "Advertiser," page azíii. race. Perth. Department of Defence, Melbourne: Medical Officer at Central Flying School, Laverton, Victoria. Department of the Navy: Medical Officers. NEW ZEALAND: Alfred Hospital, Melbourne: Medical Superintendent. WELLINGTON Royal North Shore Hospital of Sydney: Honorary Dermat- DIVISION. Friendly Society Lodges, Wellington, ologist. — New Zealand. Hospital for Sick Children, Brisbane: Honorary Ophthalm- (Hon. Sec., Wel- ologist. lington.)

Medical Appointments. Diary for the Month. IMPORTANT NOTICE. May 10.—Tas. Branch, B.M.A.. May 10.—N.S.W. Branch, Medical practitioners are requested not to apply for any B.M.A., Ethics Committee. May 11.—Melb. Prediatric Society (Vic.). appointment referred to in the following table, without having May 12.—Vic. Branch, first communicated with the Honorary Secretary of the Branch B.M.A., Council; Election of a- named in the first column, or with the Medical Secretary sentative on Representative Body. May 13.—N.S.W. Branch, B.M.A., of the British Medical Association, 429 Strand, London, W.C.. Clinical. May 13.—Q. Branch, B.M.A., Council. May 13.—S. Aust. Branch, B.M.A., Council. Branch. APPOINTMENTS. May 17.—N.S.W. Branch, B.M.A.; Executive and Finance Committee. Australian Natives' Association. May 17.—Illawarra Suburbs Med. Assoc. (N.S.W.). May 18.—W. Aust. Branch, B.M.A.. Ashfleld and District Friendly So- cieties' Dispensary. May 20.—Eastern Suburbs Med. Assoc. (N.S.W.). May 24.—N.S.W. Branch, .B.M.A.; Medical Politics Commit- Balmain United Friendly Societies' Dis- NEW SOUTH pensary. tee; Organization and Science Committee. May 25.—Vic. Branch, B.M.A., Council. WALES. Friendly Society Lodges at Casino. May 26.—S. Aust. Branch, B.M.A.. " Leichhardt and Petersham Dispensary. (Hon. Sec., 30-34 Manchester Unity Oddfellows' Medical Elizabeth Street, Institute, Elizabeth Street, Sydney. EDITORIAL NOTICES. Sydney.) Marrickville United Friendly Societies' Dispensary. Manuscripts forwarded to the office of this journal cannot minder any circumstances be returned. North Sydney United Friendly Societies. Original articles forwarded for publication are understood to be offered People's Prudential Benefit Society. to The Medical Journal of Australia alone, unless the contrary be stated. Phcenix Mutual Provident Society. All communications should be addressed to "The Editor," The Medical Journal of Australia, B.M.A Building, 30-34 Elisabeth Street, Sydney. (Telephone : B. 4635. ) THE MEDICAL JOURNAL OF AUSTRALIA. VOL. I.-8T1I YEAR. SYDNEY: SATURDAY, MAY 14, 1921. No. 20.

An Address.' many medical men are busy educating school teachers and members of institutions to assist in the dissemina- By Arthur T. White, C.M.G., V.D., L. & L.M.R.C.P., tion of literature regarding the many evils due to L. R.C.S., L.A.H., louring President of the Western Australian Branch of the the disease. With our present knowledge of syphilis British Medical Association. it ought not to be long before a decided check is put on the spread of the disease and by skilful treatment In taking office as President last year, I emphasized patients might be allowed to marry after a proper the importance of certain diseases, especially malaria, course of injections, etc.. bilharziosis and venereal diseases, which had been We all know what misery is caused by the fact that brought back by returned soldiers and which were by many of the laiety the disease is supposed to be liable to spread throughout the State. However, with incurable ; melancholia, drunkenness or suicide is a the present system of notification and means adopted frequent result. by the health authorities for combating these diseases, Now that free clinics have been opened at our it is hoped that before long a considerable decrease public hospitals, there is no necessity for concealment in the numbers will eventuate. I now wish to touch of the disease. It means, of course, that every tax- briefly on these and other diseases which are of vital payer is paying for the misdemeanours of others, but importance to the public and like the poor "are in the interests of the community this ought not to always with us." be considered. The treatment of malaria seems to be narrowing I will just refer to tuberculosis which claims so itself down to quinine administered either by the many victims each year. It is a subject for the con- mouth, intra-venously or intra-muscularly. sideration of every practitioner and should not be left Liver troubles with extensive destruction of liver to the specialist only. By the endeavours of the tissue sometimes occur through quinine making its child welfare movement, by preventing young men way from the alimentary canal. Arseno-benzol has and women from being driven to hard work beyond not been followed by the success that was anticipated their powers and by protecting the adult worker from In the vast majority of returned soldiers the benign the more evil consequences of his labour by secur- tertian parasite has been found ; also in the majority ing proper conditions in the mines, workshops and of recurrences. factories, a large percentage of tubercular cases might This year a perfect plague of mosquitoes has been not develope. experienced and every endeavour should be made to This work not only concerns, medical officers of exterminate the pest. Fortunately the less danger- health, but should be supported by every medical ous variety has been most in evidence, but should man in his endeavour to minimize the evils of the malaria once get a footing, a vast amount of suffer- disease. The economic aspect must be considered. ing would ensue. What are the chances that a child born and reared Bilharziosis, as you are aware, is giving our pro- in a tuberculous family will not acquire the disease fession much anxiety and vigorous steps are being which, according to a considerable majority of taken to minimize the ravages of this disease. With authorities, is definitely communicable °? Either the the treatment by tartar emetic it is hoped to eradi- child should be removed from its infected relatives cate the disease completely. or the latter should be removed from it. Many patients present themselves suffering . from Sanatoriums are often inadequate to deal with all antemia, debility, loss of weight, etc., without any the patients and those in the advanced and most dan- definite reasons. Bilharziosis must not be lost sight gerous stages remain at home to infect the • children. of as a possible cause, particularly if the patient be Undoubtedly village settlements would be beneficial, a returned soldier. but the cost would be enormous and the difficulty of The cystoscope, of course, lends valuable aid to getting patients to remain in them would be great. the discovery of lesions. The recent war has revealed the number of physi- You are all aware of the ravages venereal diseases cally defective men who were unfit for active service. caused in the ranks of the Army and the evil effects These defects could not have been due to poverty of transmission will be felt for many years in Aus- in such a country as this; therefore they are in most tralia in the form of invalidism and sterility. It is, cases preventible. therefore, desirable to assist in every possible way the In order to build up a strong race, children should stamping out of the scourge. be thoroughly inspected and all defects, such as Many women will doubtless present themselves for adenoids, enlarged tonsils, defective teeth, errors in treatment suffering from ovarian and uterine diseases, sight, discharge from ears, should be treated. One which you will be able to trace to gonorrhoea or most important matter, the proper feeding of infants, syphilis and no doubt a great number of syphilitic must be recognized. Too much reliance is placed by children will be added to the burden of the com- mothers now on artificial foods, which save the neces- munity. sity of nursing as Nature intended. Every endeavour should be made to educate the Advice is often sought by patients as to the effect public as to the dangerous nature of the disease and of physical training on their children and their fear Read at the Annual Meeting of the Western Australian Brunch of the British Medical Association on March 20, 1921. of dilatation of the heart occurring. This condition 396 THE MEDICAL JOURNAL OF AUSTRALIA. [May 14, 1921.

is more likely to be brought about by want of regular The sacrifice of time your country asks of you exercise than by constant work and we know that is not great and the time spent could be made both the healthy individual is not injured in any way useful 'and recreative. by hard muscular work, provided that an excessive It is impossible to train a man in a short time and pace is not adopted. Medical men are largely respon- no war can be carried on successfully without a re- sible for keeping the attention of the public and liable and complete medical service. governing bodies to these causes of physical defects The regimental medical officer is an important in- and for insisting that proper steps be taken for their. prevention. dividual in war time, his duties requiring a knowledge of water supplies, hygiene and sanitation, camp I would like to refer to specialists. Owing to the inspections, as well as billets, huts, ablution places, rapid expansion of knowledge within the last few kitchens, food, clothing, training, of stretcher-bearers, years, specialism is becoming the feature of the day as well as his medical work and prevention of sick- and it must be admitted that no one man can acquire ness and general care of men in camp and on the expert knowledge in all cases that present march. Such duties can only be learnt in times of themselves in the daily round of a general practi- peace and not during the excitement and bustle of tioner. Ifbelieve that a man who feels that he has a active service. special talent for a particular branch of the art, With vaccination and inoculation men must be up would be wise in selecting a special subject for study after he has been through the multifarious work of a to date and throw their whole soul into the work in general practitioner. order to be a credit to themselves and the profession. You all remember the splendid work of the teams The place of the radiologist has come to stay and in regard to blood transfusion. Special study should almost every day one finds the necessity for his work be made of this means of prolonging life. to assist diagnosis and help minimize the pain which used so often to be caused by examination of frac- In conclusion I would ask the members to take a tures without an anwsthetic. lively and earnest interest in all matters concerning What an enormous amount of suffering has been the welfare of the Branch and particularly to watch spared by the radiologist in locating foreign bodies over the difficulties that at times assail the country during and since the war ! Without his assistance it members, who often think that because they are far would be impossible to locate many bullets and frag- away from the centre, no interest whatever is taken ments of shell and the probe would often have to in their movements. wait for the development of a suppurating track to If a typed copy of each lecture with discussions indicate their position. could be sent to each country member it would mater!- Orthopa dic surgery has been given a great impetus ally aid him in keeping in touch with the centre. The lately and a wide field is open for those who seek to country member is often quite ignorant of the pro- restore the functions of injured muscles and nerves. ceedings at meetings and unless he sees extracts in Specialists in this branch ought to have a busy time the journal, remains ignorant of many important in the future. matters which affect his welfare. Judging from the results at the Base Hospital, many I wish to thank you all for giving me such a patient patients who would have been considered hopeless in hearing and express my gratification at having been the past, are now fitted for work and able to take honoured by your appointing me President for the their places in the ranks of useful citizens. I under- last year. stand that our public hospitals are woefully deficient It has been a great pleasure to me to have had ill plant and every endeavour should be made to have your confidence, but I am afraid I have not always as complete an outfit as possible in order to give the carried out the duties successfully. best results and due credit to the specialists concerned. Last subject, but not least. Let me say a few words THE TREATMENT OF ACUTE ANTERIOR on the military medical service. In view of the fact POLIOMYELITIS. that a new organization for the military medical service is shortly to come into operation, I would strongly By Wilfred Vickers, D.8.O., M.B., Ch.M. (8yd.), urge all young medical men to undergo a course of Honorary Assistant Surgeon, Honorary Director of the Dc- training in order to fit themselves for any future partment of Massage and Medical Gymnastics, emergency. Royal Alexandra Hospital for Children, Sydney. As most of you are aware, field ambulances are These few notes are written in the hope that a few officered by medical men and the whole success of practical details in the treatment of infantile paralysis these valuable units depends on the efficiency of the will be of service at the • present time. If I merely officers. Therefore, it is necessary that all those who reproduce the ideas of Robert Jones and others, my intend to join, should attend camps of training and excuse is that my experience at the Royal Alexandra nalify for the various duties to be performed. Hospital for Children shows that the principles You all know how few trained medical officers took stated by them are not universally known. the field in the .last war and with what signal success The main factor in the treatment of infantile their work was credited. Remember this was only paralysis is relaxation of the affected muscles. In possible through their pre-war training and the num- the older method of treatment, before splinting was bers who had any experience were very few. How- suggested, rest in bed in the recumbent position was ever, I hope in the future that many will take ad- thought to be sufficient. I think that the best argu- vantage of the training and thereby prove their util- ment against that method of treatment is obtained ity, should their services be required. from a study of the muscles which most frequently May 14, 1921.] THE MEDICAI,, JOURNAL. OF AUSTRALIA. 397

remain paralysed after it has been applied, viz., the unless the external rotators are affected more than dorsi-flexors and invertors of the foot, the external the internal. In that ease the splint can be made rotators of the thigh, the abductors and internal with the piece for the forearm to bend upwards at rotators of the arm. In the ordinary position of rest an angle of 45° with the arm-piece. With this splint in bed these muscles are all stretched. Might not flexion and extension of the forearm and wrist and the statement that these muscles are the most fre- pronation and supination can be controlled as re- quently attacked and the most difficult to cure be to quired and more or less allowed as recovery takes some extent a fallacy born of the old inadequate place. method of treatment 2 However, with adequate splint- After all pain and tenderness are gone from the ing to prevent stretching of these muscles, we see muscles, the splint can be removed and an attempt fewer of these deformities to-day. made at minimal movement. Special care must be taken that no stretching of affected muscles is allowed. A.—Trunk Muscles. As a. The effect of gravity must be completely eliminated rule, complete rest in bed, with the back in these early movements and the limb must be placed slightly arched, is sufficient. in such a position that the muscle is only called upon

B. — Muscles of the Lower Limb. to act through a very small angle. For example, for ln complete paralysis of the lower limb, a back the deltoid the patient should be lying on his back, splint with a small pad behind the knee, to keep it with the arm on some smooth surface (a polished slightly flexed, a foot-piece to keep the foot at right board is the best). The arm is lowered about 10° angles and a cross-piece to prevent rotation of the and the patient makes an effort to pull the arm back. whole limb will meet all the indications. This needs Should this be impossible, even with assistance, the • to be varied as certain groups of muscles recover. splint is re-applied and another attempt made three Frequently it is found that there is early recovery of or four days later. Another method'that can be used the plantar-flexors of the foot and sometimes these in the case of the extensors of the hand is to hold the muscles are acting strongly. In these cases I have hand in the position of complete dorsi-flexion and to found the ordinary back-splint with foot-piece quite ask the patient to try to retain it there when the useless unless constantly supervised by a trained per- support is removed. The muscles will be felt to son. In these cases I use adhesive plaster, brought contract. from one side of the leg, just below the knee, under As movement returns, the muscle must not be the sole over the heads of the metatarsal bones and fatigued or stretched. Later, massage can be used up on the other side of the leg and secured by two with the gentle movements suggested ; but I do not cross-pieces so arranged as to produce no constriction think that electricity does any good. It is certain of the leg. In other cases a well-fitting plaster of that both do harm if applied too early. Paris casing or celluloid splint is to be preferred. The time when splints should be discarded is diffi- When the child can walk, and before the boot and cult to fix ; but I consider that it is better to retain iron stage, a walking plaster is often useful. Inver- them until the muscle can do its work against the sion and eversion, according to the necessity, can effect of gravity. be applied. In very severe cases I think that the splints should Coming to the thigh, the quadriceps and hamstrings be retained for at least a year before the surgeon con- have to be treated. The quadriceps is one of the cludes that no more recovery will take place. I have muscles that frequently remain weak. Here again we known cases of paralysis of the quadriceps of many have an example of a stretched muscle, because, after months' standing, in which a considerable amount of a few weeks, the patient is often allowed to sit up in dower has been recovered when a calliper has been a chair with the knees bent. After the back-splint provided. I have had cases of paralysis of the an- stage a calliper is the best treatment for these groups terior tibial group, producing a marked equinus, in of muscles. which recovery of the power to lift the foot followed The external and internal rotators, flexors, etc., of after tenotomy of the tendo Achilles and over-correc- the thigh can all be controlled by these means and tion of the foot for a few months, notwithstanding they should be carefully watched, in order that re- the fact that the acute attack had occurred three or laxation may be provided for them. four years previously.

C.— Upper Limb. In the stage of complete paralysis, the position of A NEW TEST OF RENAL EFFICIENCY. abduction to a right angle at the shoulder, with the A PRELIMINARY REPORT ON THE RESULTS OF APPLICATION OF muscles of arm, forearm and hand in the mid-position THE UREA CONCENTRATION TEST (MACLEAN) TO is satisfactory. Care should be taken to prevent CASES OF URINARY SURGERY. stretching of the internal rotators of the arm, which By Robert J. Silverton, M.B., Ch.M. (Syd.), F.R.C.S. (Ed.), is most likely to occur when the arms are merely Sydney. pinned to the pillow above the head. The "aeroplane" splint fulfils all requirements. It consists of a body- In 1919 Hugh McLean published a lengthy report piece and a bar at a right angle, the angle fitting into on war nephritis, (1) in which regarding the ques- the axilla. The bar is jointed at the elbow and ends tion of prognosis and treatment, he emphasized the in an expanded piece that can be used to flex or ex- fact that clinical signs are not sufficiently early guides tend the wrist and fingers and thumb. In this con- and moreover are often unsure ones. Cases of acute nexion I think the mid-position, i.e., the forearm on nephritis which do not completely resolve but go on the same level as the shoulder, is the most suitable, to a chronic course, fall as a rule into either the 398 THE MEDICAL JOURNAL OF AUSTRALIA. [May 14, 1921.. azot emic or hydr emic group according to whether this test in surgical urological cases. I could dis- there is nitrogen or chloride retention in the blood. cover no report on the results of this test in surgical These types correspond more or less closely to chronic cases, but considered that as a modification of the interstitial and chronic parenchymatous nephritis re- valuable but inconvenient French test above described spectively. In the azotamic (interstitial) type it was it should prove of distinct use in urinary surgery. found that when urea is taken by mouth in large The type of nephritis occurring in kidney destruc- amount, the kidneys fail to concentrate it in the urine tion due to surgical diseases of the organs themselves to the same degree as healthy organs. or to the back pressure of lower urinary tract ob- The basic idea of the test is not new, for a similar struction is almost always azotwmic. The hydreemic but altogether impracticable test has been used for element, characterized by oedema is very rarely seen. some years by the French in the form of what they Therefore the urea concentration method is a test term "the search for the maximum concentration of of excretion eminently suitable to surgical urinary urea. cases. In order to discover the highest point to which a On applying the test first of all to healthy people healthy man could concentrate urea in the urine, I found that the reading usually rose to the neigh- Ambard originally used the plan of putting the bourhood of 3% during the second hour after the patient on a salt-free diet, restricting fluids a good ingestion of the urea. In disease the reading was deal and administering urea by mouth in repeated lowered in proportion to the extent of renal damage. fractional doses. He discovered that this was not The lowest reading obtained was 0.65%. This was a convenient method. Later on (in 1913) working in the case of a man whose kidneys proved at autopsy with Legueu and Chabanier(2) he evolved a diet con- to be very extensively destroyed. The cause was back sisting of the coagulum of milk, freed from whey and pressure due to enlarged prostate. flavoured with sugar. On this diet (highly nitro- In applying the test certain precautions are abso- genous and salt-free) the subject suffered from no lutely necessary. These are not mentioned by Mac- urgent thirst and on about the third day the maxi- Lean, but as they are very important I shall describe mum concentration of urea was reached. This point them. The reading may be seriously influenced by was found to be 5% to 5.6% in healthy individuals; the composition of neighbouring meals and even when the kidneys were diseased the maximum point more seriously should the patient ingest any fluids was lowered. The test is a very valuable one in or solids before or during the test. In all the cases I itself, but is of course entirely unsuited for practice. tested a fixed routine was adopted in order to keep The French themselves admit this and prefer in the method as uniformly accurate as possible. A practice to measure the blood urea or work out Am- breakfast of 230 c.cm. (8 ounces) of tea and one bard 's ureo-secretory constant. round— MacLean has, however, studied the variations in of buttered toast was given at 8 a.m.. At the concentration of urea in the urine immediately 10 a.m. the 15 grammes of urea dissolved in 100 c.cm. after the ingestion of a known weight of this sub- of water were taken. Except this nothing was eaten stance and has evolved what he terms the "new urea or drunk from breakfast until 12 noon, that is until concentration test which may be considered as a after the collection of the second hour's urine had modification of the French test, but infinitely more been made. In this manner all disturbing influences convenient in practice. Fifteen grammes of urea are are avoided and this is the routine I would recom- given by mouth, dissolved in 100 c.cm. of water to mend to surgeons who may desire to employ the test. which are added a few drops of tincture of orange. Forty-four cases of various types of prostatic ob- The urea percentage in the urine quickly rises in struction were submitted to the test, as well as four health, but since during the first hour the reading cases of renal tuberculosis, one case of calculons does not reach its maximum point on account of pyonephrosis and two cases of urethral stricture. The diruesis caused by the urea, only the urine of the results were briefly as follows : second hour is tested. The first hour's specimen is (1) In Urethral Obstruction. discarded. In this group the value of the test was found, un- MacLean states that a concentration of 2% or over fortunately, to be definitely limited. Catheter collec- may be taken as evidence of efficient kidneys. A con- tion of the urine is of course impossible and the centration of 1.5% indicates moderately efficient kid- occasional presence of residual urine in the bladder neys, while 1% or less means very inefficient organs. falsifies the readings by lowering them. The presence The test was applied extensively by MacLean in of residual urine in stricture is denied by some, but medical cases and found to be of the highest value in . there is no doubt that it is occasionally present, even the prognosis of the azotEemic type. While the read- in large amount. ings were distinctly lowered in the latter group, they were unaffected in the hydrEemic (chloride retention) (2) In Prostatic Obstruction. type. This applies to the chronic stage; during acute The collection was made by a catheter in the blad- exacerbations' the readings were decreased in both der. The test was definitely proved to be of value by types. Of course there are mixed types of chronic noting the post-operative histories of the patients, nephritis in which both the chloride output and the and in the fatal cases by microscopic and macroscopic urea concentration are lowered. examination of the kidneys removed at autopsy. While working during the first part of 1920 as All types of prostatic case were studied, just as senior house surgeon to the St. Peter's Hospital for they came up for diagnosis and yet nearly one-half Urinary Surgery, London, I was permitted to apply gave readings of 2% or over. Nearly all the latter group May 14, 1921.] THE MEDICAL JOURNAL OF AUSTRALIA. 399

of patients were subjected to one-stage prostatectomy Reports of eases. with happy results. The fad, then, of performing a two- SOME ILLUSTRATIVE CASES OF DUCTLESS GLANDS stage operation in all prostatic cases, is not justified by THERAPY IN THE INSANE.' necessity. The results of my investigations tend to show that with readings down to 1.7%, the operation By James Bentley, M.C., M.B., B.S. (Edinburgh), Assistant Medical Officer, Hospital for Insane, Claremont, may be completed in one stage. All these remarks, of Western Australia. course, only concern the kidney risks of operation; In publishing the following cases, which have been treated these are the greatest risks, but it must not be for- by ductless glands, I do so chiefly with the object of stimu- gotten that they are not the only ones. Where the lating others to investigate this line of treatment. The readings are between 1%o and 1.7% preliminary cys- first three cases are cases of dementia prcecox. Although Case III. bears some close similarity to acute melancholia, tostomy is advisable, but when the reading is below on the whole it is considered to be a case of dementia prcecox. 1% even a preliminary cystostomy must not be risked The treatment of these cases was encouraged by the work of Dercum and Ellis, who examined post mortem eight at the outset. In such severe cases eareful catheter patients the subjects of dementia prcecox. All these patients drainage should precede the eystostomy, the latter had died from tuberculosis. In seven the thyreoid was intervention being withheld until the functional level under weight. There were variations in the adrenals. They state that their findings are in keeping with the inference becomes moderately increased. that anomalies exist in the ductless glands in dementia prcecox. (3) In Renal Diseases. Generally speaking, there are two groups of ductless The collection is made by catheterizing the ureter glands, one of which are accelerators, which consist of the thyreoid, pituitary, adrenals and reproductive glands. The of the less diseased or presumably healthy side. second group are retarders and comprise chiefly the pan- Rarely both sides have to be catheterized. Before creas, parathyreoid and possibly the thymus glands. The chief work in this institution has been done with the nephrectomy is allowable the test should give a read- accelerator group, as the following cases show; but it is ing of 2% (preferably more) from the opposite kid- now intended to try the retarding group in maniacal cases. Hey ; the latter organ should be cytologically and bac- Hormotone. teriologically free from disease. CASE I.—B.L.A., aged 28, was admitted on May 31, 1919. . The . new test proved to be quite reliable at this The certificate set out that he would not speak, smiled in- anely, stared fixedly into space, at times refused food, but level, the truth of its indications being amply con- would give no reason, showed little sign of intelligence, seemed firmed by operations in the renal cases tested. fearfully depressed about something, behaved peculiarly. He had a similar attack about six years ago, but got quickly My conclusion is that the urea concentration test better. He was a well developed man; his height was 177.8 may , be - considered as a valuable addition to the cm. and his _ weight 64.4 kilograms. His organs were au urologist's armamentarium. Its value in • surgical healthy and his reflexes were normal. On admission he took food well, lay listlessly in bed and urinary cases is even more general than in the "medi- paid no attention to his surroundings. He would not reply cal nephritides, as the latter are not always of the to questions, although he showed that he understood what was said to him by protruding his tongue when asked to azotamic type. Tests of retention (e.g., blood urea) do so. On June 15, 1919, he was in a cataleptic condition; still hold their place, of course, and are - necessary in he resisted his limbs being moved and if they were placed stricture cases, while advisable as a check on tests in any particular position, he would hold them in that position for a long interval. Later the catalepsy disappeared, of excretion in prostatic cases. In renal diseases, but he had not spoken since admission. He refused food tests of retention are of very doubtful value on ac- at times and required to be kept in bed continually, because he was so dull. count of the phenomenon of compensatory hyper- On September 9, 1919, he was put on hormotone and ten trophy on the undiseased side. days afterwards he spoke a little for the first time since admission and expressed the delusion that his bowels were As a test of excretion, the new urea test does not blocked. displace the phenol-sulphonephthalein test, which On September 27, 1919, he was conversing freely and was gives more finely graduated estimations of renal dam- up and about and a month later proved to be an extremely useful worker in the hospital, but was still slightly dull. age. Certain fallacies, however, which vitiate the re- On December 29, 1919, he was discharged as recovered. sults of the phthalein test (catheter blocking, extra His father reports that he has kept well and worked on catheter leakage in renal cases and the presence of the farm since his discharge, but that he is affected by blood) do not aff the heat and he is rather reticent; otherwise he can notice ect the result of the new urea test, nothing the matter with him. He is in a somewhat similar as it is purely a test of concentration. condition to that in which he was previous to admission. I desire to acknowledge my great indebtedness to He is still taking hormotone three times a day. CASE II.—F.H., aged 44, was admitted on December 2, 1919. the surgeons under whom I worked at the St. Peter 's The medical certificate sets out that he was very depressed, Hospital, for the opportunities they gave me of pur- restless and troublesome and at times had to be restrained. He heard voices which told him he was bad morally. He suing this investigation of their cases and for their saw visions of insects and animals crawling about and had encouragement while I was engaged on the work. delusions that he was suffering from leprosy. Except for a systolic murmur in the mitral area, his organs were healthy. References. On admission he was very depressed and miserable and (1) H. MacLean: "Albuminuria and War Nephritis," Med. it was difficult to get him to answer questions; he would Research Comm. Report, London, 1919. only reply in monosyllables. He was very confused and at night he was restless and slept badly. He heard a voice (2) L. Ambard: "Physiologie normale et pathologique des reins," Paris, 1920. 1 Read at a Meeting of the Western Australian Branch of the British Metjicai Association on Mareh 20, 1921, 400 THE MEDICAL JOURNAL OF AUSTRALIA. [May 14, 1921.

and said that the same voice talked to him continually, but There was a large, puffy swelling round his neck, like a he did not know tò whom it belonged. A week later he was collar, except at the centre, in front and behind. Mentally in a state of catalepsy. He took no notice of his surround- he was dull, stupid and listless. He did not speak, smile or ings, resisted having his limbs moved and held his limbs in cry, but lay quietly in bed. At first he was put on thyreoid any position in which they were placed for a considerable extract, but did not make very much headway. About two time. He would not speak, refused food at times and had months after admission he was put on hormotone and he to be fed. then began to improve mentally and physically. On December 20, 1919, he was put on hormotone and a On April 22, 1917, he spoke more distinctly, ran about week later the cataleptic condition had disappeared; but he and played and showed considerable interest in his sur- still heard voices. roundings. He looked forward eagerly to picture shows. On December 30, 1919, he conversed freely and took food On March 3, 1919, hormotone was unobtainable. He was well. therefore put on thyreoid extract, when he deteriorated men- On January 20, 1920, he was considerably improved, talked tally and physically; he became very dull and the collar freely, ate well and worked in the ward. At this time the of fat returned. Later on, when hormotone was procurable, hormotone was reduced to one tablet thrice daily, as he was he again made considerable improvement, both mentally and becoming rather excitable. physically. Pecently he has been put on thyreoid and again He was discharged as re'covered on May 2G, 1920. became (lull and the teacher noticed that he would not His wife reports that he is his old self again since his play with toys that required any mental effort. His thyreoid discharge, but he has not taken any hormotone, as his wife gland also enlarged. Now he is on hormotone. At the did not think there was any necessity to continue it. present time his mental age is about five years. CASE III.-E.S., aged 35, was admitted on July 7, 1916. On This case is a very peculiar one, inasmuch as, according admission he was very depressed and would not speak. He to our accepted knowledge, he should improve on thyreoid, understood what was said to him, but would only nod and whereas this was not the case; he only improved under shake his head in answer to questions. He did not actively hormotone. resist examination, but was inclined to negativism. He took In the following case hormotone was given, but the patient his food well and was clean in his habits. He remained in deteriorated mentally under that line of treatment. this negativistic state, rarely speaking, apparently not taking CASE VI.-E.H.B., aged 42, years, was admitted on October much interest in his surroundings; when he spoke he only 9, 1915. The certificate set forth that she was an imbecilic spoke in a whisper and said: "It's awful." cretin, unable to walk or talk. S'he has been under thyreoid On May 25, 1920, he was put on hormotone and about treatment for some considerable time with considerable four months later he seemed somewhat brighter and was benefit; but owing to bad seasons her mother was unable eating better. In January of this year he began to speak to continue it. freely to his brother and initiated conversation, which he On admission her weight was 12.25 kilograms. She was had not previously done since admission. About a month unable to walk, stand or talk and was accustomed to being later he spoke freely to me in reply to questions and in fed with a feeding bottle. Her hair was coarse and inclined reply to a question as to how he was said: "Not bad." Re- to grow down her forehead; her head was square and her cently he has been reading the papers and entered into eyebrows were overhanging. Her nose was flat and her discussion with other patients in the ward. He is now tongue protruding. There was a collar of fat on both sides doing ward work every day and looks as if he would soon of the neck. The abdomen was protruding and umbilicus be fit for discharge? prominent. Her hands and feet were short and broad. On CASE IV.-J.P., aged 45, was admitted on November 19, admission she was unable to speak, was dull and cried imme- 1919. A case of acute melancholia. The medical certificates diately she was touched by strangers. She was put on thy- set forth that he thought that he was being chased by blacks reoid exttact and a month later she took notice of play- and others. He ran away into the bush, thinking he. was things, laughed and smiled. A year after admission she being pursued. With regard to his physical condition, there made some attempts to speak and walked better. Her weight was nothing to note. was 14.5 kilograms. She now talks a little and asks *ques- On admission he had hallucinations of sight; he said that tions. Her mental age is about four years. he saw blacks and others chasing him and that he galloped his horse for two miles until the horse became exhausted, Pineal Gland. that he was going to drown himself, because if these people Pineal is generally regarded as being depressant in got him, they were going to torture him, that the reason grown-up people. For this reason it was prescribed in the that he was chased was because there was an enmity be- following two cases of acute mania with somewhat startling tween him and one of his pursuers. He was very depressed results, as, in place of acting as a depressant, it had the and miserable and he slept badly. Later he thought that very opposite effect. I intend to try this treatment on some two years previously he had been poisoned by a woman cases of melancholia. and that the poison was now going through his system. CASE VII.-W.F., aged 53 years, was admitted on March On May 7, 1920, he was still very worried and in a general 26, 1919, suffering from senile acute mania. On admission state of unhappiness; he felt at times that he would like he was incoherent in speech; his memory was defective. to destroy himself by stabbing himself or taking poison or At times he sang and whistled and was noisy at night. He jumping off something. He still retained his delusions in thought that he could send wireless messages to England regard to the poisoning. by tapping the bed. He had no idea of time or place. He On June 1, 1920, he was put on hormotone and on Sep- remained in this acute maniacal state until August 18, 1919, tember 20, 1920, he was much brighter and working well in when he was put on pineal gland, one tablet three times a the ward. He said he did not now feel worried and had no day, each tablet corresponding to 0.03 grm. of the fresh gland. thoughts of suicide. At this time he was detached and In a few days he was more excited than he had been previ- worked on the farm for about two months. At the end of ously, becoming quite unmanageable. Our supplies of pineal this time he was discharged as recovered. gland became exhausted at the end of about a month and CASE V.-J.J.Q., aged 11 years, was admitted on June 28, so the treatment was discontinued, when he settled down 1916. A case of sporadic cretinism. On admission his cer- to his former state. tificate set forth that he would not answer questions and On February 18, 1920, a fresh supply of pineal gland was could only speak in monosyllables; he was unable to dis- obtained. The treatment was restarted, when he again be- tinguish between "yes" and "no"; he could scarcely walk; came quite unmanageable and most restless than previ- he was wet and dirty in his habits; he was originally a ously. At the end of a fortnight this treatment was stopped. hydrocephalic. On physical examination he presented all On May 25, 1920, he settled down and worked on the farm the symptoms of cretinism. His forehead was overhanging and was discharged on November 1, 1920, as recovered. and wrinkled, his eyes sunken, bridge of nose flat, lower lip I do not in any way attribute this patient's recovery to the protruding, hair coarse and his scalp was covered with scales pineal gland treatment, but simply quote the case as show- of epidermis. His skin was thick and coarse and of a dusky ing the excitant action from this gland. yellow colour; his abdomen was prominent and umbilicus CASE VIII.-G.A.M., aged 53 years, was admitted on Octo- projecting. His back showed a deep furrow over the spine. ber 11, 1919, suffering from senile acute mania. On admission he was restless, talkative, incoherent and would not The patient answered questione freely at the meeting, stay in bed. He was exalted and continually talking in a May 14, 1921.] THE MEDICAL JOURNAL' OF AUSTRALIA. 401 loud voice and in an extravagant manner. He remained in inoculation small-pox 'gives 'a protection which is by any this state until September 27, 1920, when he was put on means absolute; indeed, the protection does not seriously pineal gland. He was appreciably more restless. He -decor- differ from that given by vaccination. ated himself with grass, which he had not previously done, The value of vaccination, in its protective power and its and hoarded rubbish. This was continued for about a month, freedom from risk, is dealt with. The statistics that are when he was taken off this treatment. quoted in this section, are not drawn to any great extent On January 7, 1921. he was again put on pineal gland, from the tropics, but rather from European sources. three tablets a day, when he again become more restless A large amount of information is given about the origin and almost unmanageable. This treatment was discontinued. of the vaccine virus and the best conditions under which it These two cases tend to show that pineal gland substance can be produced by passing small-pox virus through bovines. excites the cerebrum and on this account I intend to try The technique of the vaccination operation in human it in cases of senile melancholia. beings and in bovines, the preservation and ' carriage of These cases are not the only ones treated by means of the lymph in the tropics, the selection of a site for a vaccina- ductless glands. Not all the cases have been successful; tion institute, with a discussion of the effects of the meteoro- neither are all the successes included. For example, no im- logical conditions as they affect lymph production, are set provement was shown by two cases of senile acute melan- out in all practical detail. cholia and some old cases of dementia praecox showed no im- In reference to the preservation of lymph, much informa- provement whatever. tion is given as to the relative keeping qualities of glycer- This line of treatment Was considerably interfered with Inized and lanolinized lymph, from which there can be no during the war period, as during portion of that time sup- doubt that the lanolinized lymph is very much more suit- plies were unobtainable. At the same time, it seems to have able for tropical use. This seems to bear on small-pox vac- opened up a new field in the treatment of mental diseases, cination in Australia, where the vaccine lymph is supplied which I hope others will assist in investigating. from a central institute in the southern part of the con- e tinent. This institute is a three weeks' journey from some of the remote districts, so that it is extremely likely that the lymph will become impotent if any failure in the cool Reviews. storage arrangements occurs during transit. This is a VACCINATION IN THE TROPICS, matter which should be considered very carefully by those in charge of the Commonwealth Serum Institute. The duration of potency of vaccine lymph under condi- "Vaccination in the Tropics," by W. G. King, C.I.E., is a small volume' written by an eminently practical individual. tions of tropical heat and local conditions of transport is discussed in detail and in an appendix a short account is It ought to be of immense usefulness to those engaged in given of Noguchi's method of making vaccine lymph in the the making of vaccine lymph. testicles of rabbits. This section, however, is not very good, ' On the literary side the book is rather weak. The author as the author himself has not employed the method. shows a fondness for the use of the 'long sentence, -although We consider that this hook should be in the hands of all he has not by any means acquired dexterity in its use. His those engaged in vaccine lymph production, either within syntax in certain parts of the book is very bad; this is aptly or without the tropics. illustrated, for example, on page 26: "This is far below yields in temperate climates with European breeds." On page 28: "Once introduced into an institute, its eradication, may be- PRACTICAL .NURSING. come a difficult matter with the celerity desirable."' A'''And on page 64: "As a result of continued transfers from rabbit to "Theory and Practice of Nursing," by Sister M. A. Gullan, rabbit of the strain." of Saint Thomas Hospital, London, should be of estimable Dealing in detail with the scope of the book, we find in value to young women undergoing training and also useful Section I. descriptions of the different types of small-pox as a reference to those who have become nurses.' The book that have been observed, the mortality rates associated with is well arranged, each chapter comprising a complete survey these different types, the variations in mortality in families of the various subjects which a nurse must know. Inter- and races and also the differentiation of the mild type of leaved at frequent intervals are blank leaves for additional small-pox from varicella. notes and data, which should encourage the permanent re- In this section a reference is given to the work of Force cording of much which is learnt in the daily routine and Beckwith, who showed that an intradermal inoculation of the ward work and later forgotten. into the sensitized rabbit of the contents of a vesicle in a From the comprehensive title of this book, the reader doubtful case, gives a reaction if the case is- one of mild would expect to find adequate treatment of the subject of small-pox, but none if it is varicella. surgical nursing. A chapter on surgical bacteriology and A short sketch of the work of the King Vaccine Labora- methods of sterilization alone comprises what is strictly sur- tory is also given. It is shown that, owing to systematic gical. No guidance is given as to the dressing of wounds, vaccination, 572,000 odd lives were saved in the decade 1892- no mention is made of the various complications of wounds. 1902, at the small cost, of 2,410,000 rupees. It is estimated Nothing is said of post-operative nursing, other than that that the expense that would have been entailed by the ill- of general nursing. ness obviated in this way would have amounted to no less The chapter on enemata is especially worthy of mention, than 32,232,000 rupees, although no consideration is included being well arranged. The purpose of the various enemata in this account for the actual value of the lives that would commonly in use is clearly indicated. The nutrient enemata have been lost. The cost is computed on the cost cf food of milk, eggs, etc., are rightly set aside in favour of the for the sufferers during illness, the cost of funeral and more useful one of glucose in saline solution. We note with funeral ceremonies and the loss of wages. The actual saving regret that the quinine enema finds no place in this other- was evidently much greater. Had such a number of lives wise complete chapter. The description of the normal pulse been saved by the activity of our trans-Pacific cousins. and its variations in disease is exceptionally good. as is that we cannot but think that it would have been very much dealing with baths and sponging. The book closes with a more widely known. few notes on gynæcology, which are to the point and not A very interesting section of the book is that dealing with too expansive. ' the history of inoculation. It is shown that the Chinese a inoculated by blowing powdered small-pox scabs into the nostrils and that inoculation was practised in India before naval and military, the method was borrowed from the Turks by the people of western Eu rope. APPOINTMENTS. Personal experiences collected by the writer, dealing with the protection conf erred by natural small-pox, inoculation The following appointments, promotions, etc., have been small-pox and vaccination against vaccinia are of , great in- published in the Commonwealth of Australia Gazette, No. terest, since they show that neither natural small=pox nor 38, of April 28, 1921:

1 Vaccination in the Tropics, by W. G. King, C.I.E.: '1920. London: 1 Theory and Practice of Nursing. by M. A. Gullan ; 1920. London: Tropical Diseases Bureau; Royal 8vo., pp. 64, illustrated. Price, 5s. net . Iì. K. Lewis & Co., Ltd. : Demy 8vo., pp. 214. Price, 10s. 6d. net. 402 THE MEDICAL JOURNAL OF AUSTRALIA. [May 14, 1921.

Permanent Naval Forces of the Commonwealth (Sea-going Retired List with the honorary rank of Briga- Forces). dier-General, and with permission to retain such Fixing Salary of an Officer- rank and wear the prescribed uniform, 1st Janu- The salary of Surgeon-Commander Edward Thomas ary, 1921. Philip Eames, R.N., Director of Naval Medical Captain (provisional) J. H. Hornbrook to be trans- Services, to be at the rate of £1,000 per annum, ferred from the Australian Army Medical. Corps, inclusive of all allowances except travelling; to First Military District, and to be Captain, 30th date from 1st July, 1920. March, 1921. Transfer to the Retired List- The temporary rank of Lieutenant-Colonel granted Surgeon Lieutenant-Commander Jack Rupert Law to Honorary Major R. B. Wade is ,terminated, Willis is transferred to the Retired List at his 1st March, 1920. own request. Dated 18th February, 1921. iThe temporary rank of Major granted to the undermentioned officers is terminated from the dates Australian Imperial Force. shown against their respective names: Captains To be Captain- C. G. Allen, 28th June, 1920; T. G. Allen, 29th Captain W. Smellie, Australian Army Medical Corps, December, 1920; B. M. Befth, 6th October, 1920; 11th September, 1916. C. R. Hodgson, 1st August, 1920; Honorary Cap- tains H. S. Marsh, 28th February, 1919; C. W. Appointments Terminated. Whiting, M.C., 19th June, 1919; W. Blaxland, Second Military District. 24th March, 1921; J. C. Booth, 1st June, 1920. Captain P. G. Crago, 13th March, 1920. Third Military District. Third Military District. Australian Army Medical Corps- The notification respecting the appointment of Austin Major H. B. Lee, D.S.O., M.C., is appointed from the Mahon to be Captain, Army Medical Corps, which Reserve of Officers with corps seniority as from appeared in Executive Minute No. 436/1916, promul- date of transfer, 2nd March, 1921. gated in Commonwealth of Australia Gazette, No. Captain P. J. Campbell is transferred to the Reserve 56, dated 11th May, 1916, is cancelled. of Officers, 13th January, 1921. The resignation of Captain A. Lyons of his Australian Military Forces. provisional appointment is accepted, 2nd March, First Military District. 1921. Australian Army Medical Corps- To be Captains (provisionally)- Captain (provisional) J. H. Hornbrook to be trans- Charles William Adey and James Amess Troup, ferred to the Reserve of Officers, Second Military 26th February, 1921, and 30th March, 1921, District, and to be Captain, 30th March, 1921. respectively. Captain J. Hardie, M.C., to be transferred to the Re- Captain S. Crawcour to be appointed from the serve of Officers and to be Major, 30th March, Reserve of Officers, with corps seniority as 1921. from date of transfer, 30th March, 1921. Reserve of Officers- Captain H. A. Derayin to be transferred to the The temporary rank of Lieutenant-Colonel granted Unattached List, 30th March, 1921. to Major (Honorary Lieutenant-Colonel) H. H. Captain M. D. Silberberg to be transferred to B. Follitt is terminated, 30th September, 1920. the Reserve of Officers, 25th February, 1921. Captain (Honorary Major) A. V. Meehan is trans- Major (Honorary Lieutenant-Colonel) J. C. Mor- ferred from the Australian Army Medical Corps, ton and Captain (Honorary Lieutenant- Second Military District, and to be Major, 31st Colonel) E. B. Allan to be transferred to the March, 1921. Reserve of Officers and to be Lieutenants- Colonels, 30th March, 1921. Second Military District. Reserve of Officers- Australian Army Medical Corps-- Captain II. Fleming Dunstan, Reserve of Officers, Captain A. L. Kerr is granted the temporary rank Fourth Military District, is granted the tern- and pay of Major whilst acting as Senior Medical porary rank and pay of Major whilst employed Officer, Citizen Force Camps, Liverpool, New at No. 11 Australian General Hospital, 21st South Wales, 29th March, 1921. March, 1921. Major K. S. Parker, M.C., is appointed from the The temporary rank of Major granted to Honorary Reserve of Officers and to be Captain, with Captain W. H. Steel is terminated, 5th Febru- corps seniority as from date of transfer, 16th ary, 1921. March, 1921. Australian Army Medical Corps Reserve- Major (Honorary Lieutenant-Colonel) H. R. G. Poate The temporary appointments of Honorary Captains is transferred to the Reserve of Officers, and to D. .T. Thomas and A. W. Shugg are terminated, be Lieutenant-Colonel, 31st March, 1921. 29th October, 1919. Captain (Honorary Major) R. I. Furber, D.S.O., is transferred to the Reserve of Officers, and to be Fourth Military District. Major, 31st March, 1921. Australian Army Medical Corps- Captains K. R. W. George, and T. A. Grieves are The honorary rank of Major granted. to Captain transferred to the Reserve of Officers, 31st P. W. Rice is terminated, 1st April, 1921. March, 1921. Reserve of Officers- The resignation of Captain N. P. Boulton of his The temporary rank of Major, granted to Honorary commission is accepted, 31st March, 1921. Captain G. Brown is terminated, 1st April, 1921. The resignations of Captains W. G. Shellshear, G. A. Buchanan, and J. E. V. Barling, of their pro- Fifth Military District. visional appointments are accepted, 31st March, Australian Army Medical Corps- 1921. Colonel D. M. McWhae, C.M.G., C.B.E., to be trans- Captain (Honorary Major) A. V. Meehan is transferred to the Reserve of Officers, 1st March, ferred to the Reserve of Officers, First Military 1921. District, and to be Major, 31st March, 1921. Captain (provisional) S. Mathews to be transferred The temporary rank of Lieutenant-Colonel granted to the Reserve of Officers and to be Honorary to Captain (Honorary Major) A. V. Meehan is Captain, 1st March, 1921. terminated, 30th March, 1921. Captain (temporary) E. C. East to be transferred Reserve of Officers- to the Reserve of Officers and to be Captain, Colonel T. H. Fiaschi, D.S.O., V.D., is placed on the 30th March, 1921.

May 14,, 1921.] THE MEDICAL JOURNAL OF AUSTRALIA. 403

Medical Association is approximately 22,000, of which 3,000 are attached to the Australian Branches. It Che Medical Journal of Mustralia. is very rare for more than one-half of the members to be represented at a Representative Meeting. This

SATURDAY, MAY 14, 1921. means that if a "card vote" were taken on this matter of vital concern to the overseas members, the corporate membership of the .Association. unanimous wishes of the members of the Association in Australasia would probably determine the issue. The report of the Council of the British Medical The admission of incorporated bodies, correspond- Association on "The Question of Steps to be Taken ing to the Branches of the Association, does not in- Whereby the Association may Become in Part a volve any new principle. In effect the problem re- Federation," as published in the Supplement of the solves itself into the creation of machinery necessary British Medical Journal, of March 5, 1921, demands to permit certain more or less isolated Branches of very careful and detailed study by all members of the Association to do all those things which the the Association in Australia. That the Council has parent Association can do without involving the not appreciated the difficulties which beset the parent Association in any financial or other re- Branch in the Commonwealth, is both apparent and sponsibility. regrettable. The report deals with the proposals for Before considering the proposals of the Council, giving effect to the demand for admission to the it may be of importance if reference be made to the membership of the Association of three distinct Memorandum of the Association. The Association classes of bodies. In the first place there are the bodies, exists for the promotion of medical and the allied at present Branches of the Association, which desire sciences and the maintenance of the honour and in- to retain all the privileges of membership and at the terests of the medical profession and may achieve same time power to carry out all the objects of the these objects by holding meetings, by publishing British Medical Association, as set forth in the journals, transactions and the like, by granting sums Memorandum of Association. To enable these of money for the promotion of the medical and the Branches to gain a sufficient degree of autonomy to allied sciences and by doing such other lawful things carry out all the functions of the parent Associa- as are incidental or conducive to the attainment of tion, it is essential for them to become incorporated the objects. It is a matter of history that the chief under the Companies Acts of the States, Dominions reasons actuating the Association . to apply for a or Provinces in which the areas of the Branches are Royal Charter in 1905-1907 were its desire to pro- situated. The second class of bodies comprises out- mote the candidature of any member of the Associa- side medical societies, whose members are not neces- tion for Parliament, to undertake the defence of in- sarily members of the British Medical Association, dividuals in civil or criminal legal proceedings in- and whose objects are not co-terminous with those volving the honour or interests of the medical proof the Association. The third class includes societies fession, to provide facilities for the sale or transfer with non-medical members. These societies would of practices, to organize and manage provident or embrace the allied sciences and professions. We may benevolent funds and to undertake and carry out the dismiss the questions involved in the consideration of execution of trusts. It was found that the Associa- the second and third classes of members with a few tion could not obtain power to carry out these things words. The admission of outside medical bodies and under the Companies Act. Unfortunately the ap- of non-medical associations involves a new principle. plication for a Charter failed and the Association Before the Association is prepared to accept this still has no power to perform the acts just men- principle, the individual Divisions and Branches tioned. The Branches, as integral parts of the As- have to register a decisive mandate. It is as well sociation, have no power to sue or to be sued ; they to remember that the total membership of the British cannot hold property, publish a journal nor perform 404 THE MEDICAL JOURNAL OF AUSTRALIA. [May 14, 1921.

any of those things which a responsible, autonomous determine after the Branch had severed its connexion body would require to carry out for the purpose of with the parent Association. There is no word de- attaining the objects of the, Association. The Branches voted to the interchangeability of membership of the of the Association in Australia have to provide ma- incorporated body and the Association. There is, on chinery in every respect analogous to that of the the contrary, an indication in the text of the report governing body of the British Medical Association. of the Council 's opinion that the individual mem- Many of the problems confronting the medical pro- bers of an affiliated body would not be ableto enjoy fession in the Commonwealth are peculiar to Aus- full privileges of membership. In paragraph 8, it is tralia and therefore it is eminently desirable that clearly set forth that the right to vote in a referen- the Branches should possess a degree of freedom of dum is not conceded, because in the event of a large action consistent with the constitution of the Associa- body becoming affiliated, the individual vote might tion. It must, furthermore, be remembered that the control the situation. We would urge that this Branches in Australia work under the Memorandum privilege should not be extended to an outside body of Association of the parent Association and have no seeking and obtaining affiliation. The relations of a desire to go outside this legal restriction. former . Branch becoming a corporate member to the The Council proposes that the Branches on be- Association, however, are of an entirely different coming incorporated for the purpose of obtaining nature. The parent Association stands to lose noth- exactly the same powers . as it itself possesses, shall ing by granting full privileges to an overseas Branch terminate their membership of the Association and desiring wider autonomy than can be secured as a then apply to the Representative Body in which they Branch. By offering to it an emasculated member- would have no voice, for admission on terms to be ship, the Council appears to misunderstand the posi- prescribed by that body. The Council does not offer tion of the Branches in Australia and to be unaware any preferential treatment to these Branches as com- of the yeoman service of the Branch Councils dur- pared with an outside medical body or a non-medical ing the past quarter of a century. We have a right body. It is prepared to recommend the Representa- to expect a better recognition of the organizations tive Body to restrict the privileges of membership which have succeeded in attracting approximately of the Australian Branches by denying them the power 90% of the available medical practitioners to the of registering a vote at the Representative Meetings. fold. Dr. R. H. Todd, the delegate of the Australian On the other hand the Council would leave it to the Branches, will, we feel convinced, argue the case of Representative Body to fix the amount of subscrip- these Branches in a powerful manner and induce the tion by way of capitation or otherwise. In other Council to adopt a more generous attitude toward words the Branches would be disfranchised and at them. the same time would be required to pay to the parent Association for the privilege of affiliation a subscrip- THE PRINCE OF WALES'S APPEAL FOR THE tion for each member to be fixed by the Representa- BOY SCOUTS. tive Body. In our issue of March 12, 1921, we published a note, In its report the Council introduces a principle asking our readers to give their support. to the appeal which His Royal., Highness the Prince of Wales, as involving the maintenance of a close relationship be- Chief Scout for Wales, is making on behalf of the tween purely medical bodies and the Association and Boy Scouts Association. The sum of £200,000 is re- the establishment of a looser bond between bodies not quired to enable the movement to be conducted on a proper basis throughout the British Empire. We purely medical and the Association. The intention learn that £55,000 has already been collected for this is admirable, but the amendments to the Articles and purpose. -In addition the National Service League has determined to place its assets, estimated at £10,000, By-laws have been drawn up in such a manner that at the disposal of the fund. Strenuous efforts are no differentiatiòn is rendered mandatory on " the being made to. secure the remaining £135,0O0 from the Representative Body. The machinery is so elastic citizens of the Empire. It is scarcely necessary to point out in this place how valuable this movement that the conditions of membership of an incorporated is.- ' - The Boy Scouts Association stands for loyalty, Branch would be left to the Representative Body to patriotic service and preparedness. The training benefits the individual boy and fosters in the nation May 14, 1921] THE MEDICAL JOURNAL OF ATTSTRALTA. 405

a spirit of British sentiment and of British self- were obtained, which demonstrated the passage of the denial and pluck. The genius of Sir' Robert 'Baden meal from the stomach into the long intestinal tract. Powell is recognized on all sides and deserves the The cats were then operated on and the pyloric sphinc- support of everyone. ter was incised for about 1.25 cm. on its anterior ln response to the request of the P rince of Wales's aspect. The mucósa was'. left intact and in order to Boy Scout Development Fund The Medical Journal support it a small curtain of onientuln was sutured of Australia has undertaken to open a "Shilling to the musculature surrounding the incision. The Fund." Contributions of one shilling or more may abdomen was closed with catgut and the wounds, be sent to the Editor for the Prince of Wales's Fund. healed by first intention. The three animals were It is hoped that the medical practitioners of the Com- killed 7, 14 and 18 weeks respectively after opera monwealth of Australia will respond readily to this tion, but in the meanwhile other experimental meals appeal to send a substantial contribution to His were given. It was found that the food passed in Royal Highness through the agency of their own much greater quantity and with nutchl greater rap id journal. ity into the duodenum and jejunum. Post morlcm the, cat killed 7 weeks after operation showed a simrplel linear scar at, the site of incision and microscopical"' LINEAR DIVISION OF THE PYLORIC SPHINCTER. examination proved that a very thin layer of muscle. had not been severed, although the wound had gaped The rapid development of surgery in the last half widely at operation. The second cat had a shallow century is a triumph for the ingenuity and daring of bulging of the mucosa with no covering of muscle,. the modern mind. Operations which seemed a priori while the third cat, killed 18 Nveeks after operation,- the devices of madmen, have been added to the sys- showed a muscular sea r without d iverticulum. tem of surgery and have been proved rational and Dr. Pannett suggests that the operation may be invaluable. Those who first resected portion of the applied to man in three morbid conditions of the stomach for the cure of cancer, who first removed stomach, viz., cicatricial stricture resulting fente the spleen in the treatment of splenomegaly and pyloric ulcer, the pylorospasm which is commonly who, greatly daring, first replaced the pedicle of an associated with ulcer of the body of the stomach, and ovarian cyst without clamps, were men who by wise hyperchlorhydria vvhen associated with distressing temerity added greatly to the sum of surgical know. symptoms. The operation has already been attempted ledge. The great men of surgery have helped to free for the relief of the first condition, but the after - us from the shackles of our own fallibility. What results are not yet available. Dr. Pannett's investi- seemed to us.wise procedures they have proved wrong gations are very suggestive, but they are inconclusive. and what seemed to us hare-brained devices we have The results obtained from three animals are too few - now humbly admitted into our daily practice. on which to base a definite judgement and the differ- When Ram nistedt first proposed to treat the con- ent modes of healing of the pyloric wound show that genital hypertrophie pyloric stenosis of children by a different factors operated in each case. It would have simple division of the pyloric sphincter without su- been an even more interesting experiment if the ture, he aroused considerable opposition. The pro- veil of oinentum had not been sutured over the in- posal seemed at variance with the accepted principles cision. It is possible that the movements of the omen- of gastro-intestinal surgery. It was feared that the tum dragged the edges of the wound together in contents of the stomach, separated from the peri- two instances and apart in the other. Simple in- toneal cavity by a mere sheet of mucous membrane cision without the formation of an olnental curtain which might itself have been punctured with the would probably have led to more uniform results scalpel, would under pressure from the movements and it would then have been determined mvliether the of peristalsis rupture into the abdominal cavity: And tone of the musculature was sufficient to prevent yet experience showed that Rammstedt was right and leakage of the gastric contents. Dr. Pelmet -Vs ex- his opponents were wrong. Simple linear section of the periments would appear, however, to prove that in- pylorus not only freed the child from the distressing cision of the pyloric sphincter allows time more easy symptoms of pyloric obstruction and restored the passage of food from the stomach and should, there- creases of fat to his limbs and the chubbiness to his fore, be of value in the treatment of. pyloric ob- cheeks, but it was a permanent cure of the disease struction: from which the little fellow suffered no more. So successful has this operation been that Dr. Charles PROFESSOR HUNTER'S ARTICLE ON TWIN TUBAL A. Pannett,' of London, has considered the question PREGNANCY. of its applicability to the treatment of other disorders We regret to record that the illustration Figure II. in of the stomach. He set out to discover the effect on Professor Hunter's article on twin tubal pregnancy which the normal stomach of linear division of the sphinc- appeared in last week's issue, has been printed upside- teric muscle of the pylorus and he used one male down in an unknown number of copies. The block for this illustration was reversed by our printers without authority and two female cats as the subjects of his. experi- from or reference to us during the course of the machining ments. The animals were trained to remain quiet of the journal. The smaller chorionic vesicle (H 234 ) should while X-ray photographs were taken of meals of be to the left of the picture. boiled fish mixed with barium sulphate which had We have been asked to state that St. Luke's Hospital, been given after an all-night fast. The two females Darlinghurst, will be re-opened on May 18, 1921, by His Ex- responded well to the training, but the more spirited cellency the Governor of New South Wales. The hospital male cat refused to be subdued. Several skiagrams contains 30 beds, five of which will be available at a fee of £2 2s. a week, the remainder at ordinary private hospital 1 British .journal of Surgery, January, 1921. rates. 106 TIIE MEDICAL JOURNAL OF AUSTRALIA. [May 14, 1921.

Abstracts from current Medical colouration of the skin and sclerotic monia. The diagnosis of delayed reso- membranes of the eyes with bilirubin. lution is difficult by physical signs but Literature. During the recent war malingerers is possible radiographically. Extensive were detected who swallowed as much tuberculous lesions are frequently re- DERMATOLOGY. as one gramme of picric acid in order vealed by radiograms of the thorax in to produce a yellowness of the skin, which physical signs were few or ab- .sclera, blood-serum and cerebro-spinal sent, but the author considers the (169) Anaphylactoid Dermatitis. fluid, thereby hoping to evade military stethoscope superior to the radiogram That the skin of susceptible persons service. The urine contained picric when it is necessary to determine the may he sensitized by specific substances acid and at a later stage bilirubin in activity or quiescence of the pulmonary existing in the epidermis of certain ani- those instances in which a true jaun- involvement. mals and react later to direct contact dice was added to the artificial. In De- with those substances is the view of cember, 1919, A. P. Hess and V. C. (172) Treatment of Enlarged Tonsils Arthur J. Markley (Archiv. Dermatol. Meyers reported another form of with X-Rays. and .Spphilol., December, ]920). A mar- pseudo-icterus, most noticeable on the A report by Murphy, Witherbee, ried woman, aged 39 years, was ad- palms of the hands and soles of the mitted to hospital suffering from a feet, not involving the sclerotic mem- Craig, Hussey and Sturm on the induction of atrophy of the tonsils by skin eruption of six months' duration. branes and due to excessive consump- means of The rash was erythematous and papu- tion of carrots, spinach and other sub- Röntgen rays has appeared in the lar and involved the whole of the face, stances containing a large amount of Journal of the American Medical Association, neck and chest and the anterior aspects carotin. The most commonly known January 22, 1921. of the forearms. The eyes were suf- form of pseudo-icteric yellowness or The authors have had great, success in the treatment of hyperthophied tonsils fused and weeping and the patient was xanthosis of the skin, however. occurs subjected to great discomfort by the in- in association with diabetes mellitus. by this method. Early in the prac- tense itching, which was chiefly noc- The hands and feet are affected tice of radiography it was noted that turnal. As the hair was dry and the markedly, the eyes slightly, if at all. lymphoid tissue was easily destroyed, scalp scaly a diagnosis of seborrhceic The condition is said to be due to a and by experimental work the authors .dermatitis was made, but vigorous lutein-like lipoid substance in the blood. showed that it was possible to destroy practically all the lymphoid tissue in treatment for this condition failed to It is possibly related to diabète bronzé, the body relieve the symptoms. Under general as suggested in 1904 by von Noorden. by carefully applied doses of treatment which included dental atten- As a rule there is no bilirubin in the the X-rays. The dose employed vas tion and special dieting, and after re- urine, but there is a yellow colouration five milliampères of current with a 20 moval of the appendix vermiformis, the of the urine and of the blood-serum cm. spark-gap, at 25 cm. distance from affection was considerably relieved, but (xanth emia). The author records a the skin. The time varied from three it returned later in a more intense form case of congenital xanthosis, involv- to seven minutes and a three mm. alu- and the patient was in despair. Then ing the eyes and skin; in an other- minium filter was used. The rays were she suddenly remembered that the skin wise healthy man. He has been yellow directed through the tonsil from be- lesions always became worse after she since birth, is now 54 years of age, has hind the angle of the jaw, the re- cleaned out the pen of a pet guinea-pig always been healthy and has four mainder of the head and face being and allowed it to run about over her healthy normal children. There is no protected by lead. Three or four sit- shoulders. The animal was at once dis- splenomegaly and no enlargement of tings are necessary at intervals of 14 missed and the eruption entirely dis- the liver or lymphatic glands. The days. Distinct shrinkage of the ::. -.n- appeared.. Eight months have elapsed urine is clear, pale yellow, and free of sils follows the treatment and the sur- and there has been no recurrence. albumin, sugar or bilirubin, and con- faces become smooth and pale. Ade- Tests were carried out to prove the tains no excess of urobilin, urobilinogen noids are unaffected by the treatment. specificity of the reaction by the"skin or indican. A blood count showed to the irritant. Patches of hair from a 6,400,000 red cells in each cubic milli- (173) Cardiospasm. guinea-pig were bound to the side of metre and 5,710 leucocytes, while the In P. F. Butler's opinion (Amer. the patient's neck for four hours. With- hemoglobin value was 105%. There Journ. Röntgenology, October, 1920) in 24 hours local vesication and ery- was no apparent fragility of the red cardiospasm is usually secondary to thema appeared and spread to those cells. The blood serum was deeply some abnormal abdominal condition, areas of the skin involved in the origi- coloured but was apparently free of e.g., gall-bladder disease, duodenal nal eruption. The lesions on repeated bilirubin, urobilin and urobi]inoen. ulcer, appendicitis or even pelvic dis- experimentations always failed to ap- ease. Two of his patients were cured pear on other parts of the body. Con- after removal of a diseased appendix trol tests on another person and tests (171) The Diagnosis of Diseases of in each case. The spasm is at first made with the hair of other animals the Lungs. mild, but soon increases in intensity failed to yield a reaction. The relation G. N. Norris (New York Medical and the cardiac sphincter becomes of these observations to the phenomena Journal, November 27, 1920) has de- hypertrophied and the lower oesopha- of anaphylaxis is unknown. As the scribed the X-ray examination of geal musculature thickens. The chronic skin may be, sensitized by definitely lesions of the lungs. Clinically it is obstruction causes a dilatation of the non-protein substances, it is often de- possible to recognize pleural adhesions oesophagus above the stricture and this nied that these cutaneous reactions are in some cases but not in all, but an dilatation may become enormous and related to the anaphylactic state. They X-ray examination will at once de- capable of holding several litres of may be merely responses of the skin monstrate the lesion. Moreover, an fluid. The clinical features are absence to substances of the nature of toxins effusion of fluid can be discovered of pain, difficulty in swallowing (espe- rather than antigen-antibody reactions, readily by radiography but it can rarely cially in the case of fluids), an early but as the reactions are specific the be definitely diagnosed clinically until sense of fullness after food or drink, author has felt justified in using the a considerable . collection is present. term "anaphylactoid." Localized collections of fluid and copious regurgitation, loss of weight localized pneumothorax can only be and constipation due to the lack of diagnosed by X-ray examination while (170) Pseudo-Icteric Xanthosis. fluids. Cardiospasm is a condition of interlobar empyema often baffles the adult life and is commoner in males. F. Parkes Weber has written in the clinician. Abscess and foreign bodies British Journal of Dermatology and. The vomitus consists of undigested in the lungs are both easily recog- food and contains no blood and no gas- .Syphilis, March, 1921, an account of a nizable radiographically. It has been tric elements. The radiographic pic- diffuse pseudo-icterus or xanthosis of proved by X-ray. examination that the skin, usually found in certain lobar pneumonia commences centrally ture is typical, the shadow of the huge young patients suffering from diabetes and extends to the periphery and this dilatation of the oesophagus with its mellitus, This condition frequently fact explains the frequent absence of smooth lower end being quite unlike 'simulates true jaundice which is a physical signs in cases of early pneu- dilatation, May 14, 1921.] THE MEDICAL JOURNAL OF AUSTRALIA. 407

BIOLOGICAL CHEMISTRY. and Mendel fed rats on a diet that the albuminuria called "physio- very poor in fats, but containing the logical" or "orthostatic" may be in fat-soluble vitamine in dried alfalfa reality a genital albuminuria. The so- (174) Basal Metabolism and Pulse- (lucerne). The largest daily intake of called urinary mucin is not a true Rate in Hyperthyreoidism. substances (? fat) extractable with C. C. Sturgis and E. H. Tompkins mucin, for it contains no carbohydrate ether for any animal of the series have studied the basal metabolism in in its molecule. This urinary mucin, was 0.078 gramme. Nevertheless, the cases of hyperthyreoidism and corn- pseudo-albumin, or muclnoid substance animals grew on the diet with vigour. pared it with the pulse rate (Archives as it is variously named is not coagul- Inasmuch as all the animals starting of Internal Medicine, October, 1920). able by heat but by acids even in a on the diet with a body weight of ap- The metabolism determinations were cold medium. If a cloud appears in proximately 70 grammes quadrupled made on patients after they had been the urine when a few drops of acetic their weight within the usual time and fasting for twelve to fourteen hours acid are added and this cloud is in- appeared as well nourished as com- and at a time when, as the result of tensified when the acidified urine is panion rats on diets containing liberal rest, the pulse had ,reached its lowest heated, it may be assumed without doubt portions of butter, 'fat or lard, the con- rate. The expired air was collected in that the urine contains albumin. A clusion is drawn that if true fats are a spirometer and analysed in a Hal- syrupy solution of citric acid contain- essential for 'nutrition during growth, dane gas analysis apparatus. The heat ing 100 grammes of citric acid and 75 the minimum necessary must be ex- grammes of water is recommended for production in calories per square metre ceedingly small. per hour was then computed and core- use when testing for pseudo-albuminuria. Urine is floated on the surface pared with the normal standards of Du (176) Blood Chemistry of Pernicious of a few cubic centimetres of this solu- Bois. The results were expressed as Anaemia. percentages of the normal. During the A. O. Gettler and E. Lindeman made tion in a test tube. If the urine con- determinations the pulse was counted chemical examinations of the blood of tains pseudo-albumin a more or less six to nine times and the average of eighty-seven patients suffering from intense cloudy zone will appear at the these counts taken. The upper limit Pernicious anaemia (Archives of In- junction after a minute or two. If of normal metabolism has been placed ternal Medicine, December, 1920). They the urine contains only albumin there at +15%. The study shows that there found that the non-protein nitrogen, will be no precipitate nor cloudiness, is a fairly constant relation between urea and creatinin values were in even if there are five to eight grammes the pulse rate and the basal metabol- many instances somewhat higher than of albumin present in each litre. To ism in a large percentage of cases. normal. In 48% of the cases the non- Heller's test with nitric acid pser:do- In a study of 496 determinations of protein nitrogen was above the nor- albumin gives a cloud above the plane the basal metabolism of 154 patients mal limit, in 18% the urea nitrogen of separation of the two fluids, while it was found that there was a tachy- was above normal, and in 42 % the true albumin gives a cloud at the line cardia of 90 or more to the minute, creatinin was above normal. They con- of junction. if trichlor-acetic acid associated with a basal metabolism of sider than the increase was due not to. gives no cloudiness when added to +15% or more in all but 16% of the a permanent kidney lesion, but rather urine, it may be concluded that there is cases. In 70 instances when the meta- to the decreased amount of circulat- neither albumin nor pseudo-albumin bolism fell to normal, 78% of the pa- ing blood. The uric acid was increased present. If a cloud appears, Heller's tients -had a simultaneous fall in pulse in 90% of the cases and in some in- test is done and controlled with the rate to below 90. Of 52 patients on stances the values were as high as 9 special reagent. whom a number of determinations of and 10 milligrammes (the normal (178) Excretion of Indican and metabolism were made, the pulse rate figure is from 0.5 to 3.0 milligrammes). Phenols. as compared to the metabolism gave The amino-acid content was greatly F. P. Underhill and G. E. Simpson an accurate idea of the course of the increased, the increase being due to have studied the effect of diet on the disease in 85%. There is in general an excessive destruction of serum protein. excretion of indican and phenols interrelationship between the pulse rate In most of the cases the blood 'sugar (Journ. of Biol. Chemistry, October, and metabolism when a group of in- was abnormally high and the alkaline 1920). They have studied three nor- dividuals is considered. An extreme reserve was subnormal. These last mal men and a dog and they find that degree of tachycardia suggests a greatly findings show that in pernicious the excretion of both indican and phen- increased metabolism, while a slight anaemia the power of oxidation within ols varies directly with the protein in- tachycardia usually indicates a slight the cell is reduced to an abnormally take. In their smaller fluctuations the or moderate increase. The fact that a low level. The serum proteins were excretion of phenol and indican does pulse rate after complete rest of less greatly reduced, in some cases by as not necessarily vary in the same di- than 90 per minute is seldom and a much as 40% to 50% of the amount rection. In most cases a large varia- rate of less than 80 is rarely associ- in normal serum. tion in indican excretion is accom- ated with an increase in metabolism, panied by a variation in phenol excre- is of practical importance in the re- (177) Albuminuria and Pseudo- tion in the same direction. A high in- cognition of the large group of ner- Albuminuria. dican excretion by an individual does vous patients who have symptoms In the course of examinations of urine not necessarily mean a correspondingly similar to those occurring in hyper- for the presence of albumin, substances high excretion of phenol by that indi- thyreoidism. of an albuminoid nature which can easily vidual. The effect of even mild con- be confused with true albumin are stipation overshadows the effect of diet (175) Fat in Diet. sometimes found. These substances are on the excretion of .these substances, T. B. Osborne and L. B. Mendel have serum albumin and serum globulin and causing a large increase in the excre- investigated the importance of fats in the name "pseudo-albumin" has been tion of both indican and phenol. Those the dietary (Journal of Biological Chem- given to them since they have little diets which promote the growth of pu- istry, December, 1920). The authors interest other than the errors to which trefactive bacteria also promote indican point out that much work has been they may give rise. J. Leclercq lias and phenol excretion. Meat ingested in done in an attempt to prove the im- studied these substances and gives large quantities causes a marked in- portance of fat in the dietary, but pro- tests for distinguishing them from true crease in the excretion of the phenols per attention has not always been given albumin and ' from Cone another (Ga- and indican. Casein causes a mode- to the vitamine content of the fat and zette des Praticiens, October, 1920). rate excretion of indican and the phen- to the effect of absence of this factor. Leclercq also describes as pseudo-albu- ols. Gelatine, containing no trypto- Several recent writers, particularly in minuria those conditions in which hhe phane nucleus, causes cessation of Germany and Austria, have not em- urine contains albumin due to the pre- indican excretion, with no change in phasized adequately the distinction sence of seminal or prostatic fluid. In. the excretion of the phenols. On a diet in the significance of fats as sources these cases there is generally a genital, containing large quantities of lactose of energy and carriers of vitamine and prostatic or vesical lesion of bacterial the excretion of indican and the phenols of lipoids regarding the 'tile of which origin. Albuminuria of these types is was lower than when the diet con- information is incomplete. Osborne intermittent and the author suggests tained a large amount of protein,

408 THE MEDICAL JOURNAL OF AUSTRALIA. [May 14, 1921.

British Medical .Association News. Drs. Seed and Hadley were re-appointed as this Branch's rei)resen tad ves on the l'\ dcraI Committee. .■ NNUAL MEETING. Representative at the Annual Meeting. Dr. Merryweather accepted the Council's invitation to The annual meeting of the Western Australian Branch represent this Branch in England and on his return to the was held at the Hospital for the Insane, Claremont, on State reported to the Council in November, 1920, the result March 20, 1921, Dr. A. T. White, C.M.G., V.D., the President, of the meeting held at Cambridge on June 25, 1920, that in the chair. there were 2,000 members present, four of whom represented The Year's Work. the Australian Branches, namely, Drs. Pockley, Berry, Sprott The President read the following account of the work of and Merryweather. Dr. Merryweather was duly thanked the Council during the preceding twelve months. by the Council for representing them In England and for his report. Before making my Presidential Address I will endeavour Dr. F. H. Hadley was elected Branch representative on to cover the important work which has been done by the the Representative Body to be held at Newcastle-on-Tyne, Association during the past 12 months, including the Coun- England, in 1921. cil's Report. Ethical Rules. Death of Members. These having been carefully gone into by the Ethical 1 must first of all express our deep regret at the great Committee and the Council, were adopted by general meeting, loss we have sustained by the death of Dr. Blackburne at printed and issued to all members. Albany, who, in the prime of life, met a tragic death in Annual Subscription. the performance of his professional duties. I also regret Owing to the annual subscription to the British Medical to record the death of Dr. Samuel Macaulay, who was one Association being raised, it was found necessary to increase of our oldest esteemed members. Letters of condolence were the annual subscription . to members of . the Branch from sent to the relatives of both of these late members. £3 3s. to £4 4s.. In .common with other Branches in Number of Members. Australia, a protest has been put up to London to reduce Since the outbreak of war, when our members were 126, the subscription to the Australian members to its former they have increased until they number 154 at the end of amount of £1 5s.. I hope this will have beneficial results. the financial year. Incorporation of the Association. New Members. During the year the incorporation has been brought up During the year the following new members were elected: to date by the necessary lodging at the Supreme Court, Dr. Abernethy, Dr. Burns, Dr. Collins, Dr. .Field-Martell, revision of the rules and the appointment of trustees and Dr. Horan, Dr. Pailthorpe, Dr. Phillips, Dr. C. J. Quinlan, seal holders. The present trustees and seal holders ap- Dr. C. Richards, Dr. Russell, Dr. Smith, Dr. Vivian and Dr. pointed during the year are Drs. Clement, Trethowan and Wallace. Shearman. Transfers. Annual List of Members. The following •members were transferred from other Attention having been called to the fact that decorations Branches: Dr. Connell from Victoria, Dr. Dale from Birming- and orders of distinction were published in the list of New ham Branch, Dr. Stott from Victoria, Dr. Rundle from South Wales Branch members, it was resolved that orders Victoria, Dr. Stenning from London, Dr. O'Flynn from of distinction be published in the list of members of this Queensland, Dr. Hislop from Victoria, Dr. Cass from Vic- Branch. toria and Dr. M. B. Johnson from Victoria, while Dr. Barrack Medical Congress. was transferred to the New South Wales Branch and Dr. The proposal to hold the next medical congress in Perth Pomroy to the South Australian Branch. was considered during the year, but no definite action was taken and further consideration has been deferred. Resignation of Members. The Council of this Branch supported the Queensland I regret that during the year the following members re- Branch's resolution to the Federal Committee that in the signed: Dr. Alfred Webster and Dr. Morgan Richards. event of the next session of congress being held in Tasmania. Meetings. no concession or entertainments should be received from Nine general meetings were held during the year, seven the Tasmanian Government nor any representative of the at the Perth Public Hospital, one at the Hospital for In- Government take part in the congress. sane, Claremont and one at the Base Hospital, Fremantle. Repatriation of Returned Soldiers. The average attendance of members at the meetings was The question of returned soldiers being treated in the 29, compared with 1.9 last year. In addition to these gen- Perth Public Hospital, was raised at the instance of Dr. eral meetings there was the annual dinner. Instead of Kenny. The scheme to be carried out was outlined by Dr. holding the ordinary meeting in November it was resolved Barker. The result was that the Branch expressed strong to hold an annual dinner. This proved a great success and opposition to honorary attendance on returned soldiers and was attended by 42 members. If this function is continued urged that the care of these men should be entrusted to annually, it should have the effect of bringing members returned medical men, both internally and externally. together. I would suggest it being held later in the year Medical Examinations under War Gratuity Board. between Christmas and New Year, when country members The Council of this Branch has supported the Federal could attend. Committee in accepting a uniform fee of 10s. 6d. for medical The Council has held ten meetings, with an average service under the Central War Gratuity Board. attendance of six. The Ethical Committee met twice during the year with Protection of Practices of Members on Active Service. satisfactory results. During the year the. protection of practices of members who went on active service, was withdrawn. During the year interesting cases and specimens were shown by Drs. Stubbe, Trethowan, Randell, Bentley, Seed, War Patriotic Fund. Atkinson, Cantor, Holland, Anderson, T. Gill, F'. McGregor, During the year the Committee of this Fund submitted Martell, Juett, Dale, Hadley and Blackall. a detailed revised scheme. This matter was carefully gone Interesting papers were read during the year by Drs. into by the Council, who received a deputation from the Bentley, McWhae, Juett, T. Anderson and Barber. War Patriotic Fund Committee. As a result the general meeting adopted the recommendations of the Council and Federal Committee. the revised scheme with modifications was approved of. During the year the constitution has bee altered, which This should prove beneficial to the dependants of soldiers. had the support of this Branch, to provicre for' the gen- The scheme provides for the attendance of medical men eral expenses of the Federal Committee, including travelling and other personal expenses of members. at the rate of 4s. per consultation and 5s. per visit in the metropolitan area and increased fees in country districts. Re Further Powers Under the Constitution, etc..—This Those entitled to the benefits are the widows and depend- Branch supported the Federal Committee and, agreed to pay ants of soldiers who have died on active service, the wives this Branch's quota towards the expenses of a representa- t. to England, and children of disabled soldiers and also the wives and children of soldiers who have returned, but whose income May 14, 1921.] THE MEDICAL JOURNAL OF AUSTRALIA. 409

including pension does not exceed £5 per week, provided medical officers have been deleted. As this latter is contrary they are approved of by the Committee of the War Patriotic to the views of the Association, Drs. Trethowan and Hadley Fund. Any case considered deserving by the War Patriotic are being asked to interview the Attorney-General again on Fund of the dependants of returned soldiers whose wages this matter, with, it Is hoped, beneficial results. excluding pension is over £5 per week, have to be referred to the Council before being approved of as being entitled Important Notice. to benefits under this Fund. It was resolved to continue the "Important Notice, Medi- cal Appointments," in the British lIedical Journal as hereto- Opticians Bill. fore. During the. year the Opticians Bill was presented to Par- . Honorary Secretary. liament and strenuous efforts were made to oppose the During the year Dr. registration of opticians as sight testers. Although the Shearman was grunted three •inunlhs' leave of absence on account of ill health. During this Inoriod Bill has not yet passed Parliament, • very little interest or his duties were very capably carried out by Dr. T. opposition was given by the public on this all important Anderson. matter. The thanks of the Association are due to Dr. •Saw After four years' work as Honorary Secretary, Dr. Shear. for his good work in this connexion in Parliament and to man has decided to retire and not to stand for re-election. Dr. Paton for assisting the Council. I have to place on record great appreciation of the Branch Early Closing for Chemists' Shops. 'of his excellent services. The Branch was asked to send a representative to the Parliamentary Select Committee on th'e Bill. Dr. Holland Members of Council. was appointed and agreed to attend on behalf of the Branch. I regret also the decision of Drs. Clement and Merry- weather to retire from the Council and not to stand for re- Health Inspectors' Association. election. Dr. Clement has done ten years' excellent service During the year a congress was held by the Health In- for the Branch, having been Honorary Secretary from 1909 spectors' Association and two delegates, Drs. Seed and Bar- to 1913 and a member of the Council from 1915 to 1920. ber, were elected to attend on behalf of the Branch. Dr. Merryweather has been a member of Council during the past nine years, during which time he was President Conference on the Welfare of the Blind. in 1916 and represented the Branch at the Cambridgemeet- During the year a conference on the welfare of the blind ing last year. I desire to place on record the Branch's was held, when Drs. J. Thompson and Claude Morlet repre- and Council's appreciation of these members' excellent services. sented the Branch as delegates. On behalf of the Association I beg to tender our sincere Repeat Orders for Morphine. thanks to Dr. Anderson for his invitation for us to hold This matter, was brought before the Council by the Cus- our meeting here to-night and for the excellent repast we toms Department. The Council decided to circularize every have had. It is much to be regretted that it is not possible medical practitioner in the State and urge that no pre- for more country members to attend our meetings. scriptions for morphine be issued without the inscription "no repeat." They have also asked for the Pharmaceutical Treasurer's Report. . Society and the Nurses' Association to confer on this matter. Dr. W. Trethowan, the honorary Treasurer, submitted his annual report and Mal aise sheet (see page 4101. Medical Fund Agreements. The report and the balance sheet were adopted. During the year the Branch advised the doctors at Yar- loop, Bruce Rock and Menzies in reference to medical fund Presidential Address. agreement, which provided for a per capita payment and a Dr. A. T. White read his address (see page 395). wage limit. Medical Fees. Election of Office-bearers and Members of the Committee. During the year the question of medical fees was raised The result of the election of office - bearers and members by Dr. Martell and was given careful consideration at sev- of the committee was announced as follows: eral meetings, which eventually resulted in a resolution that President: Dr. G. W. Barber, C.B., C.M.G., D.S.O. the fees be raised 25%. The question of lodge fees was also Vice-President: Dr. D. D. Paton. considered and it was agreed to raise them to a minimum Honorary Secretary: Dr. T. L. Anderson, O.R.E. of 26s. per head and if this was not agreed to by the Members of the Council: Dr. R. C. Everitt Atkinson, Dr, friendly societies, the matter was to be referred to the E. A. Officer, Dr. D. M. McWhae, C.M.G., C.B.E. Council. Before approaching the friendly societies again Members of the Ethical Committee: Dr. C. M. McWhae, with a definite scheme, the Council decided to obtain the C.M.G., C.B.E., Dr. W. P. Seed, Dr. W. Trethowan. support of the members throughout the State. The matter On the motion of Dr. T. L. Anderson, seconded by Dr. was given careful consideration and a circular was issued H. H. Field-Martell, Dr. M. K. Moss and Dr. A. E. Handel! to 149 members. To date about 100 replies have been re- were elected Honorary Auditors. ceived, practically unanimously supporting the Council. About one dozen objections or suggestions have been received Induction of President. and these are receiving the careful consideration of the Dr. A. T. White then introduced Dr. G. W. Bar ber as his Council, and if necessary, the Council will again approach successor to the presidential chair. members. Dr. R. C. Merryweather suggested that the Honorary Treasurer should supply a statement in connexion with the Reduction in Subsidies to District Medical Officers. Medical Officers' Relief Fund (Federal) at the next meeting Complaints were received from one or two district medi- of the Branch. Dr. Trethowan, the Honorary Treasurer, cal officers as to the Government's action in reducing their stated that he would do so. salaries, but in no instance could the district medical officers show that they were not being reasonably compensated for Paper. the work they did and therefore the Branch was unable to Dr. J. Bentley, M.C., read a paper on "Organo-therapy iii take any action in the matter. Mental Disease" (see page 399). In thanking Dr. Bentley for his valuable and instructive Court Fees for Medical Witnesses. paper Dr. G. W. Barber suggested that good results might Drs. Trethowan and Hadley as a sub-committee of the be obtained if patients were subjected to treatment during Council interviewed the Attorney-General and urged the the early stages of the mental processes. Dr. J. Theodore Government to revise the list of fees for medical witnesses, Anderson stated that organo-therapy had been practised for post morten examinations, trave ll ing. expenses for doctors. some years within the institution. He attributed great im- The result was that the Attorney-General promised to portance to the early medical examination of school children consider the Council's views, Und@r the new Coroners Act followed by appropriate treatment. All imbecile children the fees are left to be determined by the Attorney-General in the institution were being treated with hormotone and and also under the Coroners Act all fees for salaried hospital the results were being noted.

410 nit MEDICAL JOURNAL OF AUSTRALIA. May 14, 1921,

Dr. J. Bentley, M.C., in his reply admitted that the treatment The motion was seconded by Dr. Field Martell and op- was not infrequently unsuccessful. They had found that posed by Dr. E. C. East on the ground that the hour be- age was no barrier to succesful treatment. In reply to Dr. tween five and six o'clock was inconvenient for lodge prac- J. E. F. Stewart, Dr. Bentley stated that they did not tice. Dr. Moss and Dr. Beveridge supported the motion. usually estimate the blood pressure before the treatment Dr. Merryweather thought that each member should be free was instituted. to fix his own time. The motion was carried. Dr. W. P. Seed exhibited a skiagram of a stone in the right kidney. The patient had passed a calculus 25 years Frank Edwin Dawson, Esq., M.B., 1917 (Univ. Sydney), previously and had been free fròm all symptoms. More of Adelong, New South Wales, has been nominated for elec- recently signs and symptoms had appeared indicating that tion as a member of the New South Wales Branch. a calculus was situated In the left kidney. In view of the evidence of the skiagram, the right kidney was explored The Honorary Medical Staff of the Hospital for Sick and a calculus removed. Children, Brisbane, have arranged to hold clinical meetings on the fourth Thursday in each month. The meetings are Medical Examination for Life Insurance. open to all members of the Queensland Branch of the British Dr. L. E. S. Gellé moved: Medical Association. At present no definite society has been That in all cases examined elsewhere than in the formed. It is, however, the intention of the members of the practitioner's consulting room at the request of the in- staff, if these clinical meetings prove successful, to form a surance company or its agent, a mileage fee be paid in society and to make application to the Council of the Queens- addition to the examination fee. land Branch of the British Medical Association for the ad- The motion was seconded by Dr. J. J. Holland and sup- mission of this society as the Pediatric Section of the Branch. ported by Dr. J. E. F. Stewart and H. H. Field Martell. Dr. R. C. Merryweather moved as an amendment that Correspondence. the question of mileage should be left to the individual practitioner. The amendment was seconded by Dr. W. J. THE "GA l "LE PACK" METHOD. Beveridge. The amendment was carried and was also adopted as a substantive motion. Sir: It will he conceded that one may be permitted to Dr. Gellé moved: estimate the value of any abortive or early treatment of That as regards ordinary offices the fee for medical gonorrhoea no less by its failures and sequele than by its examination be 21s. except for policies of £500 or up- successes and on that premise the following statistics are wards, the fee for which ought to be on a higher scale submitted for your consideration. proportionate to the amount of policy. This series of cases comprises a sequence of those ad- Dr. J. Theodore Anderson seconded the motion. mitted to No. 1 A.D.H., Bulford, and entering one's clinic The President referred to a communication from the during 1919, the common factors in such cases being that Federal Committee dated September 9, 1919, in which it all entered in the subacute or the chronic stages and that was set out that £1 ls. should be the minimum fee irrespec- prior to admission all had been submitted to some type of tive of the amount of insurance. treatment, either argyrol injections, urethral irrigations, Dr. M. K. Moss considered that if blood pressure readings supervised or "at home," or "the gauze pack." were required, an increased fee should be paid. For present purposes one may divide the series of 262 Dr. A. P. Thom wished the fee to be increased. cases into: Dr. W. Trethowan pointed out that the fee was paid for (a) Those previously treated with the "gauze pack," a thorough and conscientious examination irrespective of comprising 76 of the cases. the amount of insurance. He held, therefore, that the fee (b) Those previously treated by any other method, of £1 is. was 'quite equitable. being 186 in all. The motion was put to the meeting and was lost. Further, one may consider these two divisions from three points: Friendly Society Lodge Practice. (i.) The duration of treatment necessary to effect a cure Dr. J. J. Holland moved: approximating to the "standard of cure" personally satis- That it be a recommendation to the Council that at factory to Dr. A. M. Gibson, at this time officer in charge the conference with the friendly societies the question of treatment. This was found to be 70.6 days in the "gauze of no consultation after 6 p.m. be discussed. ' pack" series and 60.3 days in the other class.

Statement of Receipts and Expenditure, for Year Ended December 31, 1920.

£ s. d. £ s. d. £ s. d. £ s. d. Funds in W.A. Bank, 31/12/19: London Office 161 7 6 War Loan Bonds .. . :. 325 0 0 Medical Journal of Australia .. 145 0 0 Fixed Depeait Receipts 250 0 0 Sundry Expenses: Current AcCOunt .. .. .. 187 16 10 Printing .. .. .. 21 3 0 762 16 10 Stationery 7 17 3 Interest and Dividends: Postages, Telephone, etc. .. 25 2 9 On Fixed Deposit Receipts .. 5 0 0 Assistant Secretary's Salary 40 15 0 „ War Loan Bonds .. .. .. 18 5 0 Rent of Rooms 2 2 0 23 5 0 Attendant 2 2 0 Subscriptions and Capitation Fees .. .. .. .. 493 19 9 Cheque Book .. 5 0 Refund Medical Officers' Relief Fund, stamps .. 3 12 6 99 7 0 Dr. Pope Fund: Refund Postages 2 15 0 Funds in W.A. Bank: Fixed Deposit Receipts .. 325 0 0 Current A/c. .. .. .. .. 149 7 7 War Loan Bonds (£410) .. 400 17 0 875 4 7

Total • £1,283 14 1 Total £1,283 14 1 We have examined the books, vouchers, fixed deposit receipts, and pass book, and certify that the above statement of receipts and expenditure of the Western Australian Branch of the British Medical Association is correct. March 10, 1921. (Sgd.) ALLAN E. RANDELL. M. KASMAR MOSS. May 14, 1921.] THE MEDICAL JOURNAL OF AUSTRALIA. 411

(ii.) The incidence of soft or hardening infiltration of the the tropics, or they speak of isolated cases which have suc- anterior urethra determined at the first urethroscopic exceeded. If you suggest that as they . are so strongly in amination; that is, the incidence of potential urethral stric- favour of opening up this country entirely by the white, ture. This was found to be 36.8% in the gauze pack class then they had better go there themselves, and take their and 19.3% in the second class. Parenthetically one may re- families, they turn to you and say, "Oh, I am past the age," mark that the grossest generalized infiltrations of the entire or "I am doing all right here," or "Oh, let the returned anterior urethra were confined to the "gauze pack" series. soldier take land up there." Yes; it is always the returned (iii.) The percentage of complications on admission to man for the dirty job. He has not only to fight for you hospital, such complications including epididymitis, acute abroad, but he is to go in and rough it again up north, posterior urethritis, prostatic, Cowper's. and periurethral ab- whilst you sit down in comfort in a temperate zone. I am scesses. The "gauze pack" series showed 20.7% and the thankful to say that though I enjoyed my years in the second series 20.3%. Of actual epididymitis, the figures were tropics and did good work there, as a single man, my wife 10.6% and 8.1% respectively. had enough common sense to say, "If you intend to carry Yours, etc., on your work entirely in tropical countries, then I will not KENNETH McLEAN, M.D.. marry you, not only for my own sake, but for the sake of 105 Collins Street, any children we may have, for I know it would mean a Melbourne, life largely of separation if the health of myself and our children is to be maintained"--and this, mind you, in coun- April 28, 1921. tries that are not devoid of native labour to do the house- work. From a poetical and theoretical point of view the Sir: I have just read Dr. Fogarty's letter re my criticism "White Australia" is good—every one of us agrees with of his "gauze pack" method of treating urethritis. When that—but that it is going to be practical in the moist tropical Dr. Fogarty's article on his method appeared in the British north, well, honestly I do not think any resolution passed Medical Journal I was greatly interested and followed his by the Medical Congress at Brisbane is really worth a snap technique exactly in my next two cases. I was disappointed of the fingers on the point. You must get your opinions to find that they did not get better any quicker than others from the men and women who really know their tropics and treated by irrigation. It was shortly after this that I was the conditions of life in the tropics, to be of any real value, told by others of their opinion of the gauze pack method. and not from casual visitors. I am certain of this, all these Yesterday I was at a meeting of the Western Medical As- people who know, will say you must have help of some sort sociation at Parkes, subject gonorrhoea. I was late in arriv- and that help will not be of an Anglo-Saxon breed. There ing but heard a part of the discussion. One speaker said are exceptions undoubtedly, but they are very few, and it that when at Bulford he had seen cases which had been is numbers we want if the country is to go ahead. treated by the gauze pack method and who had what he Yours, etc., called a "gas-pipe" urethra, hard and dilated and, what R. W. HORNABROOK. is more important, still suffering from urethritis. Melbourne, I am still as anxious as ever to know the best method April 26, 1921. of treatment and if Dr. Fogarty can convince me that his is the best and most expeditious method, I will use it. I wish that others who have tried it would give us their PRELIMINARY EXAMINATIONS AT THE MELBOURNE opinions. I think it is rather unkind of Dr. Fogarty to UNIVERSITY. say that I am throwing "cold water on an honest attempt at progress" and that I am not consistent because I did Sir: May I amend the statement in your Education Num- not find his method all that was claimed for it. ber (page 374) concerning conditions of entrance to the Yours, etc., Medical School of the Melbourne University. Candidates J. W. SUTHERLAND. qualifying in Victoria for entrance must have passed both Narromine, the intermediate and the school leaving examinations. In- New Srouth Wales, termediate Latin and geometry are compulsory, unless the April 23, 1921. Faculty of Medicine grants a dispensation, which is given when candidates have obtained honours at the school leaving examination in one language and one other subject. Candi- SETTLEMENT OF TROPICAL AUSTRALIA. dates qualifying in other States for entrance must have passed examinations approved by the Faculty of Medicine. Sir: Dr. Arthur's letter in your last issue is opportune. Yours, etc., To any man who really knows his tropics (by tropics I H. E. ALLEN. mean the moist tropics), the doctor's remarks on the Bris- • The University of Melbourne, bane Congress and the resolutions passed at it do not May 4, 1921. come as a surprise when we see by whom those resolutions were passed. We have a gathering of medical men, the great majority of whom live in temperate climates and may NOMS DE PLUME AND ANONYMOUS at most have had only a fleeting acquaintance with the COMMUNICATIONS. conditions of life in the tropics and that as a rule at the most agreeable time of the year and under the most favour- Correspondents from time to time send us anonymous com- able circumstances, saying, "We see no reason why Aus- munications often dealing with matters of considerable in- tralia as far as its tropical north goes should not be de- terest. Unfortunately, no notice can be taken of these letters veloped by the white." By white I presume they mean the unless they are accompanied by the writer's card or by some Anglo-Saxon, for that is the class of white we really want other indication of his name and address. in Australia and generally think of when we say "white." Correspondents are also informed that the habit of send- Speaking from experience, and after a few years in the ing letters for publication in our columns over a nom de tropics—and that with the assistance of my native ser- plume should be avoided except in special circumstances. vants to make life comfortable—I cannot conceive it pos- The expedient rarely serves a useful purpose and is fre- sible to develope any moist tropical country without coloured quently inadmissible, especially when the subject dis- help of some sort to do the drudgery. We must remember cussed involves a question of policy or includes a personal this, that after all it is not the man alone that developes the reference. country to thick population, but the woman. It is the AIN woman who carries the baby, it is the woman who has the It is announced that Dr. Robert Fowler, O.B.E., drudgery of the house-keeping, it is the woman who rears has been appointed Surgical Clinical Assistant to Out- the children, and it would be a good thing for all of us Patients at the Alfred Hospital, Melbourne. if we looked to her side of the question a little more. Talk to any one of these men who have so much to say on the Dr. F. A. Bennett has been appointed a Director of the development of northern tropical Australia and what do Sydney Hospital. A vacancy occurred recently through the you find? Either that they are not married, if still in death of the late J. Garland.

1`1[1: 11KMD[CAL JOURNAL O P AUSTRALIA. [May 14, 1921. Books Received. Branch. BLOOD PICTURES : An Introduction to Clinical 1Yzematology, by Cecil APPOINTMENTS. 'Price-Jones, M.B. Second Edition 1920. Bristol: .John Wright & Sons, Ltd.. London : Simpkin, Marshall, Hamilton, Kent & Co., Ltd. ; Demy Svo., pp. 64. Price, 6s. (id. net. '1'13E PHYSIOLOGY OF PROTEIN METABOLISM, by E. P. Cathcart, All Institutes or Medical Dispensaries. M.D., D.Sc., F.R.S..; New Edition ; 1921. London: Longmans, Green & Co. ; Royal 8vo., pp. 176. Price, 12s. 6d. net . Manchester Unity Independent Order TIIE DIAGNOSIS AND TREATMENT OF INTUSSUSCEP'T'ION, by of Oddfellows. Charles P. B. Clubbe, L.R.C.P., M.R.C.S.; Second Edition; 1921. Ancient Order of Foresters. London : The Joint Committee of Henry Frowde, Hodder and Stough- VICTORIA. ton ; Sydney : Angus and Robertson, Ltd. ; Demy 8vo., pp. 91. Price, Hibernian A ustralian Catholic Benefit 7s. 6d. net. Society. TREATMENT BY HYPNOTISM AND SUGGESTION OR PSYCHO-THERA- (Hon Sec., Medi- PEUTICS. by C. Lloyd Tuckey, M.D. ; Seventh Edition ; with a Chap- Grand United Order of Free Gardeners. ter on Treatment by Suggestion During the War, by A. Percy Allan, cal Society Hall, Sons of Temperance. M.D.. B.S.: 1921. London : .Baillière, Tindall & Cox ; Demy Svo., pp. 41::. Price, 21s. net . East Melbourne.) order of St. Andrew. AI)VANCEI) SUGGESTION (NEURO-INDUCTION), by ITaydn Brown. Australian Prudential Association l'ro- L.R.C. P.. 'tc. ; Second Edition ; 1921. London : Baillière, Tindall & prietary, Cox : Crown 8vo., pp. 402. Price, 10s. 6d. net . Limited. CLINICAL BACTERIOLOGY AND. H2EMATOLOGY FOR • PRACTI- Mutual National Provident Club. TIONERS, by W. D'Este Emery, M.D., B.Sc. ; Sixth Edition ; 1921. National Provident London : H. K. Lewis & Company Limited ; Demy 8vo., pp. 310 with Association. 66 illustrations, including 11 plates. Price, 15s. net . THE CLINICAL. EXAMINATION OF DISEASES OF THE LUNGS, by E. M. Broekbank, M.D., F.R.C.P., and Albert Ramsbottom. M.D.. F.R.C.P.; 1921. London: H. K. Lewis & Company, Limited; QUEENSLAND. Crown Svo.. pp. 58 with 13 illustrations. Price, 4s. 6d. net . Australian Natives' Association. DIATHERMY, its Production and Uses in Medicine and Surgery, by Elkin Brisbane United Friendly P. Cumberbatch. M.A., B.M., M.R.C.P.; 1921. London: William (Hon. Sec., B.M.A. Society In- Heinemann (Medical Books), Ltd. ; Demy 8vo.. pp. 192, illustrated by Building, Adelaide stitute. 38 figures and 44 plates. Price, 21s. net . Street, Brisbane.) Stannary Hills Hospital. AN INTRODUCTION TO CHEMICAL PHARMACOLOGY; Pharmaco- dynamics in Relation to Chemistry, by Hugh McGuigan, Ph.D., M.D. ; 1920. Philadelphia: P. Blakiston's Son & Company; Demy Svo., pp. 418. Price, $4.00 net. BIBIIOGRAPHIE DES LIVRES FRANCAISE DE MEDECINE ET DE SOUTH AUS- SCIENCES, publiée par La Section de Médecine du Syndicat des TRALIA. Contract Practice Appointments at Editeurs; 1908-1921. Paris: Hotel du Cercle de la Librairie; Deny 8vo., pp. 146. Renmark. (Hon. Sec., 3 North Contract Practice Appointments in Terrace, Adelaide.) South Australia. medical Appointments. Dr. H. V. 1). Baret (B.M.A.) has been appointed Assistant WESTERN AUS- Medical Superintendent to the Coast Hospital, Little Bay, TRALIA. New South Wales. Dr. A. W. , Esler (B.M.A.) has been appointed a Public (Hon. Sec., 6 Bank All Contract Practice Appointments In Vaccinator at Eaglehawk, Victoria, and Dr. C. G. Godfrey of New South Western Australia. (B.M.A.), a member of the Midwives Board of Victoria. Wales Chambers, St. George's Ter- race, Perth. Medical Avvointments Ilaca?lt, etc. NEW ZEALAND: For announcements of medical appointments vacant. assistants, locum tenentes sought, etc., see "Advertiser," page zaiii. WELLINGTON University of Melbourne: Cancer Research Scholarship. DIVISION. Friendly Society Lodges. Wellington, University of Adelaide: Professorship of Zoology. New Zealand. (Hon. Sec., Wel- Alfred Hospital, Melbourne: Medical Superintendent. lington.)

medical Avvoidtments. Diary for the month. IMPORTANT NOTICE. Ma y 17.-N.S.W. Branch, B.M..A.; Executive and Finance Medical practitioners are requested not to apply for any Committee. appointment referred to in the following table, without having May 17.-Illawarra Suburbs Med. Assoc. (N.S.W.). first communicated with the Honorary Secretary of the Branch May 18.-W. Aust. Branch, B.M.A.. named in the first column, or with the Medical Secretary May 20.-Eastern Suburbs Med. Assoc. (N.S.W.). of the British Medical Association, 429, Strand. London, W.C.. May 24.-N.S.W. Branch, B.M.A. ; Medical Politics Commit- tee ; Organization and Science Committee. . May 25.-Vic. Branch, B.M.A., Council. Branch. APPOINTMENTS. May 26.-S. Aust. Branch, B.M.A.. May 26.-Clinical Meeting at , the Hospital for Sick Children, Australian Natives' Association. Brisbane. Ashfield and District Friendly So- May 27.-N.S.W. Branch, B.M.A.. May cieties' Dispensary. 27.--Q. Branch, B.M.A., Council. .June 1.-Vic. Balmain United Friendly Societies' Dis- Branch, B.M.A.. NEW SOUTH pensary. June 3.-Q. Branch, B.M.A.. June 8.-Melb. WALES. Friendly Society Lodges at Casino. Pediatric Society I Vic.). June 10.-N.S.W. Lelchhardt and Petersham Dispensary. Branch, B.M.A., Clinical. (Hon. Sec.. 30-34 Manchester Unity Oddfellows' Medical Elizabeth Street, Institute, Elizabeth Street, Sydney. EDITORIAL NOTICES. Sydney.) Marrickville United Friendly Societies' Dispensary. Manuscripts forwarded to the office of this journal cannot under any North Sydney United Friendly Societies. •ircumstances be returned. . Original articles forwarded for publication are understood to be offered People's Prudential to The Medical Journal of Australia alone, Benefit Society. All unless the contrary be stated. Phoenix Mutual Provident Society, communications should be addressed to "The The Medical Journal of Australia, B.M.A. Building, 30-34 Elizabeth Street, Sydney. (Telephone : B. 4635. ) THE MEDICAL JOURNAL OF AUSTRALIA.

VOL. I.-8T1-1 YEAR. SYDN E1' : SATURDAY, MAY 21, 1921. No. 21,

ETHER ANESTHESIA.' two evils, and for induction at least chloroform and ether or " A.C.E." was used. By F. L. Davies, M.B., Ch.B. (Melb.), It was all the same whether warm ether vapour Honorary Anaesthetist at the St. Vincent's Hospital, Melbourne. were used or not. In 1911 Dr. Dunhill brought a Gwathmey apparatus from America and very shortly In giving anesthetics so many variations are met after Dr. Devine brought another. Since that time with in regard to patients, surgeons, the nature of the we have very largely used warm ether vapour and when operation, the conditions, etc., surrounding the per- this apparatus was used, advantage was almost al- formance of the operation, that from time to time the ways taken of the chloroform bottle as well as the anaesthetist may modify the methods adopted, all the ether. Ilére I might say that so-called aids in the while working towards safety and simplicity. Any form of preliminary medication were also given a method advocated now is used not because it is with- trial and they have been discarded as being both out any defects, but because it is considered to be the useless and harmful. I could not be convinced of any best of any that may be in use and because it aims advantage in aiding anesthesia. If sufficient mor- at being fool-proof, thus insuring what should be the phine be given to bring about the vaunted results, paramount consideration in anæsthesia, i.e.; safety there must be a corresponding degree of effect on of the patient. It should be remembered that every- the medullary centres of circulation and respira- thing• that tends to make for easier working of the tion. To me the respiration is the main guide during surgeon, must also tend to insure the safety of the the whole stage of anesthesia and anything which patient. interferes in any way with it, may affect the safety For this reason the routine usage of chloroform of the patient. I would infinitely rather have the must be passed by ; I think this is practically an whole anesthetic state of the patient due to a volatile accomplished fact so far as this city is concerned. and rapidly eliminated drug than have only part The mode of administration must vary to suit the due to this drug and the other part due to a drug special operation and for that reason the anesthetist more or less fixed for the time being. It was also must be versatile enough to adopt different methods. found that the induction, instead of being facilitated, III this respect I refer especially to intratracheal was generally delayed in that the patient would dose methods which form the subject of another paper to- off long before anæsthesia was produced and would night. In certain cases I can conceive of no better require a rude awakening by the surgeon's knife in anæsthesia and I think I can claim that I have been many cases in order to persuade him to breathe as early and as persistent an advocate of intratracheal deeply enough to be anesthetized. anesthesia as anyone else in Melbourne. The pre- In an article I have to hand I would like to read a ference of ether over chloroform was a gradual pro- short paragraph. It is by Dr. Embley, who I regret cess with me. In my first thousand cases chloroform to say was unable to give a short paper to-night. was used from beginning to end in the great majority Morphine depresses respiration to a degree which varies widely with individuals and with animals. This and in most of the others, all in fact in which Clover's is especially seen when used in conjunction with chloro- apparatus was not used, chloroform was used with form or ether, in a small percentage of which cases it the ether. I can therefore claim in advocating the occurs to a marked extent. When such instances occur sole use of ether that it is not because I lack know- in conjunction with chloroform the phenomenon represents absolute failure of respiration extending over a ledge of chloroform. When the use of ether by open period of even three hours. With ether the depression methods began to be suggested and advocated, for is not so complete, but It is so much as to reduce the some reason it seemed beyond one 's capabilities to man- rhythm to even as 'few as three or four deep respirations age without chloroform. Even if ethyl chloride were per minute. The type of respiration thus induced re- used, the patient would be out of the ethyl chloride sembles that following vagotomy, except that lung ventilation is not as efficient and consequently mild degrees anesthesia before he was under the ether, conse- of anoxeemia may be observed in the more marked in- quently chloroform and ether or the "A.C.E." mix- stances. This reduced rate of respiration comes on only tures were used both for induction and from time after cessation of the administration of ether, although to time throughout the operation. Perhaps very little milder degrees of slowing may sometimes be observed during the administration of ether by the open method. chloroform was used in some cases and this was what These unusual phenomena are more apt to occur when was indicated when the term "open ether" was used. morphine is given in one-quarter rather than one-sixth I may say it was not for want of trying that aids to or one-eighth grain doses. Atropine has no counter- the ether were used because in the case of patients acting effect. with bad exophthalmic goitre, whose neck perhaps Because of what I have just said, I think that both had been infiltrated with novocaine and adrenalin it chloroform anæsthesia and open ether anesthesia are seemed quite wrong to use chloroform. Attempts were contraindications to the preliminary use, of morphine. made to give only ether, but the induction was often I am not here concerned with closed ether methods. so prolonged and the irritation of the upper respiratory It was found, however, that the amount of chloro- passages so pronounced that the use of a little chloroform used became less and without any alteration in form under these circumstances seemed the lesser of methods patients seemed more amenable to ether, and gradually chloroform was discarded both for induc- ' Read at a Meeting of the Victorian Branch of the British Medical Association on March 2, 1921. tion and during continuance of the anesthetic. I am 414 THE MEDICAL JOURNAL OF AUSTRALIA. [May 21, 1921. quite satisfied that it is a • better thing for the patients fortunately such apparatus is usually suitable only to have chloroform put completely aside. Ether is for hospital work and it is an anomaly that while in given from start to finish and nothing whatever is the public hospital where I work, we have no such given to aid it, with the exception of some cases in apparatus. We are keenly alive to its value. In which the surgeon may specially ask beforehand for another hospital where there is such an apparatus, some preliminary medication, and of other cases in it has reposed under a sheet for the greater part of private hospitals in which for some reasons quite its existence. unknown to me preliminary injections are given as No matter what anesthetic is used nor in what the a routine. I discover this during the induction and form it is administered, the successful main- in these cases I certainly do not find it any help. tenance of the air way is the keynote to suc- In adopting this method I have done so partly to cess. There is nothing conducive to greater see if a fool-proof method could be evolved which danger than the ignorance of this fact or failure to would be equally safe and pleasant to the patient recognize that such a conditon is not being accom- and as effective as any other, because I found that plished. in the teaching of anesthetics there was consider- Hewitt writes : "In considering the effects able risk that when the "A.C.E." or chloroform and produced by anesthetics in the human sub- ether bottle was there for induction, it would be ject, it is impossible to overestimate the im- used throughout and it would be chloroform anes- portance of the freedom or the want of free- thesia with its consequent dangers to the patient and dom with which the respiratory current enters and discomfort to the surgeon owing to frequent halts leaves the lungs. Many phenomena customarily as- for artificial respirations. It also seemed to me that cribed to the direct effects of an anesthetic upon this it was hardly a fair thing to impose on others and or that part of the nervous or circulatory systems are those the ones who naturally would lack the prac- often in reality referable to a greater or less degree tice, something which I did not carry out. For that of occlusion of the air tract, the presence and effects reason amongst others I have refrained from using of which are not realized." . chloroform almost entirely during the last few years. The last bottle I had was bought in June last ; that The anticipation of trouble is the best means of was used up a few months ago, the bulk of it be- preventing it and the majority if not all of the cause it happened to be in my bag and as I had troubles of anesthesia commence with imperfect free- used all my ether towards the end of an operation I dom of the respiratory passage. Moreover, so many wanted to keep the patients going a little longer. vicious circles can arise that when once the air ways are obstructed from any cause, it often takes quite The form of mask may vary, as may the cover, a while before a happy condition is again established. but they should be of a kind that all air breathed It is often claimed that ether stimulates the secretion except in the early stages must pass through the of mucus and thus is a bad anesthetic. Perhaps it covering of the mask. The smell of the ether can be does to some degree, but if the carbon dioxide element effectively disguised by addition of oil of orange. is eliminated there is very much less mucus secre- We can only judge by effects, but more than one tion. In fact a great many of the so-called disad- . medical man has assured me that he did not recog- vantages to the use of ether are due not to the ether nize it as ether when being anesthetized in this way. but to the carbon dioxide. Venous engorgement and Anesthesia is produced as quickly as the mucous all it means, want of muscular relaxation, laboured membranes will allow. Ether is poured on quite breathing with big respiratory excursion, none of these freely but at first the mask is not held firmly on the need be present in the very large majority of cases. face. This is done gradually. The anesthetist must The depth of anesthesia necessary for surgical pur- watch all the time for coughing, sneezing, breath- poses is consequently much greater when the carbon holding, swallowing or anything else which indicates dioxide element enters into consideration. It may that the vapour is irritating the air passages and if produce muscular rigidity rather than relaxation, so any of these take place, he should give more air and that the patient is pushed until all reflexes disappear get the patient to keep on breathing regularly. and the pupil is fully dilated and fixed, and even The majority of patients will, keep up an even then the muscles are hard as boards and the colour rhythm if given a chance, but some in spite of all we is such that there is often a rush for the oxygen may do, will fight against it, will hold their breath cylinder. or keep on coughing or swallowing. In these cases, If on the contrary the carbon dioxide element be they must be made to cough themselves "under" or eliminated, the patient looks absolutely normal as swallow themselves "under"; that is we must make regards colour, the breathing is quiet and easy, there induction easy for them if possible. If this cannot is good muscular relaxation and everything seems be done we should not waste time, but push it so good that the anesthetist only looks at the eyes straight off and they must go. out of curiosity, if at all, when it is found that the Drop methods should be drop methods and not pupils are small and active, and as likely as not a "pour and pause." During induction there should be corneal reflex is present. a gradual increase of depth and not a "come and Just in passing a word as to corneal reflex. I . go" and during maintenance there should be a steady know fine distinctions are made as to corneal or maintenance and not a pendulum-like condition. conjunctival reflexes. These are purely academical. For this reason any mechanical device for the even To elicit the corneal reflex, advantage is taken of maintenance of anesthesia i,s a great asset. Un- the pool of tears in the corner of the eye to moisten May 21, 1921.] THE MEDICAL JOURNAL OF AUSTRALIA. 415 the finger, which is then brushed sharply across thesia, but far less so with ether than with chloroform. cornea ; gently touching or almost touching the cor- By advocating light anesthesia I certainly do not nea will not elicit a reflex which is really present, advocate a degree of lightness which will not give thus causing confusion. muscular relaxation. If the attention be concentrated on the breathing, I know prejudices still exist against ether in cer- there is very little requiring further notice. Any tain work. Some nose and throat men claim that variation in the respiratory rhythm is noted and only chloroform can give the degree of relaxation re- accounted for and the condition causing the varia- quired. I can recall one who suggested the insertion tion is eliminated either by reducing or increasing of the mouth gag before I started with ether, as the depth of anesthesia. If it is due to reflex dis- sometimes it could not be got in when the patient turbance from light anesthesia, the anesthesia must was under. I managed to get the patient sufficiently be increased ; if conversely the respirations are being anesthetized to relax the jaw muscles. Still I have effected by depression of the medullary centre, it not yet succeeded in producing deep enough anes- must be relaxed. With a perfectly free air way, thetic to insure relaxation of the cervix uteri, as was with no preliminary medication, with ether induc- desired by a surgeon colleague of mine. I mention tion and maintenance on an open mask, in the great this to show that objections to ether are often based majority of cases the method is fool-proof and it is on ideas as to what an anesthetic should do which impossible to get the patient too deeply under. But are quiet wrong, or on conclusions formed from see- if the carbon dioxide element comes in, it is quite ing anesthetics not properly administered. a different story. As to posture I recommend comfort for the patient The preliminary examination of a patient has never during the induction. I use no pillow at all after, to me borne the importance some would attach to it. for two reasons. It is easier to maintain freedom What are the conditions contraindicating operation ? of the air way and it is the position most favour- Certainly not compensated heart bruits, certainly not able for good cerebral circulation. I hold cerebral uncompensated heart conditions, if the operation is anemia is not under any conditions desirable. Of for the removal of the cause, certainly not grossly course the position of the patient should be varied poisoned heart muscles if the anesthetic is necessary in accordance with the nature of the operation. for the removal of the cause. First of all the need for the operation must guide the giving of an anes- ANZESTHETIC NOTES.' thetic and the method I have indicated is very safe at almost any age or in almost any condition. By R. W. Hornabrook, M.B., Ch.M. (Ade.), M.R.C. S., L.R.C.P., The question of shock must enter into account in Melbourne. many operations and I think the anesthetic may have a big influence here. In this connexion some of the Morphine and Atropine. present ideas as to shock are of interest in that if I believe for the comfort and safety of surgeon, we pay attention to the capillary circulation as has anesthetist and patient that the small dose of morphine long been the custom, a very good idea as to the and atropine is absolutely essential in all operations patient's condii;ipn is obtained. After the breathing with the exception of those operations in which there the capillary circulation should be watched rather is any. question of the base of the brain being in- than the arterial pulse. volved, when the, morphine should be left out and only atropine employed. Pink blanching on pressure, with quick return to pink, shows good condition and variations in Morphine is stimulating, sedative, depressant. If colour and rate of return after pressure give accur- an anesthetist or surgeon is incapable of handling at information both as to shock and freedom of air morphine properly, that is in the small dose, then he way. I think shock is more often due to overdosage had better leave it alone, for if he does use it im- of a aesthetic than to reflex stimuli from the site properly, then he is bound sooner or later to get of the operation. If the whole system is slogged into trouble and, cause a death to occur from respir- odt with poison, fortunately far less seen now than atory failure. in the chloroform days, there must be greater likeli- Let me illustrate my point. Some years ago I met hood of shock. a surgeon whose patients at the Women's Hospital with which he was connected, all had 0.0075 grm. We are told that with light chloroform anesthesia morphine and 0.004 grm. atropine one hour before there is danger of reflex stimuli producing auricular operation. He was so pleased with the result that he fibrillation. This is not so with ether, and it is just decided to give the morphine and atropine for his another reason for avoiding chloroform. Several private patients. He told me of this and I said : surgical procedures are mentioned as requiring deep "Well, look here, sir ! If you are going to use mor- anesthesia in order to avoid shock. One of these is phine and atropine for your private patients, be dilatation of the sphincter ani, a procedure re- careful how you do so and avoid both a large dose commended specially to revive an overdosed patient. of morphine and chloroform as the anesthetic because Others are pulling on the vas, section of the optic if you do not, you will for a certainty get into trouble nerve, or internal of the eye. In all these I rectos and have a death." His reply was this:, "I do not have purposely maintained very light anaesthesia and follow you. I do not see why if I can give say 0.015 there has been no indication of shock. grin. morphine to a patient in ordinary circumstances, Pulling on organs in the upper part of the ab- Read at a Meeting of the Victorian Branch of the British Medical domen tends to cause breath-holding in light anes- Association on March 2, 1921. 416 THE MEDICAL JOURNAL OF AUSTRALIA . [May 21, 1921.

I cannot give the same amount under anesthesia." ana?sthetist's point of view, it is not worth anything. My answer was : "I cannot give you the exact reasons, The anesthetist who relies on it, will get into trouble for I do not know them, but I can tell you this that sooner or later. It is not the hearts that you hear if you do employ the large dose of morphine, you anything from that go out under a general anes- will kill someone and you will be responsible for that thetic : it is the heart that you do not ; in other words, death, and yet on the other hand if you employ the the sloppy, fatty heart. small dose of morphine and atropine you will be If the readers of this journal desire me to continue, absolutely safe provided you do not use chloroform I will do so. I know I am unorthodox according to as an anaesthetic." Well he went his way—like ; all the ordinary rules, but I believe in common sense, big surgeons who think they know something. He and why in Heaven 's name a patient should be stood used his 0.015 grm. morphine and chloroform and he on his head because lie is unconscious, I have never had two deaths in a private hospital within a few been able to perceive. If the Supreme Power in- weeks from respiratory failure and then he wanted tended us to stand on our heads, as many anes- to and did condemn morphine and atropine. If he thetists seem to think, when under ,operation and had been just and honest, he would have con- when back in the wards or going to the wards, then demned himself. The man who cannot and will not surely He would have given us feet where our hands. learn, had better leave morphine and atropine alone, now are. I believe with Cecil Rhodes in treating be he anesthetist or surgeon. But to condemn mor- "human beings," as he calls them, as human beings. phine and atropine because he is incapable of hand- I am very often inclined to think that as surgeons ling them, is only to reveal what a lot he has yet and anaesthetists we look upon our patients as in- to learn. I have advocated and for years I have animate objects. told the profession that they must stick to the small • dose of the morphine and atropine, viz : For adult - OXYGEN ANÌESTHESIA.' males, 0.01 grm. morphine and 0.0005 grm. atropine, GAS and for adult females, 0.0075 grm. morphine and By S. O. Cowen, M.D. (Melb.), 0.0004 grm. atropine one hour before operation. For Medical Clinical Assistant, Melbourne Hospital. children of both sexes between 8 to. 12 years, 0.005 grm. morphine and 0.0004 grm. atropine, and be- Although nitrous oxide, with or without the admix- tween 3i and S years, 0.003 grm. morphine and 0.0003 ture of air or oxygen, had been used as an anesthetic grm. atropine. for many years, certain difficulties in the technique of its administration prevented its general adoption These results are from many years' close observa- for prolonged operations, although it was widely tion and have been largely adopted by many anes- used for induction preliminary to ether or chloro- thetists, both in this country and abroad. If the form. The apparatus of Hewitt, who was the pioneer anesthetist or surgeon thinks he knows better, then of gas-oxygen anesthesia, afforded no means of sup- well and good, depart from them, but sooner or later plying the gases under uniform pressures or of adding he will be caught and have a death, especially if he ether or chloroform to the mixture, while rebreathing employs chloroform as an anesthetic, but he must was difficult to regulate. not blame me or the patient. Let him put the blame Fortunately these defects were remedied, mainly where it belongs—on himself—and let him consider owing to the efforts of American workers, before the that he has passed one more unfortunate into the outbreak of the late war. There was at hand, there- unknown. fore, an effi cient means of administering an anes- Personally, I have no time for the man who con- thetic eminently suitable for many of the procedures demns morphine and atropine. I think that the ad- of military surgery. During 1915 and 1916 Boyle(1) vantages of morphine and atropine entirely outweigh demonstrated its qualities in the class of work seen their disadvantages, if properly handled. There is in base hospitals in England. Its general adoption an absolute soothing effect on the patient—a most came slowly, however, and not until the end of 1917 important point ; the lessened quantity of anesthetic did gas-oxygen become widely used in casualty clear- required, for we know to-day that all antesthetics are ing stations where it proved brilliantly successful. tissue poisons and the less anesthetic required, the Its practicability in this class of work was first de- better for the patient. The lessening of the chance of monstrated by Major Geoffrey Marshall of the Royal broncho-pneumonia from the lessened bronchial secre- Army Medical Corps, with whom I had the pleasure tion due to the atropine; the lessening of shock from of working for some months and it was his persistent both the morphine and atropine ; the dryness of the advocacy which finally led to its widespread employ- skin after atropine, the warmth of the patient, the ment. lessened anesthetic used and the lessened risk of post- As no apparatus is available, I do not propose to operative vomiting are all a gain and a distinct gain. deal with the technique of the method, but will I know this : I would permit no anesthetist, no mat- confine myself to a brief discussion of its qualities ter how expert he may be, to give a general anes- and defects as demonstrated in war surgery and its thetic to one of my family unless he used morphine possible field of usefulness in civil work. ^' and atropine as a preliminary, but it must be in the Chief among the advantages claimed for gas-oxy- small dose and again I emphasize that fact. Every gen is that it is "the physiological anesthetic." It leading anesthetist in England and America has fol- merits the title because it enters the blood as a gas lowed me on this point. ' Read at a Meeting of the Victorian Branch of the British Medical As far as the stethoscope is concerned from the Association on March 2, 1221, -flay 21, 1921.] TI3E MEDICAL JOURNAL OF AUSTRALIA. 417 and is exhaled having the same composition with the cain was almost always necessary, since gas-oxygen addition of carbon dioxide (2) . It is carried in the produces no ,real muscular relaxation. Even with blood in physical union, causing no chemical or mor- local anæsthesia and the additi on of ether, upper phological changes and can therefore be completely abdominal work was not sal isfactory. These diffi- eliminated in one or two cycles of respiration. This culties were lessened, by close co-olieration between explains its freedom from depressing effects and the surgeon and the amesthetist, who were, in most its suitability for badly shocked patients. Under teams, on a much more equal footing than generally gas-oxygen there is a slight rise in blood-pressure obtains in civil hospital practice. Each readily ac- with some quickening of the pulse rate, the colour cepted the suggestions of the other with great ad- improves and the respirations are deep, quick and vantage both to themselves and to the patient. regular. It was, indeed, amazing to see the improve- Owing to the quick - recovery from anesthesia., pain, ment of shocked, exsanguinated patients under it. especially after abdominal operations, was more Despite the trauma of operation, the pulse and colour marked than with ether or chloroform. So notice- became better and, what is most important, there able was this, that it was often questioned whether was very little reactionary depression when adminis- gas-oxygen aneesthesia was sufficiently deep to pro- tration ceased. In this respect it proved superior tect the brain from peripheral stimuli during the to warm ether and oxygen which, though more stimu- operation. Crile(7),'chowever, states that it is much lating, was followed by a much greater "slump." more efficient in thiïs respect than ether and cer- This freedom from depressing effects renders gas- tainly the freedom from shock supports his con- oxygen a very safe anesthetic. But, while safe, it tention. - . • is by no means fool-proof. For years it was taught The further disadvantages were mainly mechanical. that nitrous oxide is dangerous only when given with The apparatus is cumbersome and weighs, with too small a percentage of oxygen and that asphyxia charged cylinders, about 27 kilograms. Marshall(8) is the cause of all deaths occurring under it. It has has devised a portable type of about 18 kilograms since been shown, however, to have a direct action weight, but even this would not be very convenient in on the heart itself, occasionally causing acute dilata- private work. tion, even when given with oxygen (3) . It has no For hospital work the cost is a serious item. The action on the vaso-motor centre nor does it cause consumption of gas averages about 273 litres and of irritation of the respiratory tract. Death under gas- oxygen about 114 litres per hour. At current local oxygen occurs extremely suddenly; I have seen a prices this works out at about £1 an hour. In pri- patient who appeared to be doing well, die, after a vate work the cost would be 25% greater. few retching movements, within a minute. This was Finally gas-oxygen can only be administered safely the only death I saw, although it was given in many and satisfactorily by an anesthetist who is expert in desperate cases to patients who in civil work would the technique; , This means an addition to the hos- have been considered unfit for any ansthetic. Its pital staff since the resident medical officer is not success under such conditions showed it to be the on full anesthetic duty for a sufficient time to be- safest of all anesthetics when given by an anesthetist come expert, nor is he on such a footing with the thoroughly slcilled in its administration. The margin senior surgeons as is essential to team-work and of safety is perhaps smaller than with other methods hence to success with this method. and, as a number of deaths in civil practice have been In the light, of our war experience, what are the reported(4, 5, 6), its lethal possibilities should not possible uses of gas-oxygen in civil. surgery? For be lost sight of. desperate cases, whether from toxemia or trau-

The rapidity of induction and recovery with gas- matism •or hirmorrhage, it would be invaluable.

oxygen reduced the anesthetic period to a minimum Fortunately , such cases • are not common in civil

—a point of great importance in casualty clearing hospitals • but when they do occur, gas -oxygen, station work. Within a very few minutes after ad- if available, might. easily tip the scale between life ministration had ceased the patient was in full pos- and death. session of his faculties and was able to ask for the For operations ou elderly people it is strongly in- inevitable cigarette. Post-anesthetic vomiting sel- dicated owing to its freedom from irritant effects dom occurred and, in my experience, was never severe on the respiratory tract. so that the nurses' work was lessened. In cases re- Coma is stated (9) • to be less frequent after opera- quiring repeated dressings under general an æsthesia tions on diabetics with this than with any other these qualities rendered the method almost indis- method. pensable. In cases requiring .repeated dressings under general The greatest disadvantage of gas-oxygen was the anesthesia and for minor procedures, such as the lightness of the anesthesia produced. Attempts to removal of abdominal plugs, it is by far the best obtain greater depth by pushing the nitrous oxide anesthetic. only led to cyanosis and increased rigidity. This de- On the other hand it is contraindicated in cases fect was partly overcome by the addition of ether where absolute muscular relaxation is required all the and by preliminary injections of morphine and atro- time, especially in upper 'abdominal operations. It pine and, sometimes, scopolamine. Even with these is unsuitable for operations in the dark, such as cys- adjuvants any traction or twisting of a fractured toscopy, since it, Is essential to watch the patient's limb was resented, though cutting produced no effect. colour very closely. In abdominal work, infiltration of the wall with novo- Certain general' contraindications to anæsthesia 418 THE MEDICAL JOURNAL OF AUSTRALIA. [May 21, 1921. apply with especial force to gas-oxygen. It should apparent simplicity. The - small surface which the be avoided where there is advanced degeneration of gut offers for the absorption of the ether vapour, the heart and vessels because of the possibility of imposes the need of a concentrated solution placed acute cardiac dilatation. The face piece renders in situ and necessarily absorbed slowly. This solu- manipulation of the jaw and tongue difficult, so that tion when once introduced into the rectum passes the method is unsuitable for cases with dyspneea or more or less completely out of our control. obstruction to the air way. The apparatus required is : In view of the facts brought forward, I believe that (1) Olive oil and ether. gas-oxygen has a wide field of usefulness in civil (2) 8 oz. measuring glass. practice. It has proved successful in many Ameri- (3) Catheter (about No. 10 or 12 rubber) and can clinics and is steadily becoming more popular rubber tubing. in Great Brithin. On the other hand, not a few sur- (4) Glass funnel geons have tried the method and soon discarded it. From the published accounts it seems that the Preliminary Treatment. majority of the failures have been due to its trial in Castor oil is given the morning of the day before unsuitable cases and to the fact that surgeons who the operation. The diet during this day should be have been used to ether antesthlesiir,, often fail to of such a nature to leave as little residue as possible realize the limitations of gas-o02eik. Although the in the bowel. method is by no means universally applicable, its sue- Warm water enemata are given on tae morning òf cesses are so striking, especially in desperate cases the operation to Secure as empty a rectum as possible. where other anaesthetics are contraindicated, that I This is preferably done about, two or three hours feel that we in Melbourne have delayed too long in before the induction of anæsthesia. making use of it and at least investigating for our- One hour before the operation a preliminary hypo- selves its merits and defects. dermic injection of morphine 0.005 to 0.015 grm. and atropine 0.0002 to 0.0006 grm. and a suppository of References. chloretone 0.3 to 0.2 grm. are given, the latter to act (1) Boyle, H. E. G.: Lancet, 1917 II., p. 667. as a local sedative. (2) Seybould, J. W.: Med. Record (N.Y.), 1917, p. 63. The solution used for anæsthesia consists of a mix- (3) Buxton, D. W.: British Medical Journal, 1916, II., p. 159. ture of ether and olive oil (50% to 75%), and the (4) Robinson, W. E.: British Medical Journal, 1916, II., amount given is reckoned upon a basis of 31 c.cm. of p. 291. the mixture to every 10 kilograms of body weight. I (5) McCardie, W. J.: British Medical Journal, 1916, II., have never used a larger dose than 240 c.cm. of the p. 109. (6) Baldwin, J. F.: Med. Record (N.Y.), 1916, p. 177. mixture for an average • healthy male. The mixture (7) Quoted by Seybould: Vide supra. requires to be shaken. The constituents remain (8) Marshall, G.: British Medical Journal, 1919, II., p. 77. blended long enough for introduction—if the mixture (9) Page, H. M.: Proc. Roy. Soc. Med., VI., p. 27. is warmed slightly, induction is quicker.

RECTAL ANÆSTHESIA 1 The Administration. The injection should be given in the ward or bed- By R. Howden, M.B., B.S., room, with patient lying comfortably on his left side. Honorary Ancesthetist, Melbourne Hospital. And I may here state that to a very nervous or panic- stricken subject the fact of being anesthetized com- The administration of an anaesthetic by the rectum fortably in bed without any face covering is a great has been used intermittently for the last 10 or 15 boon. The soft rubber catheter is introduced about years, the anesthetic used being oxygen and ether 10 to 15 cm. into the rectum and the oil and ether and later an ether and olive oil mixture. With regard mixture is allowed to flow in gently by gravity only— to the former I have no personal knowledge, but at least 10 to 15 minutes being taken for the selected Flagg says it is only possible to maintain and not dose to . run in. to induce anesthesia by that means. Vapourizing of The patient quickly becomes drowsy and excite- ether alone high up in the rectum has been tried, ment may supervene, but is usually very moderate but abandoned, owing to the amount of inflammatory and is often entirely absent. If the excitement is trouble following. Anesthesia by the injection into marked, it is perhaps best overcome by a little ether the rectum of olive oil and ether has overcome the given on the ordinary face mask. objections of the two former methods. Usually in about a half of an hour anæsthesia has Dr. •Gwathmey, of New York, found that when sufficiently developed for the patient to be removed liquid ether was mixed with a small quantity of to the operating room. olive oil, it could be injected into the lower bowel The stage of maintenance is controlled by increas- without causing irritation and that a very satisfac- ing or decreasing the freedom of the respiration, i.e., tory method of anæsthesia could thus be obtained: a towel over the face will cause the patient to sink The procedure is quite simple and no elaborate ap- into deeper narcosis by virtue of the rebreathing of paratus is required. But . as Flagg points out that some of the expired ether. On the other hand a though the method is certainly attractive from cer- pharyngeal tube will lower the level of maintenance tain points of view, it is pernicious because of its by increasing the freedom of respiration and so the amount of ether thrown off. Read at a Meeting of the Vkktoriau Branch of the British Medical Association on March 2, 1921, Anesthesia will usually be maintained for an May 21, 1921.1 THE MEDICAL JOURNAL OF AUSTRALIA. 419

hour and a half. Occasionally it is necessary to sup- Governing Modern Midwifery Practice," Dr Mar-

plement the rectal administration • by the drop garet McLorinan states : (1) ` ` That more than half method on the mask, but this is usually in big-framed, the women are permanently damaged by the so-called robust males. normal function of bearing a child." (2) That, in Should there by signs of respiratory failure, the her opinion, this morbidity is due to difficult labour, mixture should immediately be withdrawn from the the great cause of which is the disproportion of the bowel by reintroducing the catheter and allowing foetal head at the end of a nine months' pregnancy the retained solution to run o ff. And if respiration to the normal female pelvis. (3) That "we have no should fail, artificial respiration must be done—and positive evidence that within the last 100 years the rebreathing of carbon dioxide may be beneficient. If average size of the female pelvis has increased ; on the this is ineffective, it has been recommended that an contrary, the reverse would appear to be the case. intravenous injection of saline solution should be Unfortunately, the same cannot be said about the given with the object of reducing the ether tension. foetal head." (4) That "nine months is becoming . After the operation is completed it is very neces- too long a period for the foetal head to be retained sary to wash out the rectum and bowel thoroughly. in utero." To do this a tube is passed 20 to 40 cm. into the I propose to offer some comment on the text fur- rectum and a large enema of soap and water used. nished by Dr. McLorinan. Though my own long ob- It is advisable to make provision for a rectum flow stetric experience in hospital and private practice •by inserting a second short stiff wide tube about 2.5 would not justify the extent of Dr. McLorinan's claim cm. beyond the sphincter. Sufficient fluid should be as regards the damaging effects of child-birth on used until the return flow has no smell of ether ; then women, it has confirmed the views I put forth at the a little saline solution is run in, followed by 60 to Intercolonial Medical Congress, 1889, in a paper on 120 c.em. of olive oil, with a view to neutralizing any The Obligations of Gynæcology to Obstetrics," in ether that may be left behind. which I maintained that an unduly large amount of If this after washing of the bowel is neglected, the female pelvic disease was directly traceable to child- patient may fall into a deep, rather alarming stupor. birth—for reasons, however, not connected with dis- It is always well that when returned to bed the proportion of the foetal head. patient should be on his side with the head of the Dr. McLorinan says : "The increase in the intel- bed raised. lectual development of the modern human has re- The tendency to after-sickness is diminished and sulted in a corresponding increase of neopallium. often there is no sickness at all. So far as my limited Function is succeeded by structure and to this there experience goes, there has been no rectal or colonic can be no limitation." Beyond this statement she irritation following this procedure. adduces no biological evidence to support the theory The advantages of the method are : of an evolution which, ex hypothesi, must be regarded (i.) The nature of the induction in the patient's as working adversely against the reproduction of the bed is a great boon. human species. What, I may ask, is going to deter- (ii.) The apparatus is simple and economical. mine the limits of this increasing growth of the foetal (iii.) The control, when effective, is most simple. head and this decreasing size of the maternal pelvis? (iv.) When the intratracheal method is not Extending the argument, this question may be put : available, this method is very suitable for If 100 years of increased intellectuality (or 500) has operation in the oral passages, the nasal pas- resulted in such a development of th6 foetal head as sages and the head and neck, as the anæs- with a decreasing size of the maternal pelvis, necessi- thetist is out of the way of the surgeon. tates, in the interests of the mother, delivery at the The disadvantages are: end of eight months, what will be the safe limit of (i.) The increased amount of labour thrown on intra-uterine life 1,000 years hence ? the nursing staff, so that it cannot be used as a routine method. But have we any warrant for the support of such (ii.) The preliminary preparation so distresses a theory? Does Dr. McLorinan really believe that the patient. 100 years "of increased intellectuality" has speeded (iii.) It is undesirable in cases where the Tren- up the neopallium to the extent that it forces on us delenberg position may be required. in the average case the alternative, of a damaged mother or an immature child ? An evolution oper- (iv.) It is not always possible to recover . injections which may be having untoward effects. ating in this direction might well wring from us an (v.) It cannot be used for emergency cases. appealing cry to Nature for some beneficent check to (vi.) It is contraindicated in any condition of our increasing intellectuality. irritation or ulceration of the bowel or rec- To establish Dr. McLorinan's theory on a sound tum. basis it would be necessary (1) To show that difficult labour is "modern" in its incidence and that it is increasingly wide - spread. (2) To eliminate most MODERN OBSTETRICS: THE CASE FOR NATURE. of the recognized causes of difficult labour, other than By Felix Meyer, M.D., B.S., the disproportion of the foetal head. (3) To have a Honorary Consulting Surgeon, Women.'s Hospital, Melbourne. wide range of accurate measurements of maternal pelves and foetal heads within the last hundred years, In her article in The Medical Journal of Australia to compare with the corresponding measurements of of April 9, 1921, Observations on Some Principles the present day. (4) To show an immunity from 420 THE MEDICAL dOiJRNAL OP AUSTRALIA. May 21, 1921.

difficult labour- in races who have not. advanced in Primitive Peoples, " Engelmaini has shown that the the scale of intellectuality. empirical or natural obstetrics which still survives So far as my study Of the subject has among tribes or peoples dependent on their own re- guided me, it has led me to the conclusion sources, includes a great variety of mechanical and that the labour of the average woman of to- medicinal measures to meet the difficulties and day is not appreciably different from, or is not more dangers of child-birth. The illusion=a fairly wide- difficult than,that of the average woman one century spread one—that abnormal, or difficult, or prolonged or many centuries ago. Turn where you will to medi- labour is exceptional with "savage" people is rudely cal literature, from the time of Hippocrates to the dispelled by the account of the various mechanical present day, you will find convincing evidence in devices, mainly of a vis a tergo nature, to make proof of this statement. labour more speedy and less painful, such as changes I have had for many years in my possession "A of posture, swinging by the limb of a tree, powerful Manual of Midwifery and Diseases of Women and massage, simple expression, either by the encircling Children, with a Complete Atlas," by Dr. M. Ryan, arms of an assistant (generally a man) or the pa- Professor Of Medicine and Midwifery, etc., etc. ; fourth tient's hands pressing on her abdomen, "the assistant edition, 1841 (first edition, 1828) . The work repre- going so far as to trample upon the back or belly of sents a wide personal experience in obstetrics and the patient." The means, which vary with peoples, gynaecology gained in dispensaries, hospitals and pri- are as uncouth as they are endless. vate practice dating from 1815. The works of ancient Engelmann tells us that: "In Mexico and Southern. and modern writers on these subjects are laid under India the woman is shaken several times to promote contribution, as well as those of the profession at delivery ; but if this does not answer, she is rolled on home and abroad. The result is an excellent and the ground or suspended by her feet and shaken." authoritative work which received high recognition. (This method is tried after the failure of downward

Of the 550 pages of the book, the author devotes more pressure.) ` ` The Nez Percé Indians reverse the pa- than 100 to dystocia—difficult and preternatural tient if labour is prolonged and whilst the head rests labour. He deals with the immediate and remote, con- upon the ground, shake the body vi gorously in the sequences of difficult and tedious labours, which he air. The Esthonians suspend and shake the patient characterizes as "real and not imaginary evils"— vigorously if labour is retarded. In Syria the patient lacerations, inflammation, suppuration, heavy womb, is given twenty-four hours for her labour ; if then un- falling of the womb, etc.. Time and patience count delivered, four male or female friends pack her in a for much with this accomplished obstetrician and blanket, roll her about and bounce her up and down though "the exact time for applying the forceps to facilitate delivery !" One could fill pages with must, however, be subject to the judgement of the ob- these adventures in quest of eutocie. stetrician in any individual case," "it is advised as In the transactions of the Edinburgh Obstetrical a general rule that the labour should have continued 'Society (Vol. IX., 1883-84) there is an interesting twenty-four hours before the use of the forceps. first-hand account by Robert W. Felkin, F.R.S.E., No one who reads his chapter on dystocia will be per- F.R.G..S., of labour in Central Africa, delightfully suaded that labour 100 years ago was any "easier" illustrated. One can readily accept his conclusion : 'than it is to-day. "That labours are by no means so very easy in this Going back 300 years, I read in my much treasured part Of the world and are not the painless, pleasur- tome, "The Works of that Famous Chirurgion, Am- able affairs which some writers would have us be- brose Parey" (published 1649) , that, ",because that the lieve"—a conviction endorsed by Professor Simpson, travail of the first time of childe birth is wont to be who says elsewhere that : "The accidents and difficul- verie difficult and grievous," he prescribes a soothing ties described as so frequently occurring amongst such ointment to lubricate the passages, etc..' . Ambrose primitive peoples proved that labour among the black Paré (1509 to 1590), the re-discoverer and perfecter races was not the safe and easy process it was some- . of podalic version, represents early scientific obstet- times supposed to be." rics, as contrasted with the empiricism of Hippocrates Where, then, are we to look for the cause of the and his disciples, and some of his ideas about diffi- unduly large morbidity following child-birth? For cult labour have a curiously modern touch. most of it, I maintain, now, as in a former article, in It is a long way back to Hippocrates (420 B.C.), unscientific obstetrics. The theme has been so well Celsus (30 B.C. to A.D. 14), Soranus, the father of expounded in Dr. Fourness Barrington's luminous ad- ancient obstetrics (A.D. 98 to 117), Mosehion (A.D. 117, to 138), Galen (A.D. 131) and later writers on dress as President of the Section of Obstetrics and medicine and there is abundant evidence to show Gyna cology at the Australasian Medical Congress, Brisbane, 1920 (published in that difficult labour, as we Understand it, was of The Medical Journal of September 11, 1920), that, for the pur- common occurrence in those far off times. Hippo- Australia, crates compared the infant's head to an olive in the poses of this article, it covers the ground of com- neck of a bottle and mentions instruments for the plaint completely. One quotation from Dr. Barring- extraction of the feetus. And from the accidents and ton's address will suffice : ` ` The truth is not always difficulties of child-birth there was built up, even in pleasant ; but it may be said here that when the prac- those remote days, a gynæcology applicable to a path- tising obstetrician realizes his great responsibility ology which finds its analogue in our modern day. and that no small share of this terrible maternal mor- An inquiry into the coiditions of child-birth among tality and morbidity lies at his door, he has made the uncivilized or inferior races would carry us very far first step towards progress." There will be no doubt attached, to Dr. Barrington's meaning when he says afield. In -his 'exhaustive study of "Labour Among May 21, 1921.] THE MEDICAL JOURNAL OF AUSTRALIA. 421

that : "Labour is a natural process, which is best left factors in the post-natal development of the imma- to itself and which, in the great majority of cases, ture foetus. it is criminalto ad isturb. " Potel's figures (Dissertation, Paris, 1895) work out The human race has not, so far, conducted its to a mortality of 30.1% for the premature foetus of mating 'on eugenic principles. Nature has produced 7i months and 35.5% for the eight months' foetus. in the past, and will continue to produce, contracted Someone has said that : "Child-birth is an effort of pelves and large foetal heads and Caesarean section Nature protected by Providence." ' And it may be and obstetric surgery generally will continue to have added that neither the effort nor the protection will their legitimate application. But even with appar- be sensibly diminished by "a masterly inactivity" ently "impossible natural delivery," the impossible on the part of the obstetrician. happens. In his address on obstetrics at the annual Meanwhile, the indictment of unscientific obstetrics meeting of the British Medical Association (1909), must stand alongside of Dr. McLorinan 's arraign- Sir John W. Byers, Professor of Midwifery and Dis- ment of Nature, "the head and front of whose offend- eases of Women and Children in Owen's College, Bel- ing." is, in her judgement, the over-developed foetal fast, etc., said : head. One of the most interesting and important lessons we have learnt in maternities in recent times is the occurrence of spontaneous delivery in many patients with Reports of Oses. contracted pelves. My own observation has taught me more and more that in a maternity hospital—where we CLINICAL REPORTS OF TWO UNUSUAL CASES. can get rid of the importunities of the patient's friends educated in the former too-frequent practice of early By Gerald Doyle, M.B., B.S., B.Sc., interference and where we have an opportunity of ob- Si. Arnaud, Victoria. serving Nature's own methods unobscured and not interfered with by unnecessary operative procedure—far MALARIA CONTRACTED IN VICTORIA. more cases will terminate spontaneously under such con- ' W.W., at. —, was admitted to the St Arnaud Hospital on ditions than one would suppose. Dr. Munro Kerr has January 7, 1921, complaining of headache, fever, malaise had the same experience in the Glasgow Maternity Hos- and pain in the left side. The patient had been ill several pital, as well as Zweifel at Leipzig, while quite recently days before his admission to hospital. His past history was Professor Schauta has shown that in his great clinic at uneventful. Vienna actually about 80% of the births with 'narrow 'Habits.—Non-smoker and non - drinker. pelvis occur spontaneously, only full-term births being Present Illness.—This began about four days ago, with considered. But we have learnt something more and similar symptoms to those complained of on admission. He that is that spontaneous delivery in contracted pelves had noted that he felt ill one day and the next day felt much is by far the best method, both as regards the mother better. This alternate recovery and relapse took place until and the child. Not only are the soft parts of the mother his admission to the hospital. not injured under these circumstances, but the child's His temperature on admission was normal and the physical head is not compressed, and, as Professor Schauta puts examination failed to reveal any pathological change, except it: "Of all the possible methods of treatment of labour for an enlarged and tender spleen. in contracted pelvis, the expectant treatment gives by The blood serum did not induce agglutination in the Widal far the best results for the mother as regards both mor- test. The temperature rose every . second evening to about tality and morbidity." 38.9° C. and dropped next morning to 36.8° C. and remained about normal till . the evening of the second day, when it All of which goes to show that if Nature does pre- again rose to about 39 ° C.. sent us with faulty as well as faultless "presenta- As the patient had never been out of Sr. Arnaud in his tions," she has, in the co-ordination of those nervous life, except for fourteen days spent in Mildura, the possi- and muscular energies which constitute the bio- bility of malaria was not at once thought 6f. The examination of the blood by Dr. Andrew Brenan, of dynamics of labour, provided a mechanism which has St. Vincent's Hospital, revealed benign tertian malarial para- withstood, and withstood to some purpose, the de- sites, Plasmodium vivax. naturalizing influences of our modern civilization. It The further course of the patient was uneventful, the fever, is to the misunderstanding and consequent mal- and pain rapidly subsiding when the patient was put on administration of this mechanism that is largely due quinine therapy. the morbidity of child-birth deplored by Dr. McLori- CANINE TOOTH IN THE ANTERIOR NARES. G.C. consulted me for general weakness, with which were nan and by all who have given the matter con- associated attacks of fainting. In the course of examination, sideration. he informed me that he was unable to breathe through the Dr, McLorinan says that : "The advantage of an left nostril. extra month to the foetus cannot be reconciled with On examination with the frontal mirror and nasal specu- lum, a large white mass was seen to fill up the anterior the disadvantage to the mother." nares on the left side, lying just anterior to the inferior Recent studies of ante-natal and post-natal child turbinate bone. It was hard and not tender. As It appeared physiology by Dr. W. M. Feldman, Assistant Phy- loose on probing it, I inserted a forceps and to my surprise sician to and Lecturer on Child Physiology at the In- extracted a complete canine tooth. The patient then volunteered the information that, eighteen fants' Hospital, London, have Ied him to very definite years before, he had been kicked in the mouth by a horse. pronouncements: "Hugounenq's and Hoffström's Several of the teeth were smashed and he thought that one analyse§ 'show that the amount of mineral salts and had been driven upwards, but had never been sure. The iron retained by the foetus during the last three removal of the tooth gave complete relief to the nasal months is twice as great as that fixed during the whole obstruction. of the six months. Hence the premature expulsion of the foetus is a calamity, the seriousness of which it is Reviews. not easy to exaggerate." Thermal instability, defective devel4fant of the central nervous system PRACTICAL OTO-RHINO-LARYNGOLOGY. and the general circulation, which is still of the foetal A new book on laryngology, rhinology and otology, claimed type and therefore unsatisfactory, are all discounting by the author to have been written from a practical point 422 THE MEDICAL JOURNAL OF AUSTRALIA. [May 21, 1921. of view, a volume of some 646 pages of large type with SOME LECTURES BY BLAND SUTTON. nearly 200 textual illustrations, has been presented by Dan McKenzie.' To those who knew and enjoyed Bland Sutton's "Liga- The claim appears to be justified and the book should ments" his new book' comes as an old friend to whom the provide an excellent guide for the senior student and the years have given added knowledge and charm. The` original general practitioner. Its outstanding features are simplicity, chapters on ligaments have been incorporated with a series clearness and brevity in description and avoidance of a of articles reprinted from The Lancet and British Medical multiplicity of alternatives in treatment. The illustrations Journal along with other essays illustrative of the author's include numerous original drawings and photographs of varied interests and written in his own charming and read- merit and a plate of rare and historic interest. The latter able fashion. Bland Sutton has been gifted with the power is a reproduction of coloured drawings of a larynx by Lennox of minute observation and being endowed with a retentive Browne, done in 1870 for Morrell Mackenzie, In a case of memory, has been able to piece together and co-ordinate aneurysm of the aorta with pressure on the left recurrent many facts of common anatomical and biological knowledge nerve. Considerable attention has been paid within the which are of practical interest in the living human being. limits available to operative surgery, but detailed descrip- In the preface he states that after 40 years of almost daily tions of technique, except in the commoner procedures, are teaching In the Middlesex Hospital Medical School, he ven- not included. Pitfalls and difficulties are pointed out and tures to present these lectures and essays that they may means of overcoming them suggested. The author specially serve as a reminder to old students of the hours spent together mentions the methods he himself has found efficacious. Re- studying the dead with the hope of aiding the living. This condite aetiological theories are omitted. The normal for ambition is richly revealed in these essays as well as in all all operations In various regions are described once and 'his other writings and should encourage the reader to try for all, thus avoiding repetitions and economizing space. to follow in his footsteps. No medical man can say he is Wilfred Trotter's operation for transthyreoid pharyngotomy too busy to afford the time for "outside interests" after such is clearly set out and eight pages are given to affections of an example as set by Sir John Bland Sutton, for he was busy the thyreoid gland, especially those having a bearing on such .as few others ever are, but maintained his enthusiasm laryngology. The futility of trying to secure the disappear- all along in the anomalies and rarities of the biological world. ance of adenoids by respiratory gymnastics is referred to. One very forceful lesson to be learned is that the consultant and particularly the surgeon should have a good working Spasmodic stricture of the cardiac end of the oesophagus knowledge of comparative anatomy. is attributed by McKenzie to paresis or paralysis of the This volume is to be highly recommended to all as being vagus. This is not an universally accepted view as he interesting reading, taking us from the beaten path, but himself admits. William Hill, for instance, stoutly holds repaying us well for the time given to it. The subject that It is due to spasm of the diaphragmatic crura and matter *is presented in. a clear and lucid fashion, the print that the stenosis occurs at the phrenlc level and not at is excellent and the wood block engravings add considerably the cardia. to the reader's enjoyment. No medical man who really The author deprecates the use of paraffin in rhinoplastic cares for his profession and its many problems, should be work and suggests in lieu thereof cartilage and bone graft- without this book. ing. For local anaesthesia in the nose he prefers cocaine- adrenalin paste. In cases of hypertrophie rhinitis he advocates sub-mucous resection of the inferior turbinate to DISEASES OF THE EYE. avoid destruction of ciliated mucous membrane. He is of opinion that the Caldwell-Luc operation is seldom necessary It is obviously fair to base one's criticism of a book upon as his simple antrostomy opening anterior to the inferior the claims and purposes set out by the author. A. J. Ballan- turbinate, with extension backward if required above that tyne styles the subject of this review,' "A Pocket Book of bone, gives sufficiently free access in the majority of cases. Ophthalmology" and in a miniature preface a note book The operation of antra-nasal dacryocystotomy . is described which he recommends the student to carry with him to the and illustrated with diagrams. Killian's operation is stated lecture-room and clinic and to use the blank pages for the to have been abandoned by most modern rhinologlsts in insertion of diagrams and supplementary notes. cases of simple chronic suppuration of the frontal sinuses. By skilful and ingenious compression, the subject of ophthalmology is expounded In 112 small pages; there is no The chapters devoted to otology are models of terse and diagram or illustration in the book, but, instead, between lucid exposition. Methods of examination are succinctly out- each page of text is a blank sheet for the student's own use. lined and explained, the tests of hearing enumerated and It would be interesting to examine a number of students' the scheme adopted by the Otological Section of the Royal copies, to see how the system works. The argument is a Society of Medicine added. perennial one: the relative value of a reasonably full text- The description of the vestibular tests and the discussion book, well written and pleasantly illustrated, versus that of of the findings serve to convey in small compass most of the compressed tabloid digest. The truth is probably that the important features of our present knowledge of vestibu- each serves its own purpose. As to the subject matter, it lar phenomena, but no attempt has been made to discuss almost goes without saying that it is sound and admirable, all the bearings of the subject. Having regard to the great the writing is •terse, lucid and agreeable. It is sufficiently variety of detail observed by operating otologists the author up to date without being futurist. Gordon Holmes's corti al has limited himself generally to a description of his own localization is referred to. To any student desiring an accu- methods and practice. He advises the resection of a portion rate summary of modern teaching, the book may be highly of the jugular vein in all cases of lateral sinus thrombosis. recommended. Air He attaches importance to the seriousness of neglecting the employment of vigorous measures in the treatment of ENTRANCE EXAMINATION AT ADELAIDE. exudative catarrh of the Eustachian tube and middle-ear cleft, In order to avoid the less amenable sequelce of chronic In our Education Number (April 30, 1921, page 374) the adhesive catarrh. In the concluding chapter he describes statement is made that for admission to the Medical School the lymphatic system of the nose, throat and ears. - In at Adelaide the candidates must have passed the Senior perusing this book we are struck by the fluidity and clarity Public Examination in five subjects, including English, arith- of thought evinced in the consideration of the subjects metic, algebra, geometry and either Greek, French or Ger- treated and by the singular and graceful ease with which man. Through an oversight Latin was omitted as a com- it is given expression by its author. The general arrange- pulsory subject. Mathematics (arithmetic and algebra) are ment of the subject matter has been planned to give ready regarded as one subject. access to any section and a copious index facilitates ' Selected Lectures and Essays, including Ligaments and Their Nature reference. and Morphology, by Sir John Bland Sutton ; Fourth Edition, 1920. Lon- don: William Heinemann (Medical Books), Ltd. ; Demy Svo., pp. 317, with Diseases of the Throat, Nose and Ear, by Dan McKenzie. M.D.. 111 illustrations. Price, 15e. net . - 2 F.R.C.S.E. 1920. London: William Heinemann (Medical Books), . Ltd.; A Pocket Book of Ophthalmology, by Arthur Jas. Ballantyne, M.D. • Royal 8vo., pp. 646, with two coloured plates and 199 figures in the Crown Svo., pp. 119. F.R.F.P.S. • 1920. Edinburgh : E, & S. Livingstone; text. Price, 42e. net . Price, ie. Cd. net;

May 21, 1921.] THE MEDICAL JOURNAL OF AUSTRALIA. 423

part-time work introduced .gradually many years ago. In the case of the first professors of medicine Cbe Medical Journal of Mustralia. and surgery, the school has every reason to applaud the Senate on the action taken which led to the selec- SATURDAY, MAY 21, 1921. tion and appointment of two Australian graduates of unusual merit. Both have proved their. ability. • Choosing a Professor. The Senate of the University of Sydney has not The Senate of the University of Sydney at times always been wise. Its latest determination in regard exhibits wisdom. Not long ago, when placed in a to the establishment of chairs in the medical school more advantageous position in regard to funds than involves a principle which we regard as quite un- the governing bodies of the Universities of Melbourne sound. It is usually held that a chair represents a and Adelaide, a chair of medicine and a chair of sur- great department of a teaching school, not a sub- gery were established. The Senate was faced with division. Usage has determined on logical grounds a• serious difficulty when it considered the conditions that the main sciences on which all medical know- attaching to the two professorships and met these ledge is based, should command separate departments difficulties by choosing the lesser of two .evils. It ill the medical schools. Under the older formule, recognized that the most competent practitioners in these fundamental sciences have been called anatomy, medicine and in surgery would not be attracted by biology and physiology. We have claimed that this- the remuneration offered to a university professor. arrangement admits a sort of admixture of pure It therefore became necessary to seek men who would science, a hybridization, as it were. We have sug- give a moiety of their time to the immensely im- gested that it would be more economical and certainly portant task of controlling and maintaining essential more rational to re-arrange the fundamental sciences departments of the medical school. The compromise into medical physics, medical chemistry ór bio- was not to -the advantage of the school, but the Senate chemistry and biology. In a similar manner we have realized that it was essential to insure efficiency. frequently clamoured for the recognition of three Moreover, it has to be remembered that the practice ultimate or professional branches of medical educa- has gradually insinuated itself among the professors tion, namely medicine, surgery and preventive medi- of the Medical Faculty of the University of Sydney cine. The Senate erred seriously. a few years ago in of undertaking work not directly connected with the creating a chair of pharmacology. This step signified teaching of students or the prosecution of research. the advancement of a sub-division of medical educa- This practice arose as a direct result of the inade- tion to the level of a great main department. The quate remuneration of the men responsible for the same mistake is now being made by the establishment organization and proper conduct of great depart- of a chair of psychiatry. It would seem as though a ments of the medical school. The Senate has al- precedent had been established, for there are indica- ready yielded to the force of circumstances. Rather tions that in the immediate future a chair of ob- than lose the services of the professors who had built stetrics will be founded. It is imperative that the up the inimitable reputation of the school ; they sanc- practical and theoretical instruction of both obstetrics tioned outside work, because they were not prepared and psychiatry should be extended, improved and to increase the remuneration. We hold that the developed. This can be done without the creation price paid was too great; that a supreme effort of a chair or of a main department in the medical should have been made to compensate the professors school. The appointment of expert clinical teachers, reasonably, if not generously, but to insist on the tutors and demonstrators who would be prepared to concentration of their undivided attention to their devote time and energy in teaching these two highly university duties. It is late, at the present time, to important subjects, would be much more effective revolt against the principle of part-time professors, than the creation of what promises to become merely since it is a not-illogical corollary of the germ of a lectureship with a high sounding title. The 424 THE MEDICAL JOURNAL OF AUSTRALIA. [May 21, 1921.

student should be freed from the tedious and doubt- damaged hearts a trade adapted to their altered fully useful duty of listening to endless systematic physiological state. It is stated that much useful information was collected at this home, on which lectures. He can read all that the lecturer may say further advance could be based. In 1915 there was in some of our admirable text-books. He should be formed the Association for the Prevention and Relief given ample time to attend practical instruction in of Heart Disease. The objects of this incorporated body were to collect information concerning heart the• lying-in wards and in the demonstration rooms, disease, to develope and to apply measures of pre- as well as in the wards and other departments of the vention, to promote the establishment of special dispensary classes for patients with heart disease, to pro- hospitals for the insane and of the institutions for vide suitable occupation for these patients, to ex- incipient diseases of the mind. tend the opportunities for the adequate care of convalescents from cardiac disease, to seek means for The Senate of the University of Sydney has been the permanent care of persons with hopelessly unwise in instituting unnecessary professorships, crippled hearts and to encourage the establishment of similar institutions in other cities. When America while there is still no chair of preventive medicine. entered into the war, there were more than twenty But it has been more than unwise in perpetuating a heart dispensary classes in New York. Then the movement was compelled to suspend its operations. custom, necessary in the early days of our Universi- In the latter part of 1919 a fresh start was made ties, long since past The selection of the best can- and in the first year of its renewed activity the As- didates for the position of professor of psychiatry sociation certainly succeeded in justifying its existence. It is remarkable that the endeavour to combat is to be made by a committee in London, 12,000 miles one of the most extensive and disastrous evils affect- from the portals of the Sydney University. Are we ing human beings has been launched in a wealthy and great city with very limited financial backing. never to grow up ? Are we always to ask mother to From the inauguration in 1915 till November 30, feed us ? We can conceive of no franker admission 1920, the total fund available amounted to only $8,558. of incompetence than to delegate the choice of our Less than £1,000 was spent in 1920. Careful perusal of the last annual report reveals that the programme own professors to a committee of friends in London, on which the Association is working, does not call who may, but probably do not, possess a full ac- for a large expenditure. Little has been attempted in the way of prophylactic measures. It is held quaintance of the conditions in Australia and of the that the best methods of prevention must be sought ability of the Australian candidates. It is advisable in the early detection of cardiac defects. Surely this and even necessary to advertise the vacancy. in very laudable and necessary aim belongs to the Great remedial measures. Prophylaxis has a totally differ- Britain. To ask our own graduates to submit their ent significance. The Association apparently antici- applications to an English committee is no longer a pates more success in the campaign to limit the amount of cardiac damage in the individual than in the reasonable procedure. endeavour to control the causes of vascular disease. • The Association sought the collaboration of the Board of Education and induced the Board to arrange for THE RELIEF OF HEART DISEASE. a systematic examination of children at selected schools and the establishment of special classes. At In the year 1911 an out-patient clinic was opened seven schools experimental work is being conducted at the Bellevue Hospital, New York, for the con- to ascertain the effect of segregation and physical tinued treatment of patients suffering from heart training on children with organic cardiac lesion s disease after discharge from the wards. The pa- characterized by signs of cardiac insufficiency. This tients were invited to attend at definite intervals, no work is also to be extended in another direction by matter whether they felt ill or well, in order that the establishment of ungraded classes. The centre the control kept . on them might be continuous and from which this school work is conducted is called rational. Attached to the clinic was a trained social the Cardiac Clinic. There are now sixteen of these service worker who visited the patients in their homes clinics attached to public hospitals. The Association and supplemented the endeavours of the physicians is busy in co-ordinating the cardiac clinics with the in charge of the clinic by advising the relatives how hospital wards, nose and throat departments, con- the home environment might be adapted to the pa- valescent homes, exercise classes, laboratories, X-ray tient 's physicial disability and helping to secure work departments, dental departments and patients' homes for the patient suited to his cardiac complaint. In by means of a well-organized social service. In `addi- the following year the Hospital Social Service took tion there is activity in the direction of vocational up the idea thus begun and obtained incorporation training of adults handicapped by damaged hearts of an institution called the Trade School for Cardiac and of .a popular education campaign. The scheme Convalescents. This organization embraced a coun- and its early application has been ingeniously try convalescent home, where the experiment was , planned and launched with enthusiasm. On paper started of teaching labouring men affected with it is very attractive. Whether its social significance May 21, 1921.1 THE MEDICAL JOURNAL OT' AUSTRALIA. 425 is as great as it would seem from the published re- sequently these girls get into trouble. In addition cord, remains to be proved in the course of time. to the risk incurred by the nurses, the thoughtless The President of the Association, Dr. Lewis A. use of lying-in hospitals for surgical work inflicts a Connor, and his collaborators are to be congratulated wrong on the owners of ordinary private hospitals on their plucky attempt to attack this very important who make full provision for the nursing and care of matter. We have consistently called attention to patients in any illness, whether surgical or medical the fact that cardio-vascular disease is responsible for treatment is required. Medical practitioners labour more suffering and premature death than any other under the erroneous idea that by "feeding" the pri- group of diseases. The war has given us much in- vate lying-in hospitals in this way, they are bene- formation concerning the frequency of the affections fiting the proprietresses or managing nurses. On grouped in this class. It has long been recognized the other hand, the nurses hesitate to refuse admis -' that rheumatism, syphilis, alcohol and possibly over- sion to the patients, because they do not wish to offend indulgence in rich living are all removable causes or disappoint the practitioner. We feel sure that the of cardio-vascular disease. Moreover these patho- practice will be discontinued as soon as the real logical processes are responsible for the vast major- state of affairs is recognized. ity of the cardio-vascular affections. It is appalling to consider that approximately 25% of all deaths ADVERTISING IN DIRECTORIES. fall within this definition. The aim of the New York organization is admirable, but it is merely ameliora- The General Medical Council referred a short time tion. It is well worth all the energy expended, pro- ago to the Executive Committee the question of the vided that it supplements and does not replace the position of medical practitioners who allow their urgent work of true prophylaxis. The beginning names to be advertised in a publication called the has not been made to check the ravages of rheumatic "Buff Telephone Book." On February 21, 1921, the infection. Many pathologists have endeavoured Committee resolved : . singly to disclose the real pathogenesis of these in- That the Executive Committee is of opinion that the insertion of the name of a medical practitioner for pay- fections. Until an extensive and properly co-ordin- ment, whether with or without typographical display, in ated campaign under the direction of a master mind a list issued to the public and purporting to be a list has taken this problem in hand, no advance can be ex- of local medical practitioners, which is not open to the pected. In Australia serious steps have been planned whole of the profession without such payment, is not in accordance with the professional standards in respect to cope with the syphilis danger. We fear that to advertising and might be held to bring a practitioner the medical profession is lending a luke warm assist- so advertising himself within the terms of No. 5 of the ance and that the enthusiastic and inspiring struggle Council's Warning Notices. of a handful of large-minded patriots will be re- While it is unfortunate that the Executive Com- sultless unless the hygienic conscience of the whole mittee should have restricted the application of this profession can be awakened. Some advance has been finding to insertions for which payment is made, it is made in the fight against alcoholism, but much more clear from the context that the principle in medical remains to be done. Until the public is forced to ethics on which the Committee has based its decision, recognize the intolerable amount of harm inflicted is the undesirability of an advertisement of a prac- on the race by the poison alcohol and indeed by all titioner's name in a list issued to the public which is forms of self-indulgence, hygienists will have to face not open to the whole of the medical profession with- the cardiac problem with dismay and a feeling of out payment. The fact of payment merely aggravates helplessness. The patching up of even many thou- the offence. Moreover, it may in certain cases be sands of cardiac cripples is but a drop as compared difficult or even impossible to ascertain whether pay- with the ocean of benefit to be gained by the , elim- ment has been made or not. The ruling, no doubt, ination of the causes of cardio-vascular affections. covers the instance of the "Buff Telephone Book." In the instance dealt with recently by the Federal THE MISUSE OF PRIVATE LYING-IN HOSPITALS. Committee of the British Medical Association in Aus- tralia, this principle was applied to a publication In every State of Australia private hospitals are known as "Who's Who in the Commonwealth." Since registered for the reception of women about to be this list is not open to all medical practitioners in the confined as so-called obstetrical hospitals. The nurs- Commonwealth, it is obviously objectionable for a ing staff of these hospitals usually consists of women practitioner to allow his name to be included and trained for one year in obstetrical nursing. Only more than objectionable to permit a biographical rarely has the chief nurse or proprietress undergone a notice to be published in connexion with his name. full course of training as a general nurse. It appears that it is not uncommon for medical practitioners to POST-GRADUATE LECTURES ON CARDIAC DISEASE. use these private hospitals frost time to time for surgical work. The misuse is, we are persuaded, not The course of five lectures on cardiac disease arranged by the Melbourne Permanent Committee for Post-Graduate intentional. Medical practitioners fail to recognize Work (see The Medical Journal of Australia, May 7, 1921, that by requiring midwifery nurses to attend to pa- page 392) will be delivered by Dr. Hume Turnbull on Tues- tients undergoing surgical treatment, they are plac- day, June 8, 1921, and on the following four Tuesdays at ing these nurses in an awkward position. The Aus- 8.30 p.m. at the Walter and Eliza Hall Institute of Research in Pathology and Medicine. The fee for the series will be tralasian Trained Nurses' Association and the Royal £1 ls.. The Committee will announce at a subsequent date Victorian Trained Nurses' Association do not permit the general arrangements including fees of the further midwifery nurses to undertake general work and con- lectures on special subjects. 426 T$E MEDICAL JOURNAL OF AUSTRALIA. [May 21, 1921.

Abstracts from Current medical which are structurally weak, become three months. Great conservatism over-stretched and placed in a bad me- should be observed in the final re- Literature. chanical position, while the stronger moval of all support in these cases. groups become more spastic. All methods of treatment aim at securing ORTHOPJEDIC SURGERY. (183) Internal Splinting of Bone. muscle balance and in Stoffel's opera- In the open treatment of fractures tion this is effected by endeavouring to (179) Repair of Collateral Ligament of the steel plate has had great popular- alter the condition of the spinal reflex ity because of the simplicity of its ap- the Knee-Joint. arc, which, according to A. Bruce Gill plication. This advantage, however, In cases of marked instability of the (Journ. Orthop. Surg., February, 1921) does not justify its use since steel acts knee-joint Alec. H. Edwards (Brit. produces the spasticity. In addition to as an irritant and foreign body. In Journ. Surg., January, 1921) suggests breaking a "vicious circle," the opera- a large percentage of cases the plate an operative procedure to repair the tion improves the patient's cerebral has to be removed. Cortical bone collateral ligaments. In the case of control. Before operation is under- the fibular collateral ligament the in- taken, preliminary treatment in the plates have some advantages over steel plates, but special instruments are re- cision exposes the fascia lata, the lat- shape of correction of the deformity in eral condyle, the tendon of the biceps plaster of Paris, massage, active exer- quired for their use and they are apt to break when used for fractures of and the head of the fibula. Flaps are ` cises and galvanism should be carried large bones. The ivory key, according made of the biceps tendon, which is out. The actual operation is carried fixed with a staple into the femur, and to Paul B. Magnuson (Northwest Medi- out by attacking the nerve bundles in cine, of the fascia lata, which is similarly the intact nerve and details are given December, 1920), offers the best fixed into the head of the fibula. Strong in the case of the median, obturator, solution of the problem. A slot or key tension should be maintained in both sciatic and tibial nerves. The extent way is formed by cutting the bone with instances during the actual fixation. A of partial resection can only be gauged a twin circular saw and removing . the few stitches help to secure the flap and by experience; but often one-half or cut fragments. The line of fracture the wound is then closed. In the case more must be removed. Contractures occupies the centre of the keyway. An of the tibial collateral ligament an in- are only dealt with mechanically if they ivory plate is then driven into the key- cision is made along the medial side of persist during deep anesthesia and, if way until it reaches the cortex on the the knee, with the centre at the medial present, can usually be overcome by opposite side. An ivory peg or nail is condyle. The M. sartorius is separated forcible correction. In those cases in driven through to hold the plate into from the condyle, while the gracilis and which contractures disappear during the slot and to prevent movement in semi-tendinosus are separated and anesthesia, no after-fixation is used any place. Any section of the plate drawn forwards. Both of these ten- and in a week the patient is sent to or pegs projecting beyond the cortex dons are divided at the level of the the gymnasium for training. Opera- of the fractured bone is removed. In medial condyle, dissected back to their tion is contra-indicated in cases in cases of simple oblique fracture an attachments and drawn well forward. which there is athetosis, progressive ivory screw with a square head which The distal portions are stitched together multiple sclerosis, diffuse spasm over can be turned with a wrench is fitted and inserted into a groove cut on the the whole body, or extreme idiocy. into a thread cut with a tap. In long medial epicondyle and fixed with a Hemiplegia, both in children and adults, fractures two screws may be used. staple. The proximal part of the semi- is generally a suitable condition for tendinosus and gracilis are then operation. (184) Orthopaedic Treatment of Burns. stitched to thé sartorius. The limb is • immobilized in plaster of Paris for Harrigan and Boorstein (Annals of Surgery, fourteen days and in one month gentle (182) Restoration of Shoulder Function November, 1920) maintain active movements are allowed. that contractures due to burns can be After Loss of the Head of prevented by proper orthopedic treat- the Humerus. (180) Recurrent Dislocation of the ment. In burns of the neck a removable collar of felt is applied to over- Shoulder Joint. The only solution of the problem pre- From the standpoint of the stability sented by the great disability which correct the neck in the direction re- of the shoulder joint, the deltoid is a results from loss of the head or upper quired. In burns of the shoulder and dangerous muscle. The position in portion of the humerus following in- axilla, to prevent the "bat wing" de- which dislocation occurs, is always one fection or trauma, lies in the replace- formity, the hand is tied to the head of abduction and 'the contraction of the ment of the bone which is missing. of the bed, so as to maintain the upper deltoid really assists to thrust the head Fred. H. Albee (Surg., Gynec. and Ob- arm in extreme abduction. At the elbow through the weak inferior aspect of the stet., January, 1921) divides the cases the arm is kept in extension by tying capsule when the arm is outstretched. into two groups. In the first group are it to the corresponding side of the bed. When the shoulder becomes dislocated placed those cases in which the mus- A plaster cast is used to keep the fin- during the most trivial strain, or simply culature of the shoulder is practically gers apart in burns of this region. Re- as a result of contraction of the del- intact. A movable, functionating, recon- cently the various modifications of toid muscle, the condition may be con- structed shoulder joint may be pro- Jones's and Thomas's splints have been sidered a recurrent dislocation. To duced by replacing the lost portion of adapted for the prevention of contrac- remedy the condition a number of pro- humerus with a graft of the head and tures of the limbs. cedures have been proposed, but Alex. upper portion of the fibula. In some Gibson writes that he has found the cases the muscles may be attached in- (185) The Use of Wire in Surgery of deltoid flap operation most satisfactory dividually to the graft and are the most Bones. (Caned. Med. Assoc. Journ., March, favourable factor in the restoration of To get over the difficulties in obtain- 1921). The flap is cut from the pos- function. The second group include the ing a certain and neat fixation of wire terior portion of the dèltoid muscle and cases in which the muscles have been used in the treatment of fractures J. sutured to the coracoid process. This so destroyed that it is impossible to M. Neff and J. S. O'Malley (Surg. provides a muscular sling, which con- to restore the power of movement. The Gynec. and Obstet., June, 1920) propose tracts during abduction of the arm and treatment consists in attempting to solder the wire. Copper or silver forms a firm resistance to downward the operation of arthrodesis so that the wire previously tinned is passed displacement of the head of the hu- scapular muscles may be employed to through a drill hole in the usual way merus. Seven operations have been move the humerus. The position o f . and drawn tightly in opposite direc- done by the author and so far the re- the arm for arthrodesis which is fav- tions. This brings the ends of the wire sults have been uniformly favourable. oured by the author is one of flexion into lateral and parallel contact. at an angle of 90 ° and of slight internal Liquefied zinc chloride is applied to the (181) Stoffel's Operation for Spastic rotation, which brings the hand in point of contact and a drop of elec- Paralysis. front of the face. The humerus is trician's solder applied with a tinner's In spastic paralysis the element of attached to the scapula by a truss soldering iron secures fixation. The spasticity far overshadows the element work of tibial grafts and immobiliza- soldering iron is tinned before using. of paralysis. The groups of muscles tion in plaster is maintained for about Two cases are reported. May 21, 1921.] THE MEDICAL JOURNAL OF AUSTRALIA. 427

MORPHOLOGY. motor fibres to the M. tensor veli the anterior wall of the root and arch palatine, while the M. levator veti of the aorta and had invaded the (1186) The Growth of Neurones of the palatini is innervated by the so-called atrio-ventricular septa and partly sur Gasserian Ganglion. bulbar portion of the eleventh nerve mitral-rounded the tricuspid and A systematic study of the growth of or, to speak more correctly, by the valves. This calcified tissue was 6 to the neurones forming the cranial and inferior rootlets of the tenth nerve, 8 cm. in thickness. The only trace spinal ganglia of the albino' rat is in since the bulbar portion of the eleventh of the right atrial chamber was a pas- progress in the neurological laboratory has been shown to be really an integral sage leading from the vena cava inferior of the Wistar Institute. K. Nittono, part of the vagus. These results are and coronary sinus to the tricuspid in the Journal of Comparative Neu- based on experimental work done on portal. As a result of this condition rdlogy, October 15, 1920, presents to dogs. The author was not content all blood returning from the body above this study a contribution dealing with with observations of the movements the diaphragm (except from the coronary the Gasserian ganglion. Measure- of the soft palate. By an ingenious veins) was forced to descend to the ments were made of 25 •of the largest and careful technique he rapidly ex- abdominal cavity and enter the vena ganglion cells in 76 ganglia taken from posed the M. tensor veli palatini. When cava inferior, so that the direction of 38- normal albino rats and of the 10 stimulating electrically the nerves in the blood stream in the azygos veins largest fibres from each branch and the interior of the cranium, he took was the exact reverse of the normal. from the fifth nerve root in 39 rats. care to prevent diffusion of the current Much of the venous flow from the head The growth of the ganglion cells shows by using a weak current with unipolar and superior extremity flowed directly three distinct phases: (1) A rapid electrodes and by drying the part of into the azygos and hemi-azygos veins growing period, extending from birth the nerve stimulated. In every experi- through the anastomosis of the right to about the twentieth day of life. (2) ment stimulation of the mandibular and left supreme intercostal and ac- A slower period, lasting for a further branch of the fifth nerve caused defin- cessory hemi- azygos veins with the in- GO or 80 days. (3) A. period of much ite vigorous contractions of the M. nominate and vertebral veins. The re- slower rate, extending to maturity. tensor veli palatini on . the side stimu- mainder passed via the vena cava su- This growth rate is noted in both nu- lated. The presence of a relay station perior through the azygos vein in a cleus and cell body, but the increase in in the otic ganglion was also excluded. reverse direction to the normal. Most the diameter of the nuclei is slower After painting the ganglion with nico- of the blood entered the vena cava in- than, that of the cell body. The ratios tine, he observed no appreciable differ- ferior by a pair of anastomoses just between the volumes of the cytoplasm ence in the contraction which followed below the diaphragm close to the hepa- and the volumes of the nuclei increase stimulation of the fifth nerve. The tic veins. The remainder of the ven- with increasing size (age) of the gang- writer points. out that paralysis of the ous return passed by way of the left lion cells and in the largest cells the palate is rarely observed clinically in renal vein and left first lumbar vein. ratio is more than twice as large as in cases of disease of the fifth cranial Much of the superficial venous drain- the smallest. About 20 days after birth nerve. Under anwsthesia the raphé on age of the thoracic wall was absorbed the cell body and the nucleus show al- the palate of a dog was marked with by the thoraco- epigastric and super- most the same appearance as that in indian ink. The tendon of the M. ficial and deep epigastric veins to be the adult rat. After this time both in- tensor veli palatini was then cut and carried to the femoral and iliac veins. crease in size and there is also an in- while the swallowing reflex was being crease in the quantity of Nissl sub- set in motion, the palate was observed. (189) Controlling Factors in Amphibian stance, but the other morphological Not the slightest dragging of the pal- Metamorphosis. changes are very slight. The diameter ate to the non-paralysed side could be of the fibres is least in the ophthalmic detected. Finally, the case of a pa- John F. Fulton, Junr., writing in branch and largest in the fifth nerve tient under observation in the Johns Endocrinology, January, 1921, has re- root. Up to 80 days of age the volume Hopkins Hospital is recorded. This pa- viewed the controlling factors in am- of the ganglion cells increases at the tient had a unilateral affection of the phibian metamorphosis, a field in which same rate as the area of the head sur- fifth cranial nerve. Naso-pharyngo- most fruitful results have been face; but after thisthe growth of the scopic examination showed that the achieved. He states that results which neurone slows down, while that of the pharyngeal orifice of the Eustachian have been gained, give to these investi- head continues. The ratios between tube on the affected side remained quite gations an intensely 'practical aspect the diameters of the ganglion cells and stationary during deglutition, offering and indicates that endocrinology as a the diameters of the nerve fibres de- in appearance a striking contrast to science ' will be concerned in the fu- crease as the body weight increases. the normal reflex opening of the orifice ture not only with the physiology of The decrease after puberty is due to a on the unaffected side. This and other. mature individuals, but also with em- . longer continued growth in the dia- observations would indicate that the bryological developments. The meta- meter of the fibre, as compared with main function of the M. tensor veli morphosis of amphibians cannot take that of the ganglion cells. The neu- palatini is to open the Eustachian tube. place in the absence of the thyreoid rones in the Gasserian ganglion are In the case of the M. levator veli hormone and the feeding of growing larger, have a higher nucleus-plasma palatini, direct observation of the tadpoles with dessicated thyreoid ac- ratio and mature earlier than do those muscle was also the basis of experi- celerates their rate of metamorphosis. in. the ganglion of the seventh cervical ment. Thyreoldectomy interferes with bone nerve. However, the fibres from the growth and causes the liver, intestines, Gasserian cells have a smaller diameter (188) Collateral Circulation Following thymus, brain, kidney and spleen to re- than those of the seventh cervical tain their larval condition, whereas Occlusion of the Superior ganglion. These differences are pos- gonads and lungs develope normally. sibly related to the somewhat special- Vena Cava. But a larva so arrested will metamor- ized character of the fifth cranial nerve. Otto F. Karnpmeier records a case phose normally if fed, with' thyreoid of complete occlusion of the vena cava extract or with organic . iodine. The (187) Innervation of the Palate. superior occurring in a negress of organic extract of the pineal gland Arnold Rice Rich (Bull. Johns Hop- middle age who had suffered from accelerates metabolic processes, but kins Hosp., September, 1920) discusses syphilis and chronic mania (Anatomi- seems to inhibit the growth of the the innervation and action of the tensor cal Record, November 20, 1920). Upon testis. The thymus is primarily a lym- veli palatini and levator vele- palatini examination of the heart post mor- phopoiëtic organ and is probably not Muscles. The results of several pre- tem the major portion of the right an endocrine organ. It does not affect vious workers, both clinical and ex -. atrium as . well as an extensive area metamorphosis and has no influence on Perimental, are first reviewed and are of the aortic arch was found to be of sexual development. The cells of the found to disclose a number of conflict- a bony hardness. Upon opening up pituitary are closely related in func- ing opinions, even when they are based the heart the entire wall of the right tion to the interstitial cells of the testis. nn experimental evidence. The author's atrium and the interatrial septum was The anterior lobe probably stimulates conclusions are that the fifth nerve is composed of thick, compact, "osseous" sexual development, accelerates growth the only cranial nerve which supplies tissue which had extended .up through and assists in bone ossification. 42S THE MEDICAL JOURNAL OF AUSTRALIA. [May 21, 1921.

to such a mask he dropped ethyl chloride and ether freely British medical Association news. for induction, the period of which was very brief and con- SCIENTIFIC. sequently could not be very distressing. It was exceptional for any of the soldier patients to take longer than two A meeting of the Victorian Branch was held at the minutes to "go off" and it was to be remembered that many Medical Society Hall, East Melbourne, on March 2, 1921. of them were alcoholic. Mr. Basil Kilvington, President, in the chair. Before ' commencing administration, he arranged the Dr. F. L. Davies read a paper on "Ether Anaesthesia" (see patient's hands across the chest, with the fingers inter- page 413). locked. The effect was that in any subsequent struggling Dr. R. W. Hornabrook read a paper on "Morphine and the hands became more tightly locked and the embarrass- Atropine in Connexion with Anesthesia" (see page 415). ment occasioned the anaesthetist by the patient flinging his Dr. S. W. Ferguson spoke on the intratracheal adminis- arms about was obviated. tration of ether, and demonstrated the apparatus. He said Dr. Lee emphasized the great advantages to be gained that his remarks would be confined to the intratracheal by a preliminary talk with the patient, in which suggestion method of administering ether. He demonstrated two could be brought to bear, the patient thus rendered more apparatus, the larger one designed by Kelly and the smaller receptive. He was decidedly in favour of a small pre- designed by Dr. Lidwill of Sydney for portable use. He liminary dose of morphine and atropine and considered that always gave a preliminary injection of morphine and atro- the morphine was a valuable aid to suggestion in creating pine, the former in small dosage. The advantages claimed an amenable condition of mind in the patient. For the main- for the method were that an absolutely regular anaesthesia tenance of anaesthesia he kept to "open" ether, and ether with warmed ether vapour was attained, artificial respira- alone. It was his practice, when once anesthesia was es- tion being kept up all the time, that no matter in what tablished, to place a towel over the mask and to give ether position the patient was, a thoroughly efficient air way was intermittently, as required. He did not favour a continuous maintained with no trouble whatever. drop; it was not necessary to maintain anesthesia and It provided a clear field for the surgeon, as it was un- rendered the administration unduly arduous for the anes- necessary for the anesthetist to be within a yard of the thetist in a long operation. patient. Indeed, in many of the long plastic operations for which The anaesthesia could be deepened or lightened very he had been required to administer anaesthetics in military practice, to have given a continuous drop anesthesia was rapidly . and if any trouble occurred, warmed air only would be given or oxygen added as desired. to court being "put o ff" himself. Patients would remain The method was particularly valuable in nose and throat anaesthetized, even though the ether were given inter- operations. The current of air could be increased just enough mittently, as long as the operative manipulations were con- to overcome the normal respiratory intake and this com- fined to the same part. He had often noted, however, that bined with the exit blast of air by the side of the catheter a transfer of the surgeon's activities to another region, i.e., rendered it practically impossible for material to enter the to take a skin or bone graft, was accompanied by evidence trachea. It was invaluable in bronchoscopic examinations of insufficient anesthesia for the new procedure. and in eesophagoscopy quite eliminated the respiratory Dr. Lee drew attention to the superior qualities of the trouble invariably caused by that investigation with other Shipway mask, with its special mouthpiece, which eliminated forms of anaesthesia. all danger of the tongue falling back. It thus made for For operations on the pleura, by preventing collapse of freer breathing and consequent easier access of the surgeon the lung the method was ideal. to the abdomen. It was probably the safest form of anesthesia for any In the majority of head operations it was necessary that operation. Dr. Ferguson quoted one case in which a sur- the anesthetist should be out of the way of the surgeon. geon had removed the piles while another at the same To suit such circumstances he utilized the Shipway appara- time had been operating on the throat. In a series of nearly tus, with a foot bellows which could be operated from any 2,000 cases he had seen no pulmonary complications. distance. In such a case the two best guides to the patient's condition were to be found in the character of the respira- • In many difficult heart cases, in which the patient was far from well during the induction, the whole picture was tions and in the colour of the blood coming from the wound. changed immediately after the introduction of the catheter. In his whole experience at the Caulfield Military Hospital A further advantage was that when the operation was there had not been a single instance of failure of respira- nearing completion, the lungs could be washed out with tion; he attributed this to the Shipway mouthpiece and the warmed air. This meant the return of the patient to bed maintenance of a free air way. practically recovered from the anaesthetic effects. After- With reference to intratracheal anesthesia, Dr. Lee said vomiting was very much lessened, probably due to the fact that he preferred to introduce the catheter through a that mucus laden with ether vapour was not swallowed as tracheotomy opening, rather than insertion through the was usually the case in ordinary methods of administra- glottis. The opening should be sufficiently wide to allow tion. Not the least of the advantages of this method was of a free escape at the side of the catheter. After trache- the complete relief to the anesthetist from any worry or otomy the pharynx could be plugged, and no blood what- tension. ever need find its way into the air passages during head Dr. S. O. Cowen read a paper on "Gas-Oxygen Anesthesia" operations. (see page 416). In conclusion Dr. Lee referred to rectal anesthesia and Dr. R. Howden read a paper on "Rectal Anaesthesia" (see remarked that It was now in comparative disuse. Patients page 418). frequently became too lightly anaesthetized and found the Dr. C. R. Player also read a paper. necessary preparation very distressing. Dr. H. B. Lee, D.S.O., M.C., spoke from an ex- Mr. H. B. Devine contributed to the discussion from the perience of 18 months at No. 11 Australian Gen- point of view of the surgeon. In his association with Dr. eral Hospital, during which period he had been Davies for the last ten years he had always been keenly called upon to administer anaesthetics in some 1,400 interested in the subject of anesthesia. In 1911 he had cases. He had formerly been wedded to the Shield's brought out a Gwathmey warm ether apparatus from mask, induction by chloroform-ether mixture, and mainten- America and it had been used on the majority of his pri- ance of anesthesia with "open" ether. Owing to too fre- vate patients by Dr. Keane, until a few years ago when it quent troubles with cyanosis, he had discarded the Shield's was superseded by a Downs intratracheal warm ether ap- mask and he had also abandoned the use of chloroform. paratus imported by Dr. Davies. In the latter the ether Although engaged constantly in the administration of anes- vapour was blown into an open mask and only in cases thetic drugs, he could say that in the last twelve months of operations on the head and neck was the intratracheal he had not used a single drop of chloroform. catheter used. Dr. Lee stated that he preferred the "Schimmelbush" Mr. Devine stated that he had never believed in the use mask, covered with one layer of flannel. This was super- of mixtures for anaesthesia and had, in fact, discarded them. imposed on a face-mask composed of several layers of gauze, He had long ago realized that his surgical results were with a triangular aperture over the mouth and nostrils. On to an extent dependent upon the anesthesia; he preferred May 21, 1921. J THE MEDICAL JOURNAL OF AUSTRALIA. 429.

wherever possible that his patients should be only lightly the position of the eye, the condition of the pupil and the anaesthetized. In his opinion, there was much less shock presence or absence of oscillating movements could be noted. with light anaesthesia than with profound degrees; there The inflamed eyes seen after anaesthesia were much more was, of course, a quicker recovery and the subsequent frequently due to corneal abrasions than to the accidental vomiting was very much diminished. Light anaesthesia ne- introduction of a drop of chloroform or ether, although the cessitated very gentle and careful operating and often re- latter was always blamed for the red eye. quired special apparatus. With reference to the anaesthetic of choice in tonsillec- It was essential that the surgeon and anaesthetist should tomy, Mr. Mitchell said that he had had a large operating know each other's work and that throughout the operation experience with ethyl chloride, but had reverted to chloro- they should co-operate closely. Thus the varying degrees form and ether in equal parts. of anaesthesia sufficient for the different procedures could Dr. Gweneth Wisewould agreed with Mr. Mitchell con- be adjusted. It was his own practice to give his anaesthetist cerning the necessity for scrupulous care In dealing with the a few minutes' notice when he was about to perform any cornea. shock-producing manipulation. There was no doubt that In her own experience she had found the necessity to the anaesthetist held a certain amount of responsibility with take the corneal reflex quite exceptional and in a period of the surgeon in regard to the limitation of bad effects in four years at the Alfred Hospital had not utilized the eye operating; conversely the surgeon, by rough and unthought- reflexes except on very rare occasions. The only eye signs ful manipulation, could make impossible a light uniform and which she considered reliable, were those afforded by the ideal anaesthesia. position and movements of the globe. Mr. Devine said that his patients were rarely given a pre- While fully appreciating the advantages of ether from liminary injection of morphine. He recollected a period the point of view of safety, Dr. Wisewould intimated that when the vogue was the "A.C.E." mixture and ether, on she was scarcely prepared to abandon chloroform altogether. a Shield's mask. Looking back to that time he realized She commented on the weakness of certain present -day that there were altogether too many instances' of blueness brands of chloroform as compared with older and more and of artificial respiration. It had to be considered that in potent preparations and observed that the delayed cumu- I^ public hospitals a large number of anaesthetics were given lative effect of the former rendered them more difficult of by resident anaesthetists just through their student days administration. and if they were allowed to use chloroform, the amount given Dr. A. Norman McArthur, speaking as a gynaecologist, r , could not be controlled. In, the hospital in which he worked, remarked that anaesthesia amóng women was comparatively Dr. Frank Davies had of late years trained the students easy; their confidence was more easily gained and they to give ether by the open method without any morphine, were in every respect easier subjects than men. He had chloroform, or ethyl chloride. It was found that there was had many personal experiences of anaesthetics, including no obstacle to induction with ether for all classes of cases local anaesthetics for which he held no brief. He was and that the student very soon became a master in its appalled at the recollection of an ether induction and would use. Now-a-days there were no blue patients and no dis- never forget the nightmare of the long period which asters. He could not remember one scare with ether alone. elapsed before he lost consciousness. Ever since that occa- Whenever difficulty arose during the progress of the anaes- sion he had hoped that, if the necessity again arose, he thesia, he had always found that morphine, ethyl chloride, or might be afforded the most rapid inception of anaesthesia chloroform had been given along with ether. Every fright consistent with safety. he had experienced had been with mixed anaesthesia. Of Quite recently, owing to an accident to his finger, it had course, the great majority of mixed anaesthesias had been been necessary for him to submit to a general anaesthetic. satisfactory in capable hands, but he would not allow any Dr. Lee had administered ethyl chloride and ether and in mixed anaesthesia in any of the big shock-producing stomach contrast to the former experience of ether alone, his sen- operations where it was impossible to retreat and where a sations had been altogether delightful. He had gone to good deal of latitude was necessary. sleep very quickly and the long period of harrowing sus- In some remarks on anaesthesia in exophthalmic goitre. pense which he had come to dread, had been completely Mr. Devine pointed out that the duration of the narcosis eliminated. in these cases was of even greater importance than the type Dr. McArthur expressed his belief in light anaesthesia as of anaesthesia employed, although the latter was undoubtedly conducing to much better after-results. Pneumonia, post- important. Trouble often arose when the period of adminis- operative vomiting, acidosis could all be minimized by avoid- ' tration of "open" ether exceeded 35 to 40 minutes, by which ing too deep degrees of anaesthesia. He was thoroughly in time there was perhaps a little salivation. The operation accord with Mr. Devine's remarks regarding the necessity should always, if possible, be completed within this time for co-operation between surgeon and anaesthetist. He also and It would be found that if the length and the depth considered that the psychological point involved in gaining of ether anaesthesia were each reduced to the minimum com- the patient's confidence was of the greatest importance. patible with careful work, all exophthalmic goitre patients Mr. Frank Andrew spoke with reference to intratracheal would come through the operation quite well. He preferred anaesthesia. these patients to be anaesthetized as lightly as possible; he He had been astonished at the suggestion of a previous had even operated with the patient talking; light anaesthesia speaker that intratracheal ether should in all cases be ad- involved much less risk and was followed by a better con- ministered through a tracheotomy opening. Tracheotomy valescence. was a measure which should be reserved for cases of laryn- It had been his custom to give intratracheal warm ether geal obstruction and in which the passage of the catheter vapour in exceedingly bad cases of exophthalmia goitre and was impossible. in no. other circumstances did he consider even to do the operation in two stages of about twenty tracheotomy necessary or justifiable for the intratracheal minutes each, dealing with one lobe only at each sitting. administration of ether and In these the patient would be In some cases, however, in which the condition was com- tracheotomized or dead beforehand. There was no opera- plicated by oedema of the legs and abdomen and fibrillation tion about the head, no matter how much blood or pus, of the heart muscle (he had recently operated In such a with which intratracheal anaesthesia did not cope in an case), it was impossible to give anything else but local ideal manner. anaesthesia, at any rate for the first lobectomy. He had recently carried out an operation under suspension Mr. Leonard Mitchell asked whether a minute dose of laryngoscopy and intratracheal insufflation of ether; during morphine was not justifiable. He entered a plea for mor- the course of the operation one of his sliding blades broke phine in just sufficient quantity to abolish that "stage- off and had slipped down the trachea. It was necessary fright" which rendered the taking of an anaesthetic such subsequently to follow the piece of steel by bronchoscopy, an ordeal to many persons. He held that the cornea and to recover it from the right stem bronchus. Although and conjunctiva should be treated more delicately than was much bleeding had been occasioned by the original operation, often the practice. The day had passed when It was in the after survey with the bronchoscope no blood what- necessary to brush the eye with the finger to gauge the ever had been seen in the trachea. The reason for this was depth of anaesthesia. He considered that sufficient in- that with the intratracheal apparatus, blood, as it was shed, was blown out into the pharynx. therefore formation could be gained from an inspection of the eye; It was un- 430 THE MEDICAL JOURNAL OF AUSTRALIA. [May 21, 1921.

necessary to perform tracheotomy in order that the en- wards, in order to insure a free flow of blood to the brain. trance to the air passages might be packed off from the In his opinion a crusade was required to impress on field of operation. nurses the necessity for keeping patients warm during ans- Various speakers had emphasized the paramount import- thesia and to improve the ventilation of many of the ance of the free air way. This was a point which could operating theatres. Nurses did not seem to appreciate the not be hammered too hard. A free or obstructed air way amount of bodily heat lost under anæsthesia. He had often was the difference between good and bad an æsthesia. wondered what danger lay in the admission of fresh air, In the intratracheal method a regular supply of abundant even though it might contain a certain amount of dust. air was guaranteed from the moment the catheter was in The close and stuffy conditions prevailing in the average position. The anaesthetist's responsibilities in this respect operating theatre were very depressing and could not but ceased and the worries of both surgeon and an æsthetist affect patient and doctors adversely. were considerably reduced. Reviewing the discussion, the administration of anaes- With reference to post-operative pneumonia Mr. Andrew thetics seemed to resolve itself largely into a question of expressed scepticism as to chill as the most important the man behind the gun. Different men became equally factor. He was of opinion that post-operative pneumonia proficient in the methods to which they were severally ac- was most frequently an inhalation pneumonia. Many customed. Dr. Wilkinson was impressed with the excellence patients were pyorncceic; others had dirty mouths in other of the intratracheal apparatus, particularly for certain respects; in prolonged anæsthesia mucus often collected in special operations, but remarked that after all, simplicity the throat and round the aperture of the larynx. In- was the ideal. Modern "open" ether gave the greatest satis- halation of any such material was impossible with intra- faction for simplicity and safety. tracheal anæsthesia and post-operative pneumonia conse- Mr. Basil Kilvington expressed the indebtedness of all quently did not occur. present to the readers of the papers. An excellent discussion Pleurotomy and bronchoscopy were perfect procedures had been evoked, in which it was apparent that there was under intratracheal an æsthesia. He considered that it was some lack of agreement in matters of detail. Unanimity pre-eminently the method for oesophagoscopic work. The prevailed on two very important points, however. They oesophagoscope must constitute a respiratory embarrass- were (i.) the elimination of chloroform wherever possible ment for ordinary methods of anaesthesia, but with the intra- and (ii.) the maintenance . of the free air way. tracheal apparatus this trouble was eliminated. After all, the various modifications in method gave equally Intratracheal anaesthesia added greatly to the operator's satisfactory results in capable hands, and the personal comfort in bronchoscopy, in that the current of air and equation entered very largely into a comparison of the ad- ether vapour down the bronchoscope prevented that shower vantages of different modes of administration of anaesthetics. of blood and pus which had frequently been endountered in the past. In conclusion, Mr. Andrew said that he knew The undermentioned have been elected as members of the of no method of anaesthesia for head operations In which Victorian Branch: there was such a uniform absence of congestion and a Miss Marion Boyd Wanliss, minimum of bleeding as was afforded by intratracheal Melb.), B.S. (LTniv. 1921, Melbourne Hospital. - administration. John Holmes Shaw, Esq., M.B., B.S. (Univ. Melb), 1921, Dr. J. F. Wilkinson said that he had found it interesting Melbourne Hospital. to reflect on the changes that had taken place since the Clifford Henry Coomer Searby, Esq., chloroform days, when ether was rattly used and when em- M.B., B.S. (Univ. Melb.), 1921, Melbourne Hospital. ployed, was generally given by asphyxial methods. The Miss Beatrice Alice Warner, M.B., B.S. (Univ. Melb.), disadvantages of the earlier modes of giving ether and 1921, Melbourne Hospital. the anxiety attending the administration of chloroform were Harold William Harbison, Esq., M.B., B.S. (Univ. Melb.), in striking contrast with the comfort of present-day "open" 1921, Melbourne Hospital. ether. John Horace Kelly, Esq., M.B., B.S. (Univ. Melb), 1921, He used a mask with seven detachable layers of copper Melbourne Hospital. gauze; although it might be a little extravagant of ether, Miss Winifred Barbara Cameron, M.B., B.S. (Univ. Melb.), this mask was really an open one, led to no sense of suffoca- 1921, Melbourne Hospital. tion and was capable of being thoroughly cleansed. Oswald Robert Trumpy, Esq., M.B., B.S. (Univ. Melb.), Two important factors in successful administration of 1921, Warragul. ether were (i.) to give it slowly and (ii.) to make proper Ronald Dingwall McIntosh, Esq., M.B., B.S. (Univ. Melb.), use of morphine and atropine. By the proper use of the 1921, Canterbury. preliminary injection he meant that it should be given to the Robert Southby, Esq., M.B., B.S. Univ. Melb.), 1921, patient on the operating table, In a room adjoining the Parkville. theatre, with the blinds drawn. Talking should be for- John Francis Dunkley, Esq., M.B., B.S. (Univ. Melb.), bidden. If such a routine were carried out, the ansthetist 1921, St. Arnaud. would find the patient in an amenable and receptive condi- Louis Victor Darby, Esq., M.B., B.S. Univ. Melb.), 1921, tion and would encounter no difficulty in the induction. If Hawthorn. the patient were made to walk upstairs to the theatre, the Cyril Joseph Tonkin, Esq., M.B., B.S. (Univ. Melb.), 1921, beneficial effects of the preliminary injection were largely Glenferrie. nullified. Byron Lionel Stanton, Esq., M.B., B.S. (Univ. Melb.), 1921, Dr. Wilkinson expressed himself as in agreement with Hawthorn. Dr: Hornabrook regarding the necessity for keeping to the Sydney Bernard Hudson, Esq., M.B., B.S. (Univ. Melb.), small dose of morphine and atropine. He had known respira- 1921, Parkville. tory trouble supervene after the patient had returned to Frederick James Williams, Esq., M.B., B.S. (Univ. Melb.), bed in a case in which too large a dose of morphine had 1921, Essendon. been employed. Charles Hugh Hembrow, Esq., M.B., B.S. (Univ. Melb.), Although he often gave a chloroform and ether mixture 1921, Alfred Hospital. in the induction, he agreed that the vast majority of patients Benjamin Sheinken, Esq., M.B., B.S. Univ. Melb.), 1921, could be managed with ether alone, provided it were given East Brunswick. slowly. Clive Mansley Greer, Esq., M.B., B.S. (Univ. Melb.), 1921, In regard to eye signs Dr. Wilkinson observed that it was Upper Hawthorn. necessary to learn to appreciate in every individual patient Miss Eileen Fitzgerald, L.R.C.P. et R.C.S., Edin., 1904, the best guide to the level of anaesthesia. It might be Kew. oscillation of the globes, pupil changes or drying of the pool Edward Gascoigne Dermer, Esq., M.B., B.S. (Univ. Melb.), of tears in the canthus, but it should seldom be necessary to 1920, Alfred Hospital. touch the cornea. There was no doubt but that great help was to be derived from watching the eye. LODGE PRACTICE IN SOUTH AUSTRALIA. With reference to the position of the head, Dr. Wilkin- son said that he commenced the administration with the The Council of the South Australian Branch has issued head in whatever position the patient found most com- a memorandum to the members intimating that under fortable, but he generally lowered the head slightly after- existing circumstances it is necessary for lodge medical May 21, 19211 THE MEDICAL JOURNAL OF AUSTRALIA. 431

officers to make their own arrangements in regard to the that the chair should be established being partly supported dispensing of medicines for lodge patients. The Council, by the State Government and partly by the University. after discussion with the pharmacists, endeavoured to ar- That the Professor should have medical charge of Broughton range with the friendly society lodges that the provision Hall, the right of a certain amount of consulting practice, of medicines for lodge patients should be the subject of an that the appointment should be for seven years and that agreement between the lodges and the dispensing pharma- he should be eligible for reappointment. cists. The lodges refused to entertain this proposal. It was Applications are to be invited for the chair throughout therefore decided to revert to the previous arrangement be- .&ustralasia and the United Kingdom. The applications are tween the lodges and their medical officers for the dis- to be submitted to a committee in London. pensing of medicines. The Council ascertained from the Science Research Scholarships for the year 1911 were

Pharmaceutical Society that the terms under which the awarded to Miss Marie Bentivoglio, B.Sc.; Mr. R. S. Lee, pharmacists would supply medicines to lodge patients were B.A.; Miss Margaret H. O'Dwyer, B.Sc.; Mr. G. D. Osborne, that a dispensing charge of ls. be paid for each prescrip- B.Sc.; Mr. T. L. Willan, B.Sc.; Miss Isora G. Anderson, B.Sc. tion dispensed and that the wholesale cost of the drugs be The John Coutts Scholarship for 1921 was awarded to R. charged. It was found that the wholesale cost of drugs L. Aston, B.Sc. averaged 6.88d. per prescription. In the southern suburbs • of Adelaide the local medical practitioners discussed this VARIOLA IN VICTORIA. matter with the pharmacists and endeavoured to persuade the latter to accept a flat rate per prescription. The phar- The occurrence of variola on board the steamship macists were not prepared to undertake the work on these Gracchus, which arrived in Melbourne on April 7, 1921, and the spread terms. It was eventually determined that a dispensing fee of the disease to two or three persons in the general com- of 6d. in addition to the cost of the drugs should be munity have led to the introduction by the Federal Quaran- charged. This local arrangement which came into effect on April 1, 1921, was held to be embarrassing to the Coun- tine Service and by the Department of Public Health of Vic- cil. Fresh negotiations were undertaken with the pharma- toria of special measures to meet the threatened danger. In the Victoria Government Gazette of April 29, 1921, the cists, but as the pharmacists steadfastly refused to accept Regulations Relating to Small-Pox, adopted under the pro- a flat rate for all prescriptions, the Council has determined visions of the Health Act, 1919, are published. to ask the members to make their own arrangements with The first regulation imposes upon medical practitioners the the lodges or with the local pharmacists. It is a pity that duty of notifying all cases of small-pox by the speediest the Council has been unable to insist that the lodges shall practical means to the Commissioner of Public Health and make provision direct with the pharmacists concerning the to the council of the municipal district. In the second supply of medicine. This matter is outside the scope of regulation it is set forth that when a council receives a noti- the medical practitioner's work and save in isolated dis- fication that a person is suffering from or has died of small- tricts, medical practitioners should not be required to be pox, the council shall cause the patient or house to be responsible for the medicines prescribed by them. Perhaps visited by the medical officer of health or by any medical some pressure can be placed on the lodges at a later date, practitioner authorized by the council. The medical officer to induce them to relieve the medical officers of the necessity shall examine the patient and shall make such inquiries as of arranging for the supply of medicines. are necessary to enable the council to take measures to pre- i vent the spread of the disease. In the third regulation the duty of the medical officer of health or authorized medical University Intelligence. practitioner to carry out the visit, examination and inquiry promptly and to report to the council without loss • of time THE UNIVERSITY OF SYDNEY. is set forth. The arrangements for the isolation of all patients suffering from small-pox are governed by the fourth A meeting of the Senate of the University of Sydney was regulation. According to the fifth regulation, all persons held on May 3, 1921. The following degrees were conferred who have been in contact with a patient suffering from in, absentia, Mr. C. J. B. Armstrong, Bachelor of Medicine variola, may be isolated or placed under surveillance. The and Master of Surgery. next regulation gives the council power- to isolate any house The following appointments were made: Miss E. M. Hind- or premises on the advice of its medical officer of health. marsh, B.Sc., as Lecturer and Demonstrator in Physiology; Persons placed under medical surveillance are required to Messrs. H. Brady, M.B., B.S. (Adelaide), and G. H. S. present themselves for inspection and examination to the Lightoller, M.B., Ch.M., as Honorary Demonstrators in medical officer of health or authorized medical practitioner Anatomy. signing the order as frequently and at such times as may The Rector of the University of Louvain wrote thanking be required. Any person under medical surveillance must, the University of Sydney for the generous gift of subscribers on the appearance in himself of any symptoms or signs of sent in July, 1916, to relieve the distressed Louvainers whose illness or disease, report the facts immediately to the medi- houses and entire possessions as well as the University had cal officer of health or authorized medical practitioner. In been destroyed by the Germans in the early days of the war. the case of a child the parent or guardian has to carryout The letter stated that "academic life had resumed in Janu- these. duties. No person under medical surveillance is ary, 1919, and the number of students at the time of writing, allowed to leave the locality without permission. Every per- March, 1921, totalled 3,150." son who has knowingly been in contact with anyone suf- The Dental Undergraduates' Association wrote stating fering from small-pox, is required to report himself at once their intention of endeavouring to collect the sum of £20,000 to the medical officer of health. for the purpose of establishing a research scholarship in The councils are authorized to use such guards and force dental science. as are necessary to remove patients or contacts to a place Lectureship in Chinese. A letter was received from the of isolation and to detain them there until they are lawfully

Prime Minister's Department, Melbourne, in connexion with discharged. The councils are required to supply drugs and the establishment of a Lectureship in Chinese. other substances for the prevention and cure of small-pox An application from the President of the University Union and accommodation, medical nursing and other aid. They respecting an extension of the Union Building was re- have also to undertake the disinfection of premises as referred to the Buildings and Grounds Committee. quired by the medical officers of health. The remainder of Resignations were received from Dr. W. G. Armstrong, the regulations deal with the usual safeguards. The penalty as Lecturer on Public Health; Miss M. M. Lilley, B.Sc., Lec- for an offence against the regulations is fixed at not more turer and Demonstrator in, Pharmacology. than £20 and in the case of a continuing offence at a further It was decided to advertise the following position: The daily penalty of not more than £5. Lecturer in Public Health. A report was received from a Committee appointed to confer with representatives of the Government in reference It is with regret that we have to announce the death of to the establishment of a chair of psychiatry. The report of Dr. William Irwin, of Randwick, New South Wales, which the Committee was generally adopted and it was resolved took place on May 13^ 1921. 432 THE MEDICAL JOURNAL OF AUSTRALIA. [May 21, 1921.

reported from the area and the policy of the Commission Correspondence. is to exclude settlers who are known to have suffered from THE MALARIA DANGER. the disease. The estimation of the chances of infection in any locality Sir: The importance of the question of the establishment is not a simple one, but as Ross (Report of the Prevention of endemic foci of malaria in New South Wales prompts of Malaria in Mauritius, 1908, p. 31 et. seq.) has shown de- me to collect the records, for the most part already pub- pends on the average population, the average number of lished, of the occurrence of anopheline mosquitoes in New infected persons, the average number of these whose blood South Wales. contains enough of the sexual forms to infect anophelines, No opportunity has occurred for a systematic survey of the average number of anopheles, the average number of the whole of New South Wales, but it was a practice anopheles which succeed in feeding on a single person, the always of my predecessor, Professor J. B. Cleland, to identify average proportion of these which survive a week and the the mosquitoes in any district to which duty called him. average number of survivors that succeed in biting again. This procedure I have also adopted in country trips. The Ross's calculation (arbitrary, of course) was that only opportunities thus afforded were not numerous, but never- one quarter of the anophelines were likely to succeed in theless a fair, general idea of the distribution of mosquitoes biting human beings; that only one-third of these were in New South Wales has been obtained. likely to survive for a week or more; and that only one- The genus Anopheles (sens. lat.) is represented in Aus- quarter of the remainder were likely to succeed in biting a tralia by five species—two of which, A. corethroides Theo b. second person. Hence only one in forty-eight was ever and A. (Myzorhpnchus) barbirostris v. d. Wulf, var. ban- likely to give infection. crofti Giles have not been recorded from New South Wales It is hoped in the future to continue the mapping out of though they occur in southern Queensland. the distribution of anopheline mosquitoes in New South Two of the remaining three call for little mention. A. Wales and to investigate places from which endemic cases (Pyretophoru.$) atratipes Skuse was described from Berowra have been reported. At the present season of the year little and has been recorded from south Queensland by Dr. Ban- would be gained by undertaking such surveys. croft. We have taken it on the Hawkesbury River and at I desire to thank Dr. Clayton and Dr. Utz for their cour- Kendall (Camden Haven). It is not an abundant species tesy in allowing me to read their paper before publication and is unlikely to prove a vector for the malaria parasite. and in affording me an opportunity to examine their slides. A. (Pyretophorus) stigmaticus Skuse was described from If medical practitioners in country districts care to sub- the Blue Mountains and has not been recorded since. mit specimens of mosquitoes, I shall be glad to undertake their identi A. (Nyssorrhynchus) annulipes Walk. (= A. musivus fication. Skuse = A. mastersi Skuse). This is our common anophe- Yours, etc., line mosquito. Described originally from Tasmania, it EUSTACE W. FERGUSON, probably extends over the whble of Australia and the islands Principal Microbiologist. to the north. Office of the Director-General of Public Health of New The localities in New South Wales known to me in which South Wales, it occurs are as follows:—Coastal districts: Murwillumbah Sydney, May 9, 1921. (Cleland, May, 1916), Port Macquarie (Ferguson, July, 1919), Newcastle (Dick), Tuggerah (Cleland, October, 1914), Sir: I was much interested in your article under the Hawkesbury River (Cleland and Ferguson, January, 1915, above heading in this week's issue of The Medical Journal October, 1914), Sydney (Skuse, Cleland, Ferguson), Port of Australia, and in the reports of Dr. Clayton and Dr. Utz. Kembla (Skuse), Camden (Ferguson, October, 1913), Picton They clearly indicate the necessity for keeping in mind (Ferguson, September, 1919). now-a-days the possibility of malarial infection in cases of Mountain ranges: Walcha (Dick), Blue Mountains irregular fever, even in patients who have not resided in (Skuse), Yerranderie (Ferguson, October, 1913). recognized malarial districts. Inland: Narrabri (Cleland, May, 1919, Dick), Pilliga Scrub A few points in the pathological findings in the report (Cleland, October, 1918), Wellington (Ferguson, October, are also of unusual interest. In the first case recorded, the 1919), Narromine (Ferguson, June, 1913), Nevertire differential count shows 2% monocytes. I am unacquainted (Ferguson, May, 1914), Grenfell (Cleland, December, 1916), with this nomenclature, but presume that the cells in ques- Darlington Point (Cleland), Yanco (Cleland, December, tion refer to the large mononuclear leucocytes; in which 1919, Ferguson, January, 1920, McKeown). case, considering that the infection had evidently been pre- These records are few in number, but serve to indicate sent for about six weeks, there is an unusually low per- the extent of the distribution of the species and justify the centage of the cells which show an almost constant and conclusion that the species occurs throughout the State marked relative increase in malarial infections. Secondly, with the possible exceptions of the higher mountain ranges I would refer to the presence of the "antra-corpuscular and the trans-Darling country, though even in these regions chromatin bodies" in the "obscure" case mentioned. One it probably occurs. is familiar with the degenerative changes which can some- In regard to the relative abundance, the experience of times be observed in malarial parasites as the result of both Professor Cleland and myself was that, while wide- intensive quinine treatment (with or without arsenic) ; spread along the coast, the species is not abundant in num- nevertheless it has been my experience that the parasites bers. Inland, however, this is probably not the case, as in such instances can always be definitely recognized as reports and specimens we have received show that it does such. In the case in question it is interesting, then, to occur at times in large numbers. note that the daily administration of small doses of quinine The localities I have in mind are Grenfell, Darlington per rectum, together with arsenic at a later period, should Point and Yanco, while Professor Cleland found it abundant suffice to so in fluence the infection and affect the parasites at Overland Corner on the Murray, in south Australia. that the latter are revealed (perhaps somewhat vaguely) as The question of the occurrence of endemic malaria in "intra-corpuscular chromatin bodies," with the absence of New South. Wales following on the return of infected troops any typical forms. from New Guinea and Palestine has been seriously con- Lastly, herpes labialis le not an uncommon accompani- sidered. The conclusion come to was that, while isolated ment of malarial infection, whether the latter be accom- cases might occur, there was little likelihood of anything panied by marked vomiting or not. in the way of an epidemic. Yours, etc., This conclusion was based on (a) the relative scantiness LAURENCE H. HUGHES, of the,,.anopheline mosquito in the urban areas; (b) the 383' Glebe Point Road, scattered population in the country areas, where the ano- Glebe Point, phelines were more abundant. May 6, 1921. One district—the Murrumbidgee irrigation area—suggested a possible exception and mosquito surveys showed that ano- Sir: In your leading article of May 7, 1921, reference is phelines were breeding in that area and apparently at made to several cases of malaria in which the infection was certain seasons in abundance. No case has, however, been undoubtedly received in Australia. I desire to bring to your May 21, 1921.1 TRE MEDICAL JOURNAL OF AUSTRALIA. 433 notice a further case which was investigated by Dr. Little- others of like abilities. He finds it requires some years to john at the Royal Alexandra Hospital for Children in acquire and apply the special knowledge demanded of him. March, 1919, and noted by me in an article in The Medical As you say, "it requires expert knowledge and prolonged Journal of Australia of December 20, 1919, entitled "Anti- experience to be able to determine when a person who has Malarial Work with the Australian Mounted Division in been insane, may be released without danger." Treatment Palestine." The case was that of a child of six years from of these patients demands an intimate knowledge of psycho- Wyong, New South Wales, who had never been outside therapy, including hypnotism, suggestion, psycho-analysis, this State and in whose blood the malarial plasmodium was etc., and no greater responsibility can be placed on anyone found. than the decision which determines a man's liberty of free- The occurrence of a previous case reported by Dr. Sydney dom of action. Recent happenings in New South Wales Jamieson, the discovery of the anopheline mosquito in sev- have drawn attention to the responsibilities imposed on eral parts of New South Wales by Dr. F. W. Taylor in 1917, mental specialists and superintendents of insane hospitals. combined with the return of 18,000 troops heavily infected In England these things are recognized and superintendents with malaria from Palestine, roused grave apprehensions are paid up to £1,500 per annum. The Stafford Mental Hos- of an outbreak of malaria in Australia, particularly in the pital recently advertised for a senior medical officer at £850 minds of those members of our profession who had seen or £900 per annum, according to his attainments. It is not the ravages of malaria among the troops in Palestine, and too much to ask £1,000 per annum and allowances for medi- these fears I endeavoured to voice in The Medical Journal cal superintendents and the Association should agitate for of Australia of December 20, 1919. this salary in all the States. But have these forebodings been justified and is there In the meantime, I would strongly advise those with a any grave danger of a serious outbreak of malaria at pre- bent towards this specialty to consider carefully whether sent, as suggested by Dr. Clayton and your leading article the Victorian Government and others are offering an ade- of May 7, 1924? quate inducement to enter their services. Unless they are Two summers have passed without a single case of malaria entirely swayed by their art and consider their emoluments being reported until the present cases of Dr. Clayton and Dr. a secondary consideration, disappointment, with its attendant Doyle and even granting that some cases may have occurred regrets, awaits them. The Victorian Government, in par- and not been diagnosed, surely if the conditions in Australia ticular, is far from being an ideal employer and when its were favourable to the development of malaria to any large Ministers allow their personal feelings to determine their degree, there would have been in the years following the actions, impartial treatment cannot be expected; without influx of thousands of potential malaria carriers from Pales- this the present system must be irksome, irritating, unfair tine and New Guinea more evidence of malarial infection and sometimes depressing. than the occasional incidence of sporadic cases. May there Yours, etc., not be some other factor necessary for the gross spread of "A VICTORIAN MEDICAL SUPERINTENDENT." malaria than the incidence of the anopheline mosquito and the malaria carrier? May 5, 1921. Yours, etc., WILFRED EVANS. MODERN MIDWIFERY PRACTICE. Old South Head Road, Waverley, New South Wales, May 12, 1921. Sir: A remark of Dr. Brett in your issue of May 7, 1921, p. 393, viz., "the more reliable methods of inserting bougies or packing would surely not have been as ex- THE VICTORIAN MENTAL HOSPITAL SERVICE. hausting to the patient as having Csarean section performed after she had got much worse," raises the very in- Sir: The table of salaries paid medical superintendents teresting point as to whether Cesarean section performed in Victoria, as published in your issue of April 30, 1921, com- under modern conditions is as drastic as generally believed. pares very unfavourably with that of New South Wales. A case highly instructive in this regard was a patient under The Medical Superintendent in New . South Wales receives my care at the Women's Hospital, Melbourne, about 1917 (I £200 per annum more than his confrére in Victoria. Re- write from memory). This patient was very distressed owing cently the Victorian Public Service was reclassified and, as to a failing heart, was full time and (for a reason which I far as I can at present ascertain, every public servant have never been able to definitely determine) her tempera- received an increase •-et --salary except the medical super- ture rose steadily until the nurse reported 111 ° F. (which intendents, the Government medical officer and the Inspector- is in the region of the highest recorded temperature in man). General of Insane. The increased cost of living was the As the woman was obviously dying, I decided to induce reason given for the reclassification. It is very curious to labour as the woman's only chance lay in emptying the note how differently this factor affected various individuals. uterus, and giving the embarrassed heart a chance. The Members of Parliament ' and Ministers of the Crown were resident M.O.'s declined to a,dminister an anaesthetic (such affected to the extent of £200 per annum, the Director of is the fear the Coroner's Court apparently inspires) and as Education and the Public Service Commissioner were found I considered any dilatation of the cervix inadvisable, since to be suffering to the extent of £250 per annum, whilst it the least movement completely exhausted her, I performed was necessary to alleviate the difficulties of many high- Cesarean section under stovafne. As soon as the uterus was grade officials by adding £100 per annum to their salaries; emptied, the patient's colour altered at once and the respira- but by some miraculous dispensation of Providence the less- tory distress disappeared. About half an hour after the ened purchasing power of money does not seem to have operation she was sitting propped up in bed having a cup affected medical superintendents, who were therefore left of tea and feeling very comfortable. The temperature came exactly as they have been for many years past. It follows down and about three weeks later the patient was dis- that those in authority consider the superintendents either charged from hospital. I consider that if there is sufficient to be overpaid or incompetent. The knowledge that incre- anaesthesia to get through the abdominal parietes and a ments were recommended for us, but were vetoed by the minimum of dragging on the uterus or appendages, there Ministers has greatly . increased my already high opinion of should be very little shock in Caesarean section. I feel sure the transcendental abilities and scrupulous fairness of these that dilatation of the cervix, even if slowly performed, with gentlemen. The recent lodge dispute, which showed the subsequently delivery per vaginam, would have killed this sympathy of certain members of the Cabinet towards the patient. Yours, etc., medical profession generally, is not ' Ibr one moment thought to have influenced their decision and the smart of their J. LEON JONA. ignominious defeat has no doubt been long since assuaged Melbourne, May 10, 1921. by the tender hand of Time. Yet it were wise to point out to the younger members of our profession that, under present conditions and after a We regret to announce the death of Dr. William Macansh, long climb to the top, the medical superintendent finds him- of Brighton, Victoria, which took place on May 15, 1921, self contemptuously assessed among- glorified clerks and after an illness of several weeks' duration.

434 THE MEDICAL JOURNAL OF AUSTRALIA. [May 21, 1921.

The Librarian of the New South Wales Branch of the British Medical Association will be obliged if members who have removed any of the following journals from the Lib- Branch. APPOINTMENTS. rary of the Branch, will return them without delay. The missing numbers are required to complete the sets for binding. All Institutes or Medical Dispensaries. The Journal of the American Medical Association- Manchester Unity Independent Order 1917: Vol. 68, April 7. of Oddfellows. 1918: Vol. 71, August 24. Ancient Order of Foresters. 1919: Vol. 72, June 7. VICTORIA. Hibernian Australian Catholic Benefit 1920: Vol. 74, March 6 and 27, May 15 and 22, June 26. Society. Journal of the Royal Army Medical Corps- (Hon Sec., Medi- Grand United Order of Free Gardeners. 1919: Vol. 32, April. cal Society Hall, Sons of Temperance. Dublin Journal of Medical Science- East Melbourne.) Order of St. Andrew. 1917: August, September, October. Australian Prudential Association Pro- 1918: February, March, April, October, November. prietary, Limited. 1919: March, April. Mutual National Provident Club. Journal of Experimental Medicine- National Provident Association. 1918: July, August, September, December. Edinburgh Medical Journal- 1917: March. QUEENSLAND. Johns Hopkins Hospital Bulletin - Australian Natives' Association. 1916: March, April, September. (Hon. Sec., B.M.A. Brisbane United Friendly Society In- 1919: September, October, November. Building, Adelaide stitute. 1920: June, July, August. Street, Brisbane.) Stanùary Hills Hospital. Journal of Medical Resegrch- Volumes 35, 36, 37. The Practitioner- SOUTH AUS- 1915:. May, October, December. TRALIA. Contract Practice Appointments at 1919: January. Renmark. Annale of Surgery- (Hon. Sec., 3 North Contract Practice Appointments in 1917: May. Terrace, Adelaide.) South Australia. medical Appointments. WESTERN AUS- During the absence on leave of Dr. C. W. Reid (B.M.A.), TRALIA. Dr. P. W. Mitchell. (B.M.A.) has been appointed Acting Chief Quarantine Officer (General) for . New South Wales. (Hon. Sec., 6 Bank All Contract Practice Appointments ir, Dr. Winifred , E. Kennan (B.M.A.) has been appointed Medi- of New South Western Australia. cal Superintendent of the Queen Victoria Hospital, Victoria. Wales Chambers, St. George's Ter- race, Perth. medical Appointments (Jaca:tt, etc.

For announcements of medical appointments vacant, assistants, locum NEW ZEALAND: tenentes sought, etc., see "Advertiser," page aííí. WELLINGTON The Royal Society of Medicine, London: Nichols Prize. DIVISION. Friendly Society Lodges, Wellington, Alfred Hospital, Melbourne: Medical Superintendent. • New Zealand. Sydney Hospital: Honorary Relieving Assistant Surgeon. (Hon. Sec., Wel- Hospital for Sick Children, Brisbane: Resident Medical lington.) ' Officer. medical .Appointments. Diary for the month.

IMPORTANT NOTICE. May 24.—N.S.W. Branch, B.M.A.; Medical Politics Commit- tee; Organization and Science Committee. Medical practitioners are requested not to apply for any May 25.—Vic. Branch, B.M.A., Council. appointment referred to in the following table, without having May 26.—S. Aust. Branch, B.M.A.. first communicated with the Honorary Secretary of the Branch May 26.—Clinical Meeting at the Hospital for Sick Children, named in the first column, or with the Medical Secretary Brisbane. of the British Medical Association, 429 Strand. London, W.C.. May 27.—N.S.W. Branch, B.M.A.. May 27.—Q. Branch, B.M.A., Council. Branch. APPOINTMENTS. June 1.—Vic. Branch, B.M.A.. June 3.—Q. Branch, B.M.A.. June 8.—Melb. Pædfatric Society (Vic.). Australian Natives' Association. June 10.—N.S.W. Branch, B.M.A., Clinical. Ashfleld and District Friendly So- June 10.—Q. Branch, B.M.A., Council. cieties' Dispensary. June 10.—S. Aust. Branch, B.M.A., Council. Balmain United Friendly Societies' Dis- June 14.—N.S.W. Branch, B.M.A., Ethics Committee. NEW SOUTH pensary. June 14.—Tas. Branch, B.M.A.. WALES. Friendly Society Lodges at Casino. June 15.—W. Aust. Branch, B.M.A.. Leichhardt and Petersham Dispensary. (Hon. Sec., 30-34 Manchester Unity Oddfellows' Medical Elizabeth Street, Institute, Elizabeth Street, Sydney. EDITORIAL NOTICES. Sydney.) Marrickville United Friendly Societies' Dispensary, Manuscripts forwarded to the office of this journal cannot under any circumstances be returned. North Sydney United Friendly Societies. . Original articles forwarded for publication are understood to be offered People's Prudential Benefit Society. to The Medical Journal of Australia alone, unless the contrary be stated. All communications should be addressed to "The Editor," The Medical Phcenix Mutual Provident Society. Journal of Australia, B.M.A, Building, 30-34 Elisabeth Street, Sydney. (Telephone: B. 4685.) THE MEDICAL JOURNAL OF AUSTRALIA.

VOL. I.-8TH YEAR. SYDNEY : SATURDAY, MAY 28, 1921. No. 22.

RECENT ADVANCES IN DISEASES OF THE EYE AS stands supreme and in result, if properly carried out, AFFECTING THE GENERAL PRACTITIONER.' is brilliantly effective. As it is carried out painlessly under a local anesthesia, there is nothing to prevent By W. Wallis Hoare, M.D. (Brux.), F.R.C.S. (Edin.), M.R.C.S., L.R.C.P., nervous or feeble old people undergoing it. Brisbane. With regard to trachoma, this, alas, is ever with us in acute and chronic forms, still defying the best In response to an invitation, I am making a few efforts of the profession to cure in the proper sense remarks this evening, condensing as much as possible of the word. The majority of the patients we see and touching only on those diseases which the general come from the northern or western portions of the practitioner is likely to encounter. State. Some of the results of the disease and the One of the most important changes in dealing with heroic efforts made to combat it are sad to ' ontem- diseases of the eye by the profession in the last decade plate. We have not materially advanced in the treat- has been the almost complete uniformity with which ment of acute trachoma. As of yore, salts of silver those devoting themselves to the practice of ophthal- and copper remain the sheet anchors of treatment; mology have confined themselves to that specialty and but in the chronic stages advance has been made in not combined it with anything else. giving relief to such conditions as pseudo-ptosis, I remember in the early part of this century such trichiasis and pannus; tarsectomy, canthotomy and an anomaly existed in London, the heart of the Em- peritomy in some form or other do much to alleviate pire, that a man was general surgeon to a large teach- these conditions. Although peritomy is not a recent ing hospital and ophthalmic surgeon at Moorfield's operation it has, in my opinion, been very much at the same time. The late Mr. Silcock was about neglected ; if well carried out, I have not known it to the last of the species. We find now that men are fail in producing to some extent an improvement of reluctant to specialize in eye, ear, nose and throat vision. The late Brudenell Carter, in 1889, wrote at once, for the reason that ophthalmology is such a as follows : broad and difficult subject. No matter how great the In connexion with the inoculation with pus from ophthal- individual ability possessed, it requires all a man's mia neonatorumt and the instillation of jequirity for the cure of pannus, the cases which justify either of these severe energy and attention in dealing with its varied and forms of treatment are by no means numerous and are likely difficult problems. to become less so every year, as the treatment of acute con- Affections of the lids are frequently encountered junctivitis is better understood. They are now chiefly fur- by the general practitioner, one of the commonest of nished by persons who have suffered from ophthalmia in some remote colonial region, or in some barbarous country, these being chronic marginal blepharitis, often asso- or who have been the victims of the epidemics of contagious ciated with refractive errors and commonly treated ophthalmia which have visited certain workhouse schools. by the general practitioner and sometimes by the ocu- I wonder how the late Brudenell Carter, if revital- list with Pagenstecher 's yellow oxide of mercury oint- ized, would describe our fair State of Queensland, ment. In the vast majority of cases the effect is nil. which, with many evidences of modernity—aero- Many and varied are the drugs which have been ad- planes, telephones, etc. ,etc.—still has far too many vised for this unsightly complaint, but of recent people with acute and chronic trachoma groping about years the pathologist has been invoked and called on amongst our sparse population. to manufacture an auto-vaccine ; sometimes, in appar- It is a moot point whether any real advance has ently inveterate cases, this is quite successful. As a taken place in dealing with epiphora due to lachrymal general rule I have found "protargolage," or, in obstruction. I think I can safely say we are still other words, massage of the edges of the lids daily unable to indicate in any case of well pronounced with a strong solution of protargol, the most efficient lachrymal obstruction any method which is sure and treatment of all. certain to relieve permanently, short of extirpation Another affection the general practitioner will occa- of the lachrymal 'sac. Some years ago, West 's opera- sionally encounter is that known as congenital ptosis. tion, which consisted of an intranasal communication Judging from the numbers of patients seen in adult between the lachrymal sac and nostril, was looked life, it is reasonable to suppose that they have not upon as having a bright future ; but, alas, like many been strongly encouraged to undergo treatment there- other methods, it soon gave rise to disappointment . for. While there have been numerous operative pro- and I think most ophthalmic surgeons regard the cedures designed for the cure of the complaint, I think old treatment, that is, extirpation of the sac, as the the two most successful, namely, that of Motais, in safest and surest method of permanent relief in the which a portion of the superior rectus is harnessed to majority of cases. the upper tarsal cartilage, and Tansley Hunt's Regarding corneal affections, can I say that there method of skin advancement, are comparatively re- is any advance in the treatment of these ? To some cent. The photographs which I hand round, show the extent, notably in that form of keratitis having its effect of a Motais's operation and a Tansley Hunt origin in tubercular diathesis. It is marvellous to operation. note the rapidity with which such cases clear after For the distressing type of lid affection known as a few injections of tuberculin. In cases of interstitial senile ectropion, the modified Symonowski operation keratitis of specific origin, it is unfortunate that in-

' Read at a Meeting of the Queensland Branch of the British Medical jections of salvarsan have practically no effect, or a Association on March 4, 1921. deleterious effect, as these cases are so notoriously 436 THE MEDICAL JOURNAL OF AUSTRALIA. [May 28, 1921.

obstinate and lengthy in duration. In the treatment to wait for pain, rise of tension and steamy cornea of corneal ulcers, I think we can claim advance in to enable the surgeon to say that there is a new certain types, notably in that very serious form of growth in the eye. ulcer known as Mooren's ulcus rodent, in which the With regard to foreign bodies in the eye, they can treatment by means of a covering conjunctival flap now be more definitely proved by means of X-ray in many cases cuts short the process and preserves diagnosis. Should the foreign body be magnetizable, much corneal tissue intact. It is an advance to know it can almost certainly be removed by means of a that there are strict limitations to the use of electro- powerful magnet. In order to keep abreast of the cautery for corneal ulcer and that this form of treat- times, I imported about one and a half years ago with ment should not be used on a corneal ulcer occurring some difficulty that type of magnet known as Mel- in a child, because of the danger of contiguous death linger 's ring magnet, reputed and, as far as I can of corneal tissue in the vicinity, with resulting opa- gather, justly reputed the most efficient magnet in city and visual limp. • existence to-day. With its aid I have removed very An important point I would like to impress upon small magnetizable foreign bodies lodged in the vitre- the profession generally in connexion with corneal ous humour, through the anterior chamber when their ulcers and corneal lesions is that, prior to any treat- size permitted and by the retro-scleral route when ment, it is imperative to demonstrate the absolute their size indicated that that was the best channel of integrity of the lachrymal apparatus, because, should evacuation. Since there is only half a millimetre of there be a cesspool of micro-organisms, constantly clearance between the edge of the lens and the ciliary overflowing on to an ulcerated surface or open wound, processes in the normal human eye, it is surely only successful healing cannot take place until this cess- common sense to acknowledge that there are strict pool has been obliterated. This point is not, as far limitations to the use of the anterior route ; wisdom as I am aware, sufficiently emphasized in any treatise and prudence indicate any magnetizable foreign body on ophthalmology. of over one millimetre in diameter or longest axis With regard to iritis and irido-cyclitis, I do not should, without doubt, be removed by the posterior think that there has been much knowledge added in route. Especially so, as by means of such a magnet recent years as to either aetiology or treatment of this as Mellinger 's nothing is introduced into the vitreous disease, serious alike when present in acute form and save the small, sharp, incising Graefe knife. far-reaching in its after consequences. In the first Retinal changes of a marked type are often pre- place, I think the term iritis is a misnomer, simply sent in arterio-sclerosis and a trained observer can because, anatomically, it is practically impòssible to detect arterio-sclerosis by means of the ophthaltno- separate the iris from the ciliary body and an in- scope alone from the appearance of the arteries. He flammation of one must, perforce, mean to some ex- recognizes their silver wire reflex, their tortuosity, tent inflammation of the other. The same thing the varying calibre of the vessels in different parts of occurs in lobar pneumonia, . where you must have their course and the indentations made by them some pleuritis and again in pleuritis it is reasonable where they cross over veins. High blood pressure is to suppose that there is and undoubtedly there must often associated with macular changes and failing be some inflammation of the underlying lung tissue. sight with these changes often directs the oculist's While the vast majority of cases of iritis are attri- attention to the blood pressure, which, perhaps for buted to syphilis, gonorrhoea, rheumatism and other the first time, is then found pointing to danger. High constitutional and infective diseases and some to sep- blood pressure is a distinct menace to the success of tic origin, for instance, dental abscesses and pyor- an intra-ocular operation. Should an elderly person rhoea, there is no doubt that very many cases have whose blood pressure exceeds, say, 170 mm., undergo no discernible cause. an intra-ocular operation, no precautionary measures In relation to the dental origin of some cases of having been adopted beforehand, I am inclined to iritis, the advocates of this special theory lay stress think that should no catastrophe occur, the fortunate on the fact that they frequently occur. While they result is due more to good luck than otherwise. Mad- undoubtedly occur, I do not think they occur as often dox has drawn attention to the advisability of blood as these advocates would lead us to believe. In some letting in such cases, but quite a year before his com- cases of iritis, particularly those of post-operative munication appeared in the British Journal of origin, septic, if you like to call them so, which, under had already, acting on the sug- Ophthalmology, I ordinary lines of treatment, bid fair to run to total gestion of my friend, Dr. Lachlan McKillop, of this loss of the eye affected, I have been agreeably sur- city, bled a plethoric old lady of 700 c.cm. from the prised by the effect of a prompt sub-conjunctival in- arm a day or two prior to operating for senile catar- jection of 0.3 c.cm. to 0.6 c.cm. of hydrargyri cyanidi act, bringing the blood pressure down from 240 nuu. solution, strength 1 to 5,000, repeated if necessary to 146 rum., whereas other treatment on the usual after one or two days, in cutting short the duration lines for over a month had completely failed to re- of the disease and in rescuing from total wreck an duce the pressure. Since then I have frequently eye destined, perhaps, to give useful vision after- bled patients when I considered it advisable before wards. intra-oenlar operations. In connexion with intraocular neoplasms, we can In dealing with senile cataract operating on the claim a distinct advance in earlier diagnosis by means unripe cataract when justification exists is a decided of transillumination, when, if the tumour is not too advance in our methods. In 1918 I stated before far behind the ocular equator, the transillnminator, this Branch that I had had quite as good results giving an altered glow through the pupil, settles the from immature cataract operations as from mature question definitely. In short, it is no longer necessary and immaturity of a cataract provided always justi- Ma y 28, 1921. ] THE MEDICAL JOURNAL OF AUSTRALIA. 437

fica .tion for interference existed, did not deter me to disturb its regulation, then, to quote Priestley in the least from operating. I hold more firmly to Smith : "The pressure in the ocular chambers rises this view. While I cannot say that any great ad- above the physiologic limits and we have the complex vance has taken place in the methods of dealing with disturbance of function and structure called glau- cataracts, yet in certain details advances are being coma." Without question there is a great deal yet made principally in the adoption of safety procedures. to be done in connexion with glaucoma, not only in A novel method of extracting cataracts has lately still earlier diagnosis, but in finding the true cause been brought into notice by a Spanish oculist, which and efficient treatment thereof. Let us hope that he calls phal,.oerisis. I: t depends manly upon a tiny the day is not far distant w1 en countless thousands vacuum cup being applied to the anterior surface of will be benefited by such a. discovery. the lens ; after the suspensory ligament has been rup- The affection known as retro-bulbar neuritis has re- tured, the lens is removed by vacuum suction. ceived much more attention of late years than Theoretically, it sounds attractive, but I fear that formerly. Medical men are becoming more alive to like many other methods which promise much, it the fact that the optic nerve in its course from the will perhaps fall short in realization. optic foramen to the globe is frequently affected by With regard to glaucoma which occupies so much inflammation, acute or chronic, existing in the neigh- space in all ophthalmic journals and discussions, the bouring sinuses, to wit, the ethmoidal and sphenoidal. general practitioner of to-day should have a work- In such cases as these, the oculist receives help and ing knowledge of the changes brought about by the co-operation from the rhinologist to an invaluable lapse of time in the diagnosis and treatment of this extent. appalling malady. At one time, the word glaucoma Lastly, I wish to say something on the subject of produced in our mind a picture of a red eye, with enucleation of the globe. It is amazing how few widely dilated pupil, steamy cornea, shallow anterior members of the profession, of whom nearly all at chamber, raised tension and grave loss of sight, a some time or another have to enucleate 'an eye, con- cupped disc, if it could be seen, a complaint on the sider that the cosmetic result can be greatly enhanced part of the patient, generally an elderly body afflicted by planning to have a movable stump in the socket. with hypermetropia, that rainbows had been seen round A hollow glass or gold globe of suitable size either lights prior to the attack, complaint of great pain, in the sclerotic, known as Mule's operation, or in the even to the point of vomiting. . This picture is still capsule of Tenon, known as Frost-Lang's implanta- true of the type known as acute inflammatory glau- tion, will prevent any sinking of the upper eye-lid coma. However, there is a far more common type and will give a movable prothesis, thus rendering known as simple non-inflammatory glaucoma which the deprivation of an eye far less conspicuous and may occur in comparatively young adults, even those far less unpalateable to the patient. For my own possessing a fair amount of myopia. These eases may part, I consider an oculist who enucleates an eyeball exist from first to last without any pain, although in a dashing manner, striving to show how quickly the tension must be raised, yet to the finger of a it can be done by him and how adroitly he can do competent observer the rise is practically inappreci- it without making any such provision, is little short able. Here there is no red eye, no widely dilated of criminal. A little more time, a little more trouble pupil, often no admission of rainbows around lights, would make an incalculable difference to his patient, merely a statement that the vision is sometimes foggy . who, all things considered, expects to receive the and that it is failing. When we go into the question most modern treatment and should get it. Of course, of elucidation, we find that the tonometer shows I am not referring to enucleation in cases of pan - raised tension, the disc is probably cupped and there ophthalmitis or ocular tumour. are characteristic and more or less constant defects In conclusion, T have endeavoured to indicate of the field of vision, known as Bjerrum's sign and briefly some points which may arouse in your mind Rönne's step and always an abbreviation of the nasal a desire to investigate them further and possibly to field. As glaucoma must receive early treatment, the afford food for discussion. Owing to stress of work earlier the better in order that the person suffering and climatic exigencies, I have been unable to pre- from it may retain useful vision, it behoves every- pare any statistical array of advances in the treat- one, seeing how common the complaint is, to make ment of eye affections, but have endeavoured to keep themselves familiar with the diagnosis. The prac- well within the boundaries which the title of the tice of treating glaucoma by means of eserine drops paper demands. is neither safe nor sound. Such treatment resembles reliance on the catheter in prostatic enlargement. Undoubtedly, operative treatment offers the best RECENT ADVANCES IN THE EAR, NOSE AND THROAT chance to the glaucoma patient and should not be SPECIALTY FROM THE POINT OF VIEW OF withheld from him or her until the disc is very deeply THE GENERAL PRACTITIONER. 1 cupped and the field of vision practically at fixation By R. Graham Brown, M.R.C.S., L.R.C.P., point on the nasal side. Until a few years ago the Senior Hon. Surgeon, Ear, Nose and Throat Department, operation of choice in glaucoma was iridectomy, but . Brisbane General Hospital. latterly more modern operations, notably that known as Elliot's sclero-corneal trephine have largely taken To discuss in a detailed manner the advances made its place. Unhappily, we cannot yet state what is the in the ear, nose and throat slpecialliy during the last few actual cause of glaucoma ; we can merely say that the years would, perhaps, be not only out of place at this intra-ocular pressure is equivalent to a column of 1 Read at a Meeting of the Queensland Branch of the l3ritish Medical mercury 25 mm, in height. Should anything occur Association on March 4, 1021, 438 THE MEDICAL JOURNAL OF AUSTRALIA. [ May 28, 1921.

meeting, but would be for us all a far too lengthy and which may make the patient's life a burden to him- wearisome a proceeding. I propose, therefore, to treat self and cause no end of trouble and regret to the the subject from the general practitioner's stand- profession. To-night I wish to show you a few young point. There have been marked advances made in people who have advanced bronchiectasis; I am sure some subjects of this specialty ; many of the older that, this trouble began with adenoids. They all are ideas have been totally given up and a great number sufferers from chronic affections of the accessory of new theories propounded. Operative measures nasal sinuses and their troubles began in the early have changed a great deal in the direction not only years of infancy. They belong to the type of patient of improved technique but also in conservative aims ; who goes the rounds of doctors ; the condition is in fact the present day ear, nose and throat specialist correctly diagnosed as far as their lung changes are must be an up-to-date surgeon. There has been a concerned, but we must admit that the benefit which greater desire, wherever possible, to preserve func- they usually derive from treatment in the hands tions. of the general practitioner, is very little. In these You will realize the difficulty with which I am cases the importance of excluding the nasal accessory confronted when endeavouring to put this question sinuses as a possible source of the origin and of the before you in a presentable manner. .I ask for some continuation of the infection needs emphasis. If we leniency from you should I overlook or over-empha- learn nothing else this evening, we will do well to size any point or points. grasp this fact. Lately I have seen so many people, It would be convenient, perhaps, to treat this mat- both young and adult, in this unhappy state that I ter from the aspect of the ailments found firstly in am led to believe that the cases in this group, which go infancy and childhood and secondly those found in along unrecognized, must be very numerous. One little adult life. girl, as you see, is only 8 years of age and she has As regards the child we note that the doctor and advanced bronchiectasis. X-ray examination revealed the parents are becoming more and more educated a dull right maxillary antrum and "washing out" to the fact that the sooner little ailments are attended produced pus. The mother informed me that the to the better for the child. Hunter Tod in a recent child had "been bad" since the age of one year. I article on the question of removal or otherwise of have one patient under me now, aged 34, •who asserts adenoids in infants, points out that these vegetations that as long as he can remember, except for an odd are sometimes found so far advanced at birth as to day now and again, he has not felt well. I wish to need operative treatment then. In other words, draw your attention to the facial appearance of these adenoids may be a congenital condition. The ques- young people. It is typical of the condition and one tion of how soon and when to operate in these in- can frequently make a "spot" diagnosis. It is with stances is still being discussed, but most of us will the object of making this appearance familiar to you agree, I am sure, that the surgeon should perform his that I take the liberty of emphasizing the point so duty whenever there is any indication that the ab- much in order that the more advanced cases, at normal condition is doing harm to the little patient. least, will not pass undiagnosed. The lesson we have We all realize that adenoids, if left alone, Invariably recently learned about these cases is that they can bring in their train a series of troubles which it may be diagnosed early and that a considerable amount be sometimes impossible in the later life of the patient can be done for them if proper treatment be instituted to rectify ; frequently for this reason we must be before the condition becomes too chronic. content with results far short of the ideal. In the Let me return to the question of adenoids. The direction of the operative procedure the use of the chronic running ear in children is principally the La Force adenotome is, I think, a great advance upon result of infection from the naso-pharynx, via the the previous methods of removal with curettes, etc. Eustachian tube. We must admit that adenoids are Some of us believe that repeated removal of adenoids responsible for this in the majority of cases. We in the same patient can be avoided in practically have learned that clearing of the post-nasal space of every case, if the operation is performed by a sur- adenoids and of the infective condition is the first geon fully trained in this specialty. It is surprising step in the treatment of the running ear. If you to see so many patients needing operative treatment will allow it, I would like to emphasize this point in this direction who have had previous operations. by a personal reference. When I first went on to It is disheartening both to the parents, the general the honorary staff of the hospital for Sick Children, practitioner and the specialist that this is so. The Brisbane, we were doing as many as eight mastoidec- general practitioner still considers this operation a tomy operations a month (all absolutely necessary), very simple procedure and one which is well within and perhaps 80% of adenoidectomy and tonsilectomy his field. We may disagree upon this point but there in the same period. During the last six months that I can be no reason to question the fact that he was at the hospital I did not do one mastoidectomy should make himself competent, especially as there (for acute or chronic running ear), but I was doing are means at hand in the children's hospitals of the as many as 200 adenoidectomies and tonsilectomies capital cities to help him to this end. It is now gener- in a month. In all cases we followed this ally recognized that adenoids may be the starting rule of clearing out the post-nasal space as point of some of the worst ' chronic suppurative con- soon as practicable. The results, you will ditions of the accessory sinuses of the nose, of chronic agree, are sufficient to prove the point. We running ears (and the various complications associ- do not now wait for a drum to burst when a patient ated therewith) and of such pulmonary conditions as is brought with an earache and we discover a red chronic bronchitis and bronchiectasis, conditions bulging drumhead. We do an early paracentesis. By May 28, 192-1.] THE MEDICAL JOURNAL OF AUSTRALIA. 4:19 so doing, we relieve pain, prevent the spread of the In regard to the tonsils, it is now recognized that infection and the chronic running ear and conserve when in a diseased state, they may be the mode of hearing. Later on should the ear continue to dis- entry of organisms into the system or may act as a charge and the usual methods fail to stop the running, site for auto-intoxication. How man cases have we a Heath's conservative mastoideetomy is performed. all seen of so-called rheumatic affections in children, This operation aims at removing the cause of the con- where there have been diseased tonsils present and tinued discharge. Heath has proved that the dis- where 'upon removal of the tonsils the conditions have charge is kept up by a diseased antral mucous mem- rapidly cleared up. The operation of enucleation of brane and that this mucous membrane is invariably the tonsils in the place of the old method' of tonsil- diseased in all cases of running ear over six weeks' lotomy is now widely practised. There are some of duration. The term" conservative" is applied because us who strongly hold that if the tonsil is diseased the middle ear contents are rigorously preserved and enough to require surgical interference, it should be treatment continued via the attic and Eustachian enucleated. This fact was well borne out by an in- tube until it is cleared, when healing over of the vestigation made at the Hospital for Sick Children attic opening is allowed to proceed. The sound con- by Dr. Ellen Kent Hughes and mÿself some 18 ducting apparatus is preserved, a minimum amount months ago, a report of which has appeared in our of bone is removed, there is practically no scar and journal, on the question of "Tonsillectomy in Diph- no deformity and hearing is more or less saved. This theria Carriers." We were successful, in the cases operation is a distinct advance upon the older opera- of carriers, in obtaining pure diphtheria cultures tion of cortical mastoideetomy of Schwartze. The from the deepest portions of the enucleated tonsils. performance of the radical or complete mastoidec- Our conclusions on this question were, firstly, that in tomy (Stache) upon a child must be a last over 600 cases of faucial diphtheria not one case oc- procedure in these cases and the prevention Burred in a child who had previously had tonsillec- of loss of hearing must be within reason our tomy (complete removal) performed ; secondly, that first aim. At the same time the all too frequent it was justifiable to enucleate tonsils and perform awful complications must be avoided by performing adenoidectomy in all cases of carriers who had re- an early 'conservative operation. It may be interest- sisted usual treatment for two to three months ; and ing to quote in passing the remarkable statement on thirdly, that the swab culture media invariably middle ear suppuration which appears in the report proved negative in a very short period following tome- of the London County Council (July, 1918) and sillectomy and adenoidectomy. which is quoted by Love in his volume (Diseases of As regards laryngeal stenosis following trache- the Ear in School Children) : otomy in diphtheria cases, we do not now look upon The results of school medical inspection show that these in such a pessimistic light as hitherto. Those more than 12,000 children with discharging ears are in of us who have had experience of children's hospital attendance at school; there is, in addition, a number which cannot be estimated and who are not attending. work, will admit that prolonged retention of a suit- There are some 7,500 attending elementary schools who able tracheotomy tube, with rest to the larynx and have some appreciable deafness, and there are, in addi- perhaps dilatation by intubation at a later date, will tion 800 children attending deaf schools or hard-of-hear- generally give good results. Strictures of the a'sopha= ing classes. About 800 children of school age die in Lon- don annually from diseases closely associated with ear gus can now be directly treated with the aid of the disease. oesophagoscope and the results are becoming more The question of an inherited tendency to deafness promising. Laryngeal papillomata, likewise, can be has been emphasized by Gray in his work on " Oto- successfully dealt with by the peroral route. sclerosis" and by others. Those who are interested, Before passing on to the seeond group, i.e., adults, will find an excellent little chapter in the above men- there is one matter which Dr. Robert Godsall brought tioned book by Love entitled "The Passing of Deaf- up (during a discussion of foreign bodies in the ness." A distinction is made between congenital bronchi) at the recent Australian Medical Congress deafness and inherited deafness. It is also now recog- held in Brisbane. He strongly emphasized the neces- nized that many cases of deafness existing at birth, sity of recognizing that recurring coughing attacks or occurring soon after birth, are due to inherited associated with marked cyanosis and distress may be syphilis. Jones believes that, if the same vigorous the result of a retained foreign body in the air pas- methods are adopted in stamping out syphilis as have sages and he was of the opinion that these cases been and are being carried out towards other diseases were more frequent than one would expect. such as diphtheria, typhoid, tuberculosis, etc., there In regard to the adult, much advancement has been will be few cases of deaf-mutism. He ends up his made in endoscopie work. Such methods of examina- honk by saying that he has tried "to show that `The tion as direct laryngoscopy, bronchoscopy, oesopha- Passing of Deafness' is not a Utopian but an emin- goscopy and suspension laryngoscopy have rendered ently practical thing." It is well that somebody can the task of the surgeon more easy and much more see these visions and it is towards this goal that certain. Foreign bodies in the air passages and the present day otologist must aim. The question of oesophagus are now dealt with by peroral methods. the marriage of couples who are deaf, is being well This advance alone is well worth a prominent place discussed at the present time, and it would not be in the science of surgery. Such names as Killian, surprising in the near future to hear of laws being Chevalier Jackson, Mosher, etc., are associated with passed in some advanced demoer tie country pro- the recent work in this direction. Nasal surgery hibiting such unions, has advanced in the recognition of the middle ttlr- 440 THE MEDICAI, JOURNAL OF AUSTRALIA. [May 28, 1921.

binate vicious circle theory, which was propounded appearing on account of the aid given us by blood by Ballenger. That body, the interior turbinate, ând coagulating tests, improvement of the blood by suit- its mucous membrane (which, by the way, contains able drugs and by the use of local anesthetic. In those precious glands which, when the need arises, the majority of cases tonsils can be readily and almost supply as much as 600 c.cm. of fluid to the inspired bloodlessly removed by modifications of the Sluder air in 24 hours) are no longer treated in such a method of enucleation. Calcium lactate in solution haphazard and forcible manner and crusting noses (made by the action of calcium chloride and lactic are therefore becoming less and less frequent in acid in solution') is very rapid in its power of in- consequence of a more sensible treatment of this creasing the blood coagulating time. Six decigrammes structure. The "spokeshave" is an instrument of in solution given three times a day for four days the past. When we recall the anatomy of the middle recently brought up the blood of a young woman turbinate region, we can readily see that pressure (who, by the way, almost died on three occasions outwards of this body interferes with the proper from bleeding after removal of teeth) from 8 drainage of the frontal sinus, some of the ethmoidal minutes coagulating time to 3i minutes. Calcium cells and of the maxillary antrum. Such conditions lactate tablets are now looked upon as generally use- as sinus vacuum headaches are now more frequently less as they do not dissolve but pass through the ali- recognized. The frontal sinus is perhaps the greatest mentary tract. Hemoplastin of Parke, Davis & Com- offender in this respect. The name of Sluder is as- pany (hemostatic serum) is of great help in this sociated with work in this direction and particu- direction. It should be injected larly in the direction of the naso-palatine ganglion subcutaneously some three hours before operation. It is interesting irritation. Frequently pains radiating from the back to note that I have found that the maximum result of the ear down the neck into the shoulder can be is obtained about five hours after injection and that traced to irritation of one or other of the nasal for an hour or so after the branches of the naso-palatine ganglion. Chronic sup- injection there is a slight negative phase ; after the five hours there is a gradual puration of the sinuses has lately received a large falling off in the coagulating time. I amount of attention and it is recognized that the am grateful to Dr. Duhig for his help in carrying out a number of most evil smelling discharge may not be the worst in these tests for me. Coagulose its result on the patient. There may even be chronic (Parke, Davis & Com- pany) is a useful local hemostatic. The Royal Prince sinusitus with perhaps only a trace of pus, which Alfred Hospital pattern of may on culturing be found to contain most virulent tonsil compression forceps (Allen & Hanbury) is well worth a place in the organisms. It is therefore essential to exclude such list of the general practitioner a condition being present. Chronic suppurating 's instruments. Local anesthetics are now used to a great extent in nasal sinuses may be a site of focal infection of systemic and laryngeal surgery. A complaints. The ophthalmic surgeon and the rhin- radical maxillary antrum operation can readily be done under local anes- ologist are working hand in hand in questions such thesia and it is the method of choice in as retrobulbar affections of the optic nerve ; the re- most cases. sults are proving encouraging. "Asthma" cannot In turning to laryngeal surgery, it is now recog- be said to have been thoroughly investigated until nized that carcinoma of the larynx, if confined to the the nose, as a possible source of the reflex, has been larynk, can be satisfactorily removed by total laryn- excluded. A simple pressure, in or out, of the middle gectomy. The disappointing statistics hitherto obtained turbinate bone occurring in a cramped nose may be were primarily the result of operating in cases too the starting point of asthma ; it may also be the start- far advanced. These cases are being recognized ing point of chronic sinusitis. The naso-pharynx is earlier and treatment is begun earlier. now-a-days brought under more direct examination by the aid of the naso-pharyngoscope. This instrument forms a great help in the instrumentation of, A NOTE ON HUON PINE OIL. and the passage of bougies into, the Eustachian tubes, By W. A. Harrison, M.B., C.M. (Edin.), B.Sc. The instrument is 'a help also in determining the (Pub. Health), Bict•nie , Tasmania. origin of pus in the posterior half of the nasal chambers. This oil distilled from the branches and wood of Regarding the ears, a great advance has taken Dacrydium frankléinvi is not available at present in place in the direction of tests for labyrin- commercial quantities and the tree is practically ex- thine responses and facts in the differential tinct except around the shores of Macquarie diagnoses between labyrinthine and cerebellar Harbour on the west coast of Tasmania. My very affections are slowly but surely being evolved. limited supply was obtained from "Mr. Hartwell In connexion with this work such names as Conder, Strahan, Tasmania. BArany, Ruttin, Friesner, etc., are met with. Con- During the timber boom logs have been dug out servative operations are our aim in the treatment of and exported which were cut by the convicts and chronic running ears ; as in the case of the child, we had celery top pines a metre in diameter growing seldom need to do a radical operation if the case is on top of them. It was this indestructibility of the in seen a reasonable time. The Heath conservative timber which suggested its use for surgical dressings. mastoid operation is still within reason the operation of choice in the first instance. My first experiment was in applying muslin bags partly filled with sifted sawdust to callous ulcers on The horror of enucleating tonsils in adults, held 1 In, the latest edition of "The Extra Pharmacopeia" by Martindale by surgeons of the previous decade, is now fast dis- and westeott an exeeleitt method is fully described, May 28, 1921.] THE MEDICAL JOURNAL OF AUSTRALIA. 441

hemisphere in order to carry out psychological studies the legs of bush workers who were unable to come among the Melanesians; during the great war he was in and so required an absorbent, antiseptic and pro- enabled to study the psycho-neuroses and practice psycho- tective dressing which could be left on permanently therapy at the Maghull Military Hospital. Therefore, his until the ulcers healed., I afterwards used in such experience as a teacher and investigator' and we may now say as a practitioner puts the mark of quality on what- cases a deep dressing of oil-saturated muslin : fixed ever he thinks fit to publish. by adhesive plaster and left on so that the healing The present book' is made up partly of lectures delivered surface was not disturbed at each dressing. The re- at Cambridge and partly of republished papers written as sults were so satisfactory that I next used the oil the result of clinical experience gained during the war. Its purpose is to bring functional disorders of the nervous sys- undiluted for pyorrhoea, for injections to abort mam- tem and mind into relation with the concepts concerning mary and other abscesses and for intractable leprous their working which are held by the biologist and physiolo- sinuses and ulcers at the Peel Island Lazaret, Queens- gist. Instincts of various kinds, especially those of danger, land. These it healed in a remarkable way and self-preservation, continuance of race and cohesion of the group are dissected in the same way as psychologists have Nurse Mitchell, who came there from Robins Island dissected intelligence and attempt is made to trace instincts Lazaret, Capetown, says she has seen nothing ap- back to lower animals. Although in doing this his reason- proaching it in efficacy. ing is not always as convincing as it is clear, the subject I have successfully treated four cases .ìf puerperal matter and the pen illustrations are nowhere devoid of interest. fever by gravitating into the uterus a hypodermic Dr. Rivers, as we know, has collaborated in previous re- syringeful of oil through a male gum elastic catheter. searches with British neurologists and physiologists. Armed This is quite safe, as this quantity of oil is non-poi- with this all-round knowledge, he points out that, just as sonous, though it is very fatal to insects and parasites many physiological reflexes and phenomena react on what is known as the all or none" principle, for instance, if iso- on plants and animals. • lated nerve fibre be set in action, it responds with its full Dr. Chauncy wh,o was in, charge of the Venereal strength and produces all the effect of which it is capable, Diseases Clinic, Brisbane,.. also used it successfully in whatever the stimulus may be, similarly the "extensor treating syphilitic cavities. thrust" reflex of Sherrington occurs fully or not at all, so The oil is a pale amber, resembling sandal-wood likewise in the case of certain instincts the reaction is sudden and full. For example, it is characteristic of emotion oil. It consists chiefly of methyl eugenol. It makes that it flares up at once and leads immediately to the corre- a useful ointment for parasitic skin diseases and a sponding behaviour. An animal or child exposed to danger good skin soap. An aqua can also be prepared by may give itself to the reaction fully. If it runs away, it the British Pharmacopoeia method. may run with every particle of the energy which it is capable of putting forth. There may be no discrimination of the degree of danger. In the case of an animal, the movement of h shadow may evoke as strong a reaction as the full sight Reports of Aases. of its deadliest enemy. But this must be qualified by pointing out that the animal or child does not always behave in A BROTH OF A BOY. such thorough-going manner. After a time their instinctive behaviour may be modified by experience. It so becomes By C. H. E. Lawes, M.B., Ch.M. (Syd.), possible to distinguish two kinds of instinctive behaviour; Petersham, Sydney. one which is innate and another which is graduated and discriminative. To these forms the terms protopathin and The dimensions of a baby at whose birth I was present epicritic, originated by Dr. Henry Head in his clinical studies recently, seem worth recording. It was the biggest new- on cutaneous sensibility, are applied. born baby I have ever seen in my own practice. When To illustrate Dr. Rivers's method we may take the instinct lying in bed it looked like a child two or three months old. of immobility, one which seems to go very far back in the The mother was the English bride of one of our Diggers. animal kingdom; it is well seen in the case of the bird and The parents are by no means big people, but are rather of the newly-born calf, the latter of which, in the absence under the average size. The delivery was instrumental, of its mother, may lie in the long grass motionless for hours but presented no difficulties, and there was no laceration of and the instinct has for its end concealment from threat- the perineum or vagina. Fortunately, the mother had a ening danger. Immobility is essentially a manifestation of very roomy pelvis. suppression; indeed, it is possible that the instinctive re- I append the measurements of the baby in one column action to danger by means of immobility may have furnished and those of the average new-born child in another: one of the earliest motives for suppression of the sens•,s of fear ând pain. If immobility is to be useful, it is essential Average Male Baby. Digger M. that it shall be complete—the "all or none" principle—be- Weight: 6.8 kilos.. (15 lb.) 3.4 kilos (7.5 lb.), (Holt). cause it is well recognized that the vision of animals is Height: 54.6 cm. (21.5 inches) 52.3 cm. (20.6 inches) particularly sensitive to movement. Out of the fact that Chest: 40.6 cm. (16 inches) 34 cm. (13.4 inches) perfect immobility demands the suppression of fear and Head: pain, as in the case of the wounded, the idea has come to Occipito-frontal circum- Dr. Rivers that the suppression of mobility and sensibility ference, 39.4 cm. (15.5 in.) 35.3 cm. (13.9 inches) seen in the state of hypnosis may be regarded as a mani- Occipito-mental diameter, festation, highly modified it is true, of the instinct of im- 15.5 cm. (6.09 inches) 13.3 cm. (5.25 inches), (Tornier and Chant- mobility. He goes further in suggesting that such a con- reuil). clusion holds more naturally of the suppression witnessed I should mention that the mother thinks she was from in hysteria. He would have us believe that the paralysis 10 to 14 days over her time. Even if this were so, however, and anaesthesia of hysteria, especially that arising in modern warfare, are modifications of one of the most definite of the the measurements are very big. various instinctive processes by which animals react to danger One weak chapter in the book is that on dissociation— Reviews. dissociation in the psychological sense, the process which experience undergoes when it is suppressed. The fugue is INSTINCT AND THE UNCONSCIOUS. taken as the most characteristic example of dissociation;

1 Instinct and the Unconscious : A Contribution to a Biological Theory Dr. W. H. R. Rivers is well-known as a teacher of of the Psycho-Neuroses, by W. H. R. Rivers, M.D., D.Sc., LL.D., R.R.S. psychology at Cambridge University and at one time, as 1920. Cambridge : Syndics of the Cambridge University Press ; Demy Svo., some of our readers may remember, visited the southern pp. 252. Price, 16s. net . 442 THE MEDICAL JOURNAL OF AUSTRALIA. [May 28, 1921.

in this a person shows behaviour, often of the most com- thinks there is an innate tendency and that the attacks plicated kind and lasting, it may be, for considerable periods, may be to an astonishing degree independent of external of which he is wholly unaware in the normal state. But in influences. our experience the fugue or state of automatism is not only With regard to paranoia, the author would confine the exceedingly uncommon? but usually the product of â dis- application of this term within comparatively narrow bounds, eased brain and of small importance in regard to daily con- . excluding many cases as paranoid forms of dementia praecox duct. It is also a severe strain for the imagination to think and paraphrenias He considers that the term paranoia of the frog as requiring dissociation in order to meet its should be confined to only those cases which are developed. aquatic and terrestrial experiences; and it is hard to believe from purely internal causes, with the fo}lowing character- that man, in the course of his evolution, has passed through istics. Systematation of the delusion, its uniformity and such an amphibian. phase, one in which it was necessary stability; the limitation of the morbid process to certain that he should be adapted to two very different kinds of circles of ideas; the permanent preservation of the psychic existence and, further, that traces of this phase persist. personality and the non-appearance of the phenomena of We think we have given enough to show that the book is dementia. With this limitation he finds that considerably full of close and coherent reasoning and, although at times less than 1 % of patients admitted to mental hospitals are this reasoning is barely acceptable, it is essentially stimu- suffering from paranoia. He accounts for this infrequency lating. Moreover, the book is written in a style having by stating that the majority of patients with paranoia either 'clearness of expression and carefulness of diction as out- do not require institutional treatment or do not require it standing attributes, so making it intelligible to the general for long. as well as the special reader. The author dismisses the Freudian conception of the origin In an appendix there will be found an account of a highly of paranoia "as not supported either by a clearly defined interesting case of claustrophobia and other papers. A good conception of the disease or by evidence at all acceptable." index rounds off the book and the printing is faultless. He also says that "the cure of a pronounced paranoic by direct psychic influence could probably he expected only by a psycho-analyst!" KRAEPELIN ON MANIC-DEPRESSIVE INSANITY AND PARANOIA. University Intelligence. Dr. Mary Barclay's English rendering of Professor Kraepe- The Queensland daily press has recently commented on lin's "Manic-Depressive Insanity and Paranoia" completes the attitude assumed by the State Treasurer in regard to her translation of his description of the psychoses as given the University of Queensland. The Daily Mail publishes the in the eighth edition of his "Text-Book of Psychiatry."' It recommendations of a select committee appointed on March appears to have been very well done on the whole, though 12, 1920, on the question of the organization and expansion in a few instances a difficulty or defect in translation. lead- of the University. The report was submitted on December ing to obscurity of meaning, is noticeable. For example, 10, 1920, was adopted by the Senate of the University and on page 151 we find: "The morbid nature of the apparent was then forwarded to the Government for consideration. improvement is often now already indicated"; and again on Apparently the Government has not yet been able to elabor- page 194: "I do not think that the morbid conception of ate its policy in this regard. Among the admirable re- delusional insanity is a unity." The use of the word morbid commendations the following has direct concern with the in a few other instances also is ambiguous, if not quite in- medical profession:• admissible. The printing and general get-up of the book (ix.) Thht particulars be brought suitably under the are very satisfactory. notice of the Government with an intimation that the Professor Kraepelin, in his term, "manic-depressive in-. 'establishment of a Faculty of Medicine (including den- sanity," includes not only all periodic and circular insanities, tistry) is one of the important requirements of the but also simple mania, the greater number of states of University. melancholia, many cases of amentia, that is, confusional or The committee place this demand seventh on the list in delirious insanity and certain colourings of mood. He does order of urgency. The requirements are set out in full this because he considers they have all certain common to provide for full degree courses in medicine, surgery fundamental features, show a want of definite boundaries and dentistry, together with the staff, equipment and and often an interchangeability in the same case. Finally, accommodation needed therefor. they have a uniform prognosis. "Attacks of manic-depres- It has been decided that as soon as the decision of the sive insanity never lead to profound dementia, not even Government has been ascertained, the select committee will when they, continue throughout life almost without inter- be required to furnish a further report to deal with the ruption. Usually all morbid manifestations completely dis- immediate policy of expansion. appear; but where that is exceptionally not the case, only a rather slight peculiar psychic weakness developes common to all the types." A BLIND MASSEUSE. The descriptions of the various mental states are 'very complete and illuminating; perhaps an over-elaborate detail The attention . of medical practitioners and of those con- and tendency to repetition may be noticed; but these are nected with the management of hospitals or other medical good faults, if faults at all, in a text-book. The insertion institutions is directed to the case of a blind lady who has in a translation of occasional descriptions in the original been trained as an expert masseuse and who is thoroughly German, however, is to be deprecated. competent to undertake housekeeping and other analagous The author notes that the assumption of decreased pulse- duties. This lady lost her sight as the result of an accident rate and blood pressure in melancholia is not borne out by at the age of 17. She is a member of the Chartered Society investigations made by Weber with newer and more perfect of Massage and Medical Exercises of London and has worked instruments, a rise being noted, though greatest in depressive under the late Sir Lauder Brunton, the late Sir Victor Hors- excitement. His description of mixed states is very clear ley, Dr. Eden, Dr. Warren and others. At the outbreak of and comprehensive, though he "thinks the doctrine still war she was drafted for duty first at St. Mark's, then at too incomplete to permit of a thorough characterization at St. Gabriel's and later at Millbank. After the . war was present." His analysis of age and sex incidence as causa- over she experienced great difficulty in again picking up the tive ' factors is very elaborate and his division of tempera- threads of her private practice and was reluctantly com- ments into depressive manic, irritable and cyclothymie lends pelled to leave London on account of the exorbitant price itself to a lucid description of the infinite variety of symp- of living, the increased rents and so on. She was advised toms noted. to come to Australia. It is desired to secure for this lady, As to the real cause a.nd nature of manic-depressive in- who is well-educated and refined, a resident position in some sanity, the author is not very illuminating; in fact, he char- institution where her services as masseuse could be utilized acterizes the peculiarities of the disease as "enigmas," but to the advantage of the patient or with some private employer. The Editor will be pleased to give further particulars 1 Manic-Depressive Insanity and Paranoia, by Professor Emil Kraepelin, to anyone who is in a position to ameliorate the tragedy of Munich; translated by R. Mary Barclay, M.A. , M.B.; edited by George M. Robertson, M.D., F.R.C.P.; 1921. Edinburgh: E. & S. surrounding the life of one who is capable of working and Livingstone; Demy 8vo., pp. 280. Price, 21s. net . willing to work. 1 May 28, 1921.] THE MEDICAL JOURNAL OF AUSTRALIA. 443

years of experience have proved that these advertisements are unnecessary. Unfortunately the Branches Che medical Journal of Australia. of the British Medical Association in Australia have long since sanctioned these notices, provided that SATURDAY, MAY 28, 1921. they are stereotyped and worded according to rule. This exception is the only one allowed in the Com- monwealth. A matter of Ethics. From time to time notices appear in the daily newspapers concerning the doings of medical prac- There is only one admissible method of advertise- titioners. At times the subject is the successful pas- ment open to a medical practitioner—the perform- sing of an examination. At other times an account ance of good work. In commerce it is necessary for of war service is given. On other occasions the notices the merchant to bring to the notice of the public take the form of an account of the illness of some the value of the goods he has to sell and the ad- person of greater or lesser importance and the medi- vantages accruing to the purchaser if he obtains these cal attendance by a named practitioner. In many goods from him. The merchant is not dealing with cases the notices are inserted by the practitioner's human lives and consequently it is not detrimental to relatives or friends who, ignorant of medical ethics, the public interest for the seller to commend his think that they are performing a service to him. wares in glowing terms. Medical practitioners belong They often supply a photograph to the press, thereby to a profession which is peculiar on account of the aggravating the offence. Although the medical prac- nature of the work to be performed. The relations titioner may be unaware of the action leading to the between the medical practitioner his patient are and publication of these paragraphs in the newspapers, of a kind demanding exceptional caution and un- he cannot entirely escape the consequences. The usual exercise of restraint. The practitioner is re- medical profession expects him to employ all reason- quired to apply scientific knowledge to cure disease, able means to prevent the appearance of these to alleviate suffering and to prevent death. His wares notices. It is held that a failure to warn relatives are the product of his brain and he cannot predict and friends constitutes passive acquiescence and may beforehand how much time and energy will be needed result in unpleasant consequences. It need scarcely in the treatment of even the simplest complaint The be mentioned that deliberate acquiescence or actual patient trusts the doctor with confidences of a most insertion of a notice of the kind indicated by a medi- intimate nature ; he trusts him with his life and he cal practitioner renders him liable to expulsion from trusts him with what is almost a blank cheque. In the British Medical Association. In Great Britain these circumstances the medical profession has from the General Medical Council reserves for itself the time immemorial required its members to obey cer- right to remove from the medical register the name tain ethical rules, so that this implicit trust may not of a medical practitioner who advertises in a public be misplaced and so that the honour of the profes- newspaper. It is possible that some of the Medical sion may be maintained. Boards in Australia have the power to take a similar No medical practitioner may do anything calcu- action on a charge of infamous conduct in a profes- lated to attract patients away from his colleague to sional repect, a term which has a definite legal signi- himself. In particular a doctor may not use the ex- ficance. But even if such extreme measures are not pedient of advertisement to increase his practice. It taken, the offending practitioner is bound to suffer is generally recognized that any personal or profes- severely from the loss of the good opinion and con- sional notice published in a newspaper is likely to fidence of his colleagues. We therefore appeal to act as an advertisement of a medical practitioner. In all medical practitioners to assist in guarding the Great Britain the General Medical Council does not dignity and ideals of the profession by preventing the approve of advertisements of changes of address, appearance of personal and professional notices in the settling in practice or returning from a holiday. Long public press. 414 THE MEDICAL JOURNAL OF AUSTRALIA. [May 28, 1921.

THE SURGERY OF THE SPLEEN Splenectomy for Addison's anemia was first suggested in 1913 by three German observers, Eppinger, Klemperer and de Castello. It soon became a com- One of the fascinations of modern medicine is the mon practice in Germany and was later adopted less mystery which surrounds the physiology and path- widely in America. England held aloof. The Ger- ology of certain organs. The hidden processes of the mans and Americans believed that hemolytis became bone marrow. . the • complicated functions of the less rapid and less extensive in pernicious anaemia liver and the amazing activities of the reticular after of the spleen. Percy and Mayo showed tissue of the spleen gather their intense in- removal that considerable benefit and prolongation of life terest largely from the fact that they are but im- followed the treatment of patients along three perfectly understood. Sir Berkeley Moynihan has general lines. The first was to stimulate the pro- written in the January issue of the British Journal duction of new blood by large "step-ladder" trans- a brilliant disquisition of 54 pages on the of Surgery fusions of whole blood. The second the removal surgery of the spleen. Some of it is history, re- was of foci of infection in other counted in the delightful paraphrases of a scholar, the teeth, tonsils and parts from which their toxins some of it is a splendid summary of our knowledge hemolytic bacteria or might be absorbed ; third to the of the functions of the spleen in health and in and the was remove spleen and thereby and the disease, and some of it a judicial estimation of the protect the very young very old red cells This latter state- value of splenectomy in various anemic states. Much from destruction. ment becomes intelligible remember that of it, on the other hand, is mere philosophical specu- when we there is abundant evidence that phagocytosis of the lation, but it is the speculation of a master mind It red cells carried on by the mononuclear cells is not often that a surgeon, engaged in the daily is large in the reticular sinuses the Apart from round of a big surgical practice with all its attendant of spleen. the comparative the advant- worries and cares, is able to rival the great physicians safety of the operation in depth of knowledpe and power of felicitous ex- ages of this threefold treatment are not impressive. It is stated that one-quarter of the patients have pression. But Sir Berkeley has done this. For his their lives prolonged by two or ; one- paper is not merely a contribution to our knowledge three years half are somewhat improved in health and of the surgery of the spleen ; it is a thoroughly suc- general live a few months longer than the ; cessful advance into the preserves of the physicians average while the remaining one-quarter do not receive any benefit along the highway of internal medicine. which could reasonably be ascribed to splenectomy. The first splenectomy deliberately performed in It is obvious that conclusions drawn from the statis- modern times for the cure of pathological enlarge- tics of 53 cases are liable to error. The experience ment of the organ was carried out in 1826 by Rostock is too limited. Moreover, statements as to the pro- in Germany. The patient was a woman who had longation of life "beyond the average" are matters cirrhosis of the liver and ascites in association with of opinion rather than fact. Sir Berkeley evidently her splenic enlargement. The surgeon, moved by the accepts the Mayo figures with a little reserve as he patient's persistent entreaties, decided much against states that the surgeon should never, or rarely, urge his will to operate. She died six hours later. The operation in cases of r ernicious anemia but should first Englishman to attempt the operation was Spen- state the facts and allow the patient to decide. cer Wells who removed an "enlarged spleen" from a married woman of 34 years in 1866. Wells decided Thomas Bryant was the first surgeon to excise after full deliberation to attempt the hazardous ven- the spleen from patients with myeloid leukemia. He ture. At that time his reputation in the world of performed two operations, one in 1866 and the other surgery was such that his words and actions were in 1867. Both patients died. Up to January 1, 1918, almost invested with infallibility according to the splenectomy had been performed 51 times for the beliefs of the day. The patient died of septicemia cure of this disease. The mortality was enormous. a week later. It was not long before other surgeons Only four survived the operation ! Surgeons raised of less repute attempted removal of the spleen. The their hands in deprecation of the slaughter. As great dangers of the operation were septicemia and Sir Berkeley Moynihan puts it, the record was a hemorrhage, and of these hemorrhage was the martyrology. Then in 1912 Korânyi introduced ben- greater peril. Up to the year 1898 there were 274 zol to the treatment of leukemia and later it was recorded instances of splenectomy with 170 re- found that the X-rays, or better, radium, was able coveries. In the present century the improved tech- to reduce the size of the spleen beyond the dreams nique, the better control of hemorrhage and the more of expectation. The mortality of splenectomy after perfect asepsis have insured a heavy reduction in the radium treatment has been greatly improved, as mortality. Sir Berkeley Moynihan quotes the figures may be gathered from the quoted figures of W. S. of the Mayo clinic up to September 20, 1920. Splenec- Mayo, but the operation has fallen into a disrepute tomy had been performed on 73 patients with splenic from which only very powerful evidence will raise anaemia with nine deaths, on 53 with pernicious it. For the present clinicians have reposed their con- anemia with three deaths, on 26 with myelocythaemia fidence in radium therapy. with one death, on 32 with hemolytic jaundice with Much as opinions may differ on the question of one death, and on ten with septic splenomegaly with splenectomy for Addison's anemia and leukemia, a two deaths. Of a total of 243 patients on whom the paeon of praise has greeted the operation for splenic operation had been done for various conditions, 26 anemia and .hemolytic icterus. The first condition died while still under care in hospital. was first adequately described by Guido. Banti, a

May 28, 1921.] THE MEDICAL JOURNAL OF AUSTRALIA.

Florentine, in 1894. The relation of this disease to Eady declared that there had been no miscarriage of an associated cirrhosis of the liver and to haxnior- justice. Lord J ustice' Phi IIimore rcnuirked that rhages from the stomach is well known. Its patho- Stevens had scored a point about the analysis as the genesis is obscure. The established form of treat- preparation did not contain kralueria, but he pointed ment is splenectomy which, when performed before out that the inference which might be drawn from the disease has made hopeless ravages, leads appar- the publication, was that the .plaintiff was carrying ently to cure and certainly to great prolongation of on business according to the usual methods of the life. quacks. The onus of proof was on the defendants Hardly less wonderful are the results of the opera- and they had discharged it. Lord Justice Banks said tion for the cure of haemolytic jaundice, that curious that whatever the medicine contained, there was evi- disease in which the red corpuscles have a lowered're- dence proper for the consideration of the jury to the sistance to solutions of hypotonic saline—a charac- effect that it was to all intents and purposes value- teristic fragility which is the chief feature of the less. Stevens claims that a herb called nmekaloabo disease. There are, in addition, jaundice of the has a specific curative action in 'tuberculosis. We acholuric type, i.e., jaundice unassociated with trust that no one in Australia will be misled by the changes in the colour of the stools or urine, enlarge- unfounded claims of • Stevens or of the many other ment of the spleen and anemia of which hiemolysis is individuals who have foisted useless preparations on

the predominant feature. The pathogenesis is en- a credulous public backed solely by a cheap under - veloped in obscurity. The treatment is splenectomy. taking to cure consumption. It will be noted that The results are astonishing. A life-long jaundice in the papers distributed Stevens does not include with all its associated stigmata disappears within a one word concerning the result of the action or the few days, or even hours, of splenectomy, never to remarks of the three judges in the appeal. return. The change in a patient who has suffered from the disease from birth, is one of the most dramatic incidents in the cycle of modern surgery. Naval and military. The skin becomes clear and fresh, the muddy com- plexion vanishes and the metamorphosis is hailed APPOINTMENTS. with delight by patient and friends. The operation is a reasonably safe one; in 80 cases of two collected Australian Military Forces. series there were only three deaths. The following appointments to substantive commissions on A perusal of Sir Berkeley Moynihan's essay will the Reserve of Officers appears in the Commonwealth. of more than repay the trouble. It makes delightful Australia Gazette, No. 43, of May 4, 1921: reading and is a classic of its own kind. We com- Second Military District. mend it to the attention of our readers. To be Majors— Honorary Captain A. M. Langan, Australian Army Medical Corps Reserve, 31 January, 1920. A TUBERCULOSIS NOSTRUM. Honorary Captain K. S. Parker, M.C., Australian Army Medical Corps Reserve, 24th January, 1920. To be Captains— • It has been brought to our notice ,that some mem- Phillip Lisle Daniel, Frederick William Leslie Lig- bers of the medical profession in Australia have re- gins, Arthur Cecil Moran. ceived a booklet alleged to contain the "medical evidence" given in an action taken by one Charles H. Third Military/ District. Stevens against the British Medical Association in To be Captains— Charles Herbert Leedman, M.C., Reginald Howden, 1912, together with other pamphlets. A warning is Hubert Shepphard Bush, Robert Trevor Fether- necessary. The evidence of the medical practitioners stonhaugh, John Richards Harris, Mitchell Henry called by Stevens does not represent the medical evi- O'Sullivan. dence given at the trial. Sir Richard Douglas Powell, Fifth Military/ District. To be Lieutenant-Colonel-- Dr. Dyke Ackland, Dr. F. W. Price and Dr. Arthur Honorary Lieutenant-Colonel A. J. H. Saw, 0.11E., Latham were called for the defence. Stevens does not Australian Army Medical Corps Reserve. circularize their evidence. It is significant to recall To be Majors— that Dr. Dyke Ackland in his evidence stated that Honorary Majors G. W. Baker, F. T. A. Lovegrove and C. H. Terry, Australian Army Medical Corps if the medical witnesses for the plaintiff still con- Reserve; Honorary Captains T. L. Anderson, tinued in the opinion that the preparation was a O.B.E., and J. Kenny, Australian Army Medi- cure for consumption, they must be dishonest. Sub- cal Corps Reserve, Claude Morlet, D.S.O.. sequently he modified his allegation by the admis- To be Captains— Honorary Captains T. 'J. Lonergan, D. G. Robert- sion that a man may be honest and mistaken and that son, F. M. House, C. H. Leedman, M.C., H. O. the witnesses must have been mistaken. The action Chapman, G. F. Landon, B. F. Hussey, H. B. Gill, was taken by Stevens as a result of the exposure of G. T. Donovan, R. G. Braham and J. F. Mit- his reputed remedy in the publication "Secret chell, Australian Army Medical Corps Reserve; Honorary : Captains Alexander Juett, Arthur Remedies." The result of the first trial was unsatis- Badock and Leonard TiIsley Baker. factory. The jury failed to agree and were discharged. The case was reheard in 1914 and the jury returned a verdict for the British Medical Associa- We have pleasure in announcing that Dr. N. Hamilton tion. Stevens applied for a new trial on the ground Fairley, Ó.B.E., has been awarded the David Syme Research that the verdict was against the weight of evidence. Prize for the year 1921 for his researches in Egyptian bilharziosis. Dr. Ethel I. McLennan has been placed proxime The application was refused. Lord Justice Swinford accessit for her work on the endophytic fungus of lolium. TUE MI1DICAL JOURNAL OP AUSTRALIA. [May 28, 1921.

open, for some oedema always follows. laparotomy both gastro-enterostomy Abstracts from Current medical Débridement of the skull should be and gastrectomy are found impossible. Literature. done in the frontal and subocciptal The Pauchet operation of gastrectomy regions. Over a skull sinus trephining is recommended in which the jejunum should completely expose the sinus. is sutuned to the cut end of the stomach SURGERY. ln large eggshell fractures an effort and an entero-enterostomy also per- should be made to cleanse the track in formed. For hmmorrhage following the (190) Plastic Repair in Face Injuries. the brain, but extra-dural bone frag- operation lavage with warm saline is .T. D. VVhitham (Military Surgeon, ments should not be removed. first tried and on recurrence rapid lav- January, 1921) in the description of the age with silver nitrate solution (1 in plastic repair of face injuries holds (193) Retro-Peritoneal Peri-Renal 4,000), which is not left in the stomach. that the first stage should be one of Lipoma. Vicious circle vomiting, not amenable cleansing and primary suture. Droop- Holmes (Journ. Amer: Med. Assoc., to lavage, is due to torsion of the in- ing parts can be supported by an ar- October 16, 1920) gives details of testinal loop. In these cases re-open- rangement of the dressings. Opera- retro-peritoneal peri-renal lipoma oc- ing the abdomen is necessary. tion should be postponed till contrac- curring in a white woman, oet. ture has ceased and the possibility of 43. Adami classified retro-peri- (196) Gall Bladder Surgery. arousing latent infection has passed. toneal lipomata. into those arising G. W. Crile (North West Medicine, Ophthalmic needles are used and der- from peri-renal fat, those from mesen- March, 1921), reviewing gall bladder mol employed as a suture material. teric fat and those of doubtful origin. surgery, expresses preference for the Pedicled grafts from the chest and the The ætiology is unknown, but they are oblique incision which runs parallel to tubed pedicle method of Gillies are more common in women. The symp- the rib margin. Drainage must be commended. Large Krause-Wolf grafts toms are few and are caused by pres- adequate, lest a sub-phrenic abscess should be reserved for the non-mobile sure, e.g., oedema of the feet, ascites, develope. It is best made through a parts of the face. Platysma myoides varicocele, etc.. Diagnosis is often counter incision in Morrison's pouch. and overlying fat can be used to fill made only at necropsy or operation. In fulminant cholecysti.tis a cholecystos- in mandibular depressions. Cartilage Lipoma is most frequently mistaken tomy should be the rule, followed later is valuable for depressions of the eye- for a cyst, especially an ovarian cyst. by cholecystectomy. After choledocho- lids, nose, forehead, etc., but in the The position of the tumour, the colon tomy, if the passage of bile through the molar and zygomatic regions the writer percussion note and the semi-fluctuant ampullh, is assured, the duct wound prefers tibial bope grafts. The dif- character of the tumour are helpful may be entirely closed; but if there ferent methods of rhinoplasty are dis- points. Cystoscopy may be helpful. has been much trauma to the mucosa cussed and a preference expressed for The pert-renal lipoma is limited by the or if a stone has been present in the a modified Keegan's operation. Eye- pert-renal fascia which has been de- ampulla, duct drainage should be em- lids are best restored by temporal or scribed by Gerota, and enucleation can ployed. In cholecystectomy the exact supra-orbital flaps which must be large be carried out within this capsule site for division of the cystic duct bnough to allow for shrinkage. without danger. Recurrence is not should be decided on carefully. If too unlikely. high, a diminutive gall bladder may be (191) Diaphragmatic Hernia. left; if too low, there may be injury to Joseph Hajek (Medical Record, Feb- (194) The Treatment of Cranio- the common duct or a temporary ob- ruary 26, 1921), has described a case Cerebral Wounds. struction to the flow of bile. He con- of diaphragmatic hernia. He divides H. Neuhof (Annals of Surgery, No- siders Meltzer's magnesium sulphate this form of hernia into the usual sub- vember, 1920) appreciates the wider test a valuable aid to diagnosis. divisions of true congenital hernia, use of local anzesthesia in dealing with false congenital hernia, true acquired cranio-cerebral . wounds. Cranial in- (197) Clavicle Resection in Injury to hernia, false acquired hernia and juries with extrusion of the brain sub- the Brachial Plexus. diaphragmatic eventration. The true stance are not common in civil life. H. M. Richer (Sorg., Gynec. and Ob- type has a sac of peritoneum or pleura It is in civil cases with soiled scalp• stet., January, 1921), while insisting in or both. Congenital cases are due to wounds that the indications for treat- nerve lesions on the need for carefsl arrested development of the diaphragm. ment most closely resemble those of coaptation of the severed ends, favours The true acquired type herniates gun shot wounds. The piece-meal re- resection of the middle third of the through one of the natural openings moval of bone fragments and spicules clavicle in some cases of injury to the of the diaphragm; the false acquired from the brain, followed by drainage, brachial plexus. He reports two cases type is most commonly due to stab has never been satisfactory. Perfora- in each of which approximation had wounds, while diaphragmatic eventration of the brain by the relatively low been found impossible by the ante- tion is simply due to a thinning out explosive bullets of civil life, however, cedent surgeon. The incision runs of part of the diaphragmatic dome must not be placed in the same category from the middle of the posterior border which becomes pouched to receive the as injury to the brain from war proof the sternomastoid muscle downwards herniated viscera. The great majority jectiles, for in the former case relatively and outwards across the middle of the of all types are located in the left side little foreign matter is swept in and clavicle and then in the direction of and the opening is more commonly in the indications for débridement do not the inner border of the humerus to the muscular than in the tendinous exist. The more logical treatment of terminate at the lower border of the part of the diaphragm. The organs the late complications of hernia cerebri M. pectoralis. The middle third of the usually involved are the stomach, colon, and epilepsy must follow the extensive clavicle is removed with a Gigli saw omentum, small intestine and spleen war experience and the indications for and then the shoulder is pushed medially in the order named. extraction of intra-cerebral projectiles so as to relax the plexus. The gap left have been more clearly defined. is not bridged, but the arm and shoulder (192) Cranio-Cerebral Injuries. should be supported for many weeks. Adolph M. Hanson (Military Surgeon, (195) Cancer of Stomach. January, 1921) reports a series of 44 V. Pauchet and M. Delort (La Presse (198) Fmeal Fistula Following cranio-cerebral injuries treated by Médicale, November 6, 1920) point out Nephrectomy. operation. He believes in exposing that three of every four cancers of Weller van Hook (New York ]led. freely all head injuries. The first or the stomach are grafted on ulcers. All Journ., January 1, 1921) records a case "dirty" stage consists of cleaning and chronic ulcers should be treated by of intestinal obstruction in a woman trephining, after which all instruments operation, especially in patients of 40 who two years previously had had a should be re-sterilized, new gloves put or more years. Gastro-enterostomy nephrectomy performed. A fecal fis- on and the wound wiped with alcohol. alone is indicated only as a prelimin- tula had persisted after this operation The track should be painstakingly ary measure or in cases where focal and when her abdomen was opened for cleansed with ethyl alcohol and, if pos- or general conditions forbid gastrec- the second condition, the splenic flexure sible, the foreign body removed. The tomy. Jejunostomy is reserved for was found bound down and occluded. dure mater, if torn, should be left cases in which in the Bourse of a Apparently the splenic flexure bad been . May 28, 1921.] THE MEDICAL JOURNAL OF AUSTRALIA. 447 caught by the clamp in ligating the Ribes's bag, which brings on labour They regard manual dilatation as likely pedicle of the kidney during nephrec- pains and so stimulates the uterus to to lacerate the cervix and consider it tomy. Colo-colostomy re-established empty itself. dangerous. Cæsarean section is held to the fæcal current without any local be the operation of choice when the repair at the site of injury to the bowel. (200) Dry Labour. patient is a primipara at or near term F. A. Dorman and E. C. Lyon (Amer. and when the placenta prcevia is cen- Journ. of Obstet. and Gynec., March, tral and the dilatation of the cervix 1921). in. a critical study of 270 cases slight. For multiparæ who desire a GYNÆCOLOGY AND OBSTETRICS. of dry labour occurring in a series living child, the same holds good. of 2,000 obstetrical cases, have con- (199) The Induction of Abortion. cluded that obstetrical complications (202) Rectal Examination in John Phillips (Lancet, February 5, seem to cause dry labour almost as Obstetrics. 1921) has reviewed the indications for frequently as dry labour causes ob- W. E. Park (New York Medical the induction of abortion in the light stetrical complications. The length of Journal, November 11, 1920) advocates of his own experience. He includes time by which rupture of the mem- rectal in place of vaginal examination among abortions all pregnancies which branes precedes labour is not an im- in obstetrics. It requires practice to terminated before the end of the 28th portant factor, either in prolonging recognize the various anatomical struc- week, namely, the "embryonic" (up to labour or in causing morbidity or tures, but the advantages are so great the 12th week) and the "foetal" (from foetal mortality. But protracted dura- that it is well worth while to perfect the 12th to the 28th week). In his pri- tion of the pains in dry labour greatly the "rectal touch." The degree of dila- vate practice of 35 years he has induced increases the morbidity and triples the tation of the cervix can be recognized, abortion in 57 cases after complete foetal mortality. The morbidity risk the presenting part determined and the agreement with a consultant that it was increases proportionately with the num- level measured. These facts, together the only course to save the mother. ber of vaginal examinations. The with the information obtained by ab- The causes which indicated the in- dilating bag does not reduce morbidity dominal palpation, give the attendant duction of abortion were: acute albu- and seems unfavourable to the foetus. all the information usually required. minuria in 18 cases, glycosuria in 2, Dry labour requires operative termina- There is a distinct risk during vaginal uncompensated cardiac disease in 11, tion in one third of the number of examinations of carrying up into the incoercible vomiting in 15, acute sali- births. The risks of labour with birth canal organisms which under vation in 1, chorea in 1; placenta prcevia breech presentation are much greater favourable conditions to them may in 6 and cancer of the breast in 3. if the membranes are ruptured early. prove deleterious to the patient. From There was no maternal mortality. Csarean section in this series gave a rectal examination can be learnt all Pelvic deformity is not an indication very good results, although usually that requires to be known in 90% of for induction in his opinion. It is considered dangerous in dry labours. cases. From the patient's viewpoint better treated by Csarean section. In Of eight patients six had dispropor- this method has the advantage that it his cases the usual indications were tion between the pelvis and the pre- does not go contrary to Nature's present. Other conditions which may senting part and two had fibroids ob- method of protecting the woman in justify the operation are discussed. structing the parturient canal. All re- childbirth. From the doctor's view- Patients suffering from mental aber- covered, though labour had been pro- point it is attended with much less ration he divides into three groups: longed over an average of 30 hours, waste of the time and trouble which (1) Those who, though healthy in all with early rupture of the membranes. are consumed in sterilizing the vulva respects before marriage, have been Dry labour increased the puerperal and vagina and the surgeon's hands subjected to severe nervous stress and morbidity by 8.5% and the foetal mor- and gloves when vaginal examination on becoming pregnant have manifested tality by 3%. The causes were pro- is to be performed. It is only neces- mental symptoms. (2) "Border-line" longed labour, infection and operative sary to don a clean glove. The pro- patients who become pregnant and soon terminations. cedure can be frequently repeated with- show mental symptoms. (3) Those who out risk. are normal mentally and have a good (201) Placenta Praevia. family history, but on becoming preg- In an analysis of 100 cases of pla- (203) Intra-Vesical Repair of Inacces- nant develope an exhausting illness, centa prcevia G. L. Brodhead and E. G. sible Vesico-Vaginal Fistulae. such as chorea, urmia, etc., and begin Langrock (Burg., Gynec. and Obstet., Munro Kerr (Proc. Roy. Soc. Med., to show signs of impending mental dis- January, 1921), found that 17 of the December, 1920) records a case of turbance. If it is to be done induction patients were primipare and 78 multi- vesico-vaginal fistula following an should be performed early—before the pare, while of 5 the history of pre- operation for advanced carcinoma of 10th or 12th week. Sedatives, apart vious labours was unknown. The posi- the cervix. It was high up in the vault from opiates, should be given freely up tion of the placenta in 58 cases was of the vagina and so inaccessible that to and for some time after the opera- marginal, in 25 central, in 12 lateral repair by the vagina seemed impossible. tion. In cases of retroflexed impacted and in 5 unknown. There were 9 ma- Through a supra-pubic incision the gravid uterus the induction of abor- ternal deaths and 63 foetal deaths. vault of the bladder was opened trans- tion is indicated only when it gives Treatment varied. In 23 cases the versely. The fistula was at the base rise to grave symptoms imperilling the dilating bag and version were used, in of the bladder and was easy to reach. patient's life. Even then he holds it 17 version, in 9 manual dilatation and With the knife the mucous membrane is easier and better to open the ab- version, in 8 breech extraction, in 8 of the bladder was separated from the domen and lift the fundus up. In re- Hicks's version, in 8 normal delivery, muscle and mucous membrane of the gard to phthisis and general tuber- in 6 Cæsarean section, in 5 the dilat- vagina. He wished to insert two culosis he• holds that pregnancy does ing bag, in 4 forceps and in the re- layers of sutures and to tie one in the not accelerate the course of these dis- maining 12 cases a variety of pro- bladder and the other in the vagina. eases and is not an indication for in- cedures was used. The treatment de- Difficulty was experienced with the duction. The same opinion holds in pended on the patient's age, parity and latter. It was overcome by passing the regard to epilepsy and to paraplegia. period of gestation, on the type of vaginal sutures on straight needles and He considers that a previous history placenta, the amount of dilatation, the closing the bladder after tying off the of congenitally deformed and mentally condition of patient and infant and on bladder sutures. The straight needles deficient children does not justify in- the surroundings and surgical experi- were then drawn down into the vagina duction in subsequent labours. As re- ence of the operator. The authors and tied with long pressure forceps. gards the technique of operation, for concluded that version was preferable A self-retaining catheter was left in the early cases he advocates the use in the large majority of cases when the bladder for three days. The pa- of tents or rapid dilatation with gradu- the cervix was sufficiently dilated to tient made an uninterrupted recovery ated bougies and removal of the ovum admit the hand. Extraction should be and the fistula was completely healed. en masse with ovum forceps. In the very gradual. If dilatation is small, Kerr states that as far as he can dis- more advanced cases he prefers to use the use of de Ribes's bag without rup- cover this procedure has not been de- tents and to insert later a small de ture of the membranes is indicated. scribed previously. THE MEDICAL JOURNAL OF AUSTRALIA. [May 28, 1921.

A skiagram taken by Dr. A. T. Nisbet disclosed a shadow British medical Association news. extending upwards and backwards from the sella turcica. Stereoscopically it was seen to be placed in the same plane SCIENTIFIC. as the sella which appeared to be normal in outline. As the shadow was well over 2.5 cm. in its greatest diameter, it was obvious that the tumour was of considerable size and A meeting of the Queensland Branch was held at the lay mainly outside the sella. Dr. Marks regarded the diag- B.M.A. Rooms, Adelaide Street, Brisbane, on March 4, 1921, nosis of the nature of the growth as pure conjecture. The Dr. Graham 'Butler, the President, in the chair. choice seemed to him to lie between a pituatary cyst, a Dr. R. Graham Brown presented a patient, a returned neoplasm, a tuberculous lesion and a gumma. He under- soldier, aged 30 years, who had a transient swelling 3.75 stood that the appearances in the skiagram favoured one cm. in its greatest diameter at the root of the neck. The of the two last named. The fact that the vision on February swelling was situated just above and to the right of the 27 was °/,e on the right side and 8/9 and two letters of episternal notch. It was only brought into evidence when on the left, and that the headaches had disappeared the patient strained with his mouth closed. It was an seemed to indicate that the affection was a gumma, since air tumour and could be expressed with the fingers. A the patient had been taking mercury. Dr. Marks reasoned stalk could be felt extending into the carotid space just that as this was the only condition that would be amen- internal to the vessels. There was no history of trauma. able to treatment, it was unnecessary to apply the Wasser- The swelling caused him no inconvenience. X-ray examina- mann test. Many cases had been recorded in which tion had not thrown light on the diagnosis. improvement had taken place after treatment with In the next place, Dr. Graham Brown demonstrated a mercury or with glandular extract. Whether the series of chronic septic processes of the nasal accessory treatment had been responsible in his or the other sinuses associated with bronchiectasis. The first patient was recorded cases for the improvement was a little uncertain. a girl, aged 9 years, who had had measles at the age of 13 months and pneumonia at 14 months. Ever since that Dr. J. Lockhart Gibson said that he had had the privilege time she had been coughing and expectorating a foul secre- of examining the patient with Dr. Marks. He agreed with tion. The tonsils and adenoid vegetations had been removed him concerning the diagnosis. The X-ray photographs on February 18, 1921. At the same time the anterior ends yielded strong evidence in favour of a pituitary tumour. If of the middle turbinate bones had been amputated and the improvement had been due to the mercury, it seemed pus washed out of the right maxillary sinus. A skiagram as if the boy's life would be saved. taken before this procedure revealed a dull right maxillary Dr. J. G. Avery showed a woman suffering from tuber- antrum. The patient had a very pinched face, was a bad cular leprosy. He had three patients with leprosy at the mouth breather and had a well-marked Harrison's sulcus. Skin Department of the Brisbane Hospital. Two of the She had improved considerably in general health and in patients had not turned up. The patient shown was a appearance since the operation. married woman, aged 34 years, who had lived the greater The second patient, a boy, aged 16 years, had had a dis- part of her life at Gympie, a few years at Cairns and the charge from the nose since the age of six months and had past two years in Brisbane. About 18 months before she coughed and expectorated a copious foul secretion. He had had a miscarriage and about that time she had noticed had had diphtheria at the age of five years and had worn a "pimple" on the front of her left thigh. The spot had a tracheotomy tube for six months. The tonsils and adenoid spread gradually till it covered an area the size of a hand. vegetations had been treated surgically at the age of four The central part was atrophic, whitened and anwsthetic and again at the age of seven. He was supposed to have had to touch and pain. The edge was dark red and slightly in- lead poisoning at the age of seven. He was undersized and filtrated. Numerous other patches had appeared on the unhealthy looking and had a pronounced pigeon chest. He body. The distribution had become general. The nodules was mentally bright. A double radical antrum operation varied in size from that of a pea to that of a half a had been performed in December, 1920, under local anes- crown piece. They were reddish or yellowish red in colour, thesia. In January, 1921, a submucous resection of the sep- were macular or maculo-papular and all were infiltrated. tum had been done and the antrum had been cleared out. There was no ancesthesia. The nerves were not thickened He had improved considerably since the operation and had and the glands were not enlarged. There was some wast- grown 5 cm. in height in the following two months. There ing of the adductors of the thumb and the hands and was still some ethmoidal disease. Dr. Graham Brown pro- fingers were somewhat puffed, particularly in the region posed to deal with this at a later date. of the proximal phalanges, so that the fingers had a taper- The third patient was a girl, aged 16 years, who presented ing look. She declared that she had not lost weight and that physical signs similar to those of the two other patients. she felt perfectly well. The report from the Health De- The history was also similar. partment on the Wassermann test was that no reaction Dr. E. O. Marks showed a patient with bi-temporal hemi- had been obtained. Slender acid-fast bacilli had been found anopsia. The patient was a male, aged 18 years. He ap- in the lymph obtained from a nodule. peared to be healthy and there was no history of syphilis. The second patient was a single girl, aged 18 years, in He discovered that his vision was defective accidentally domestic service. The history of her illness dated back 18 on looking at test types exhibited in a window. He had months. She had lived in the Brisbane district all her attended the out-patient department at St. George's Hos- life. The appearances were similar to those of the first pital, London, where he had been given some medicine patient, save that there was no anæsthetic area on the which he thought caused improvement. During the voyage thigh. The face was somewhat more extensively involved. to Australia his sight had become less good. His parents One large maculo-papular area on the forearm seemed to stated that it was difficult to induce him to do anything be slightly analgesic, but this improved after one or requiring exertion. There were no signs of pituitary ex- two doses of kharsivan. She stated that she had not lost cess or deficiency. weight. She was well nourished. The Wassermann test had On January, 29, 1921, his vision on the right side was been carried out both by the micro-biologists at the Health V. and on the left 2/. The pupils were equal, but re- Department and by himself. The former had failed to ob- acted somewhat sluggishly. The media were clear and the tain a reaction on two occasions. Dr. Avery had noted a examination of the eyes revealed nothing of a definitely slight reaction. Six doses of neo-kharsivan produced no pathological nature. The vision was too defective to obtain improvement other than that mentioned above. Acid-fast a reliable field, though it was evident that there was left- bacilli had been found in the lymph trom one of the nodules. sided hemianopsia. He was given mercury and iodides. The vision had improved gradually during the month of The third patient was a man, aged 35 years, a labourer. February and satisfactory fields had been obtained. They He had been sent to the hospital on account of ulcers on had revealed complete temporal hemianopsia of the left eye his feet. The serum had yielded a positive Wassermann which had remained constant. On the right side the tem- reaction. He walked with a steppage gait, suggestive of poral field had been badly damaged, but the blind areas peripheral neuritis, but the presence of deep, indolent trophic varied at different times. The perimeter and scotometer ulcers on the soles of the feet and very active reflexes charts showed the variation. It was seen that the scotoma showed that this condition was not present. There was was situated very close to the fixation point and on the right general muscular weakness, most pronounced in the ex- side almost included it. tensors. The right hand showed a contractu re of the flexors, May 28, 1921. ] m^^ MRt)tCAL JOtJRNAt. 0V ACJSmRALtA. 449

prótlucing a claw hand. There were trophic changes at the ing the treatment of marginal blepharitis. Yellow oxide tips of the fingers. He complained of slight numbness of of mercury was useful in some cases, but the ointment did the fifth and ring fingers of the left hand. This improved not reach the organisms in the follicles. He agreed that after two doses of neo-kharsivan. Both ulnar nerves were steady treatment was needed for trachoma. He had always definitely thickened. On the left buttock and on the inner extirpated the lachrymal sac when this was necessary and side of the left thigh were two rounded areas with smooth had obtained good primary union, even when suppuration centres and slightly infiltrated, dusky edges. Slight anæs- had been present. For iritis massive doses of sodium thetic changes were detected. The patient denied that salicylate were useful in some cases, but they were harm- he had had syphilis and stated that he had suffered for ful in post-operative cases. Interstitial keratitis was not from 11 to 12 years. Deviation of complement was reported confined to children. He agreed that reliance on trans - by the micro-biologist of the Health Department. illumination alone in the diagnosis of tumours was danger- Dr. Graham Butler stated that the absence of a Wasser- ous. Some ophthalmic surgeons objected to the use of mann reaction was of no importance in these cases, as the the trephine for glaucoma, while others obtained good re- test varied. The condition could always be diagnosed by sults with it. It was superior to iridectomy in regard to the the complement deviation test if the antigen were made cosmetic results. In conclusion he made a strong plea for from the bacilli obtained from a leprosy nodule. the better study of ophthalmology by medical students. Dr. W. Wallis Hoare read a paper entitled "Recent Ad- Dr. R. Graham Brown read a paper on the recent advances in Diseases of the Eye" (see page 435). vances in diseases of the ear, nose and throat (see page 437). Dr. J. Lockhart Gibson said that he had listened with Dr. J. Lockhart Gibson said that middle ear catarrh was interest to Dr. Hoare's paper. He still looked on yellow a condition that was seen first by the general practitioner;

oxide of mercury ointment as the most valuable application in the absence of an aural surgeon, he should deal with it in marginal blepharitis. The nose and naso-pharynx should promptly. If it were treated promptly and properly, there be made healthy, if they were not so and as a rule the re- would be no need for radical mastoid operations. He had not fraction required correction. Extirpation of the lachrymal seen a single patient whose drum membrane he had had sac was occasionally necessary, even when the blepharitis an opportunity of puncturing, needing a radical mastoid was not cured by this procedure. He had found it very operation. This was because he employed Politzer's bag satisfactory. Dr. Gibson could not agree that iritis was from the first until the discharge disappeared. If the per- usually complicated with cyclitis. Theoretically it should foration tended to close, he re-opened it. General surgical be, but actually it was not. Iritis was generally due either principles and good drainage were necessary. He had been to syphilis or to a constitutional state for which massive surprised that Dr. Graham Brown had, made no mention of doses of salicylate and citrate of soda were specific. Dental Politzeration in acute and chronic middle ear disease. One causes of iritis had been much over-estimated. Post-opera- of the first essentials of treatment of chronic middle ear tive iritis was generally due to tertiary syphilis, unless it suppuration was the removal of adenoid vegetations or the were due to trauma " inflicted during the operation. Inter- rectification of a blocked nose. This was also. essential in stitial keratitis was a manifestation of syphilis, usually in- acute cases, but it should be undertaken after the acute herited syphilis. The treatment consisted in that of the condition had subsided. constitutional state. He had found inunction the best treat- Dr. W. N. Robertson, C.B.E., said that two-thirds of ment. Occasionally salvarsan was useful, but often it was nasal and throat troubles were due • to causes within the of no value. Atropine was the only drug for local treat- abdomen. The removal of adenoid vegetations at any age ment; it should only be used when there was irritation was a matter of symptoms. The youngest patient on whom of the iris. Inflammation of the uveal tract seldom com- he had operated, had been eleven months of age. Sinusitis plicated interstitial keratitis, although some authorities was due to faulty drainage of the post-nasal space. It claimed that it did. occurred after inefficient removal of adenoid vegetations. He regarded transillumination as a very dangerous method Bronchiectasis did not occur with sinus infections and the of diagnosis for tumours of the chorioid. When a chorioidal clearing out of the sinuses would improve the pulmonary tumour, which was, nearly always malignant, had grown condition. The ordinary case of running ears could be cured large enough to cast a shadow with transillumination, it by the removal of adenoid vegetations. He preferred the would be too late to remove the eye and to save the pa- sitting-up position to that of the supported hanging head. tient's life. He agreed that they were too afraid of oper- The question of hereditary deafness was in the melting ating on immature cataract. His experience of operations pot at the present time. It was frequently caused by here- for immature and hypermature cataract in very old people ditary enlargement of the tonsils and of the adenoid tissue. was that they yielded surprisingly good results. They were He regarded enucleatlon of the tonsils as the best, operation. still groping for some general treatment for glaucoma or Enucleation of tonsils gave good results in the treatment for a removable focus which caused glaucoma. He held of diphtheria bacillus carriers. Dr. Robertson held that the that Graefe's explanation held good, that glaucoma was direct suspension method was far preferable to the in- due to an increased activity of the ciliary body, just as direct method for the treatment of papillomata of the larynx. increased intra-cranial tension was due to increased activity Turbinectomy was anathema to a good rhinologist. He of the chorioid plexus or gland. He was not a convert to warned the general practitioner against performing this sclero-corneal trephining. He held that a properly exe- operation, particularly on patients in the western districts. cuted iridectomy was the best treatment. It was the only These patients tended to get dry, crusted noses with hyper- treatment for acute glaucoma which did not yield promptly trophy of the middle turbinate and pressure headaches. to milder measures. He had recently seen a patient on The posterior end was frequently left behind and became whose eye he had done an iridectomy for a bad attack loaded with dry crusts which were very difficult to treat. of glaucoma ten years previously. The recovery had been He used calcium lactate in solution, not in tablet form, for lasting, with 6/5 vision with correction of a little astigmatism. three days before operation. The other eye was affected. He decided to try eserine and Dr. A. C. F. Halford referred to the lack of interest shown large doses of salicylate and citrate of soda; a rapid relief by many practitioners in ear, nose and throat work. He had resulted. The vision had improved to e/8 and the eye stated that sinusitis was a very common cause of ill health had a perfect field. His objections to sclero-corneal trephin- and that it was only recently that the rhinologists had agreed ing were the unsightly appearance of the crystoid condi- about its diagnosis. He would like to know if Dr. Graham tion of the cornea which was rubbed on by the upper lid, Brown or any other specialist had attempted to remove the danger of hypo-tension and the . danger persisting tonsils during an acute attack of follicular tonsillitis and throughout life of infection of the globe through the thinly if he recommended this procedure. covered trephine wound. Dr. W. N. Robertson said that he had performed the Dr. J. A. Cameron stated that after having listened to Dr. Hoare's excellent paper, it seemed to him that condi- operation whenever there was marked obstruction to breathing. He did not advocate it, but preferred to mop out the tions had not altered much during the last twenty years crypts with hydrogen peroxide and iodine. except in the treatment of blepharitis. He had found yellow oxide of mercury and the compound tincture of benzoin Dr. E. Culpin said that he had removed the tonsil in a very satisfactory. case of acute quinsy with good results. He had attempted Dr. Hoare did not agree with Dr. Lockhart Gibson regard- it in a second case and severe hemorrhage had resulted. 450 TIE MEDICAL JOURNAL OF AUSTRALIA. [May 28, 1921.

This had satisfied him that tonsillectomy should not be Professor Wood-J ones exhibited an aboriginal Australian performed in acute tonsillitis as a routine measure. skull showing a fourth molar pit. He stated that the pheno- Dr. M. Graham Sutton referred to several cases of nephritis menon was rare, but that the Australian had always a that he had seen in London. Marked improvement had long post-dental alveolus. The fourth molar was much more taken place when diseased tonsils had been removed. common in nilotic negroes. The most remarkable fact about In reply, Dr. Graham Brown maintained that the general the occasional occurrence of a fourth molar in man was practitioner should be a competent surgeon before he per- that with one exception a fourth molar did not occur, even formed any naso-pharyngeal operation. He considered that as an abnormality, in any animal higher than a marsupial. every possible focus of infection should be sought before The exception was the ourang, which exhibited a fourth thyreoidectomy was performed for goitre. The tonsils were molar in one in eight or ten cases. frequently the seat of infection and the treatment of the Professor Wood-Jones also exhibited a melanistic type of tonsils led to the reduction of the size of the goitre. He the common opossum, having white tips at the distal ex- did not like removing tonsils during an acute attack of ton- tremities. He drew attention to the fact that this was a sillitis, unless there was some definite indication warrant- common phenomenon in melanistic forms. The mother of ing the operation. this opossum was of the common grey type. Dr. M. Scott exhibited X-ray plates of a case of incomplete• ossification of the bones of the tarsus. No ossifica- The undermentioned have been elected as members of tion had occurred in the scaphoid. This seems to indicate the New South Wales Branch: that Köhler's disease, in which incomplete ossification of F. R. Cumming, Esq., M.B., Ch.M., 1921 (Univ. Sydney), the scaphoid occurred, was due, not to premature ossifica- 34 Kareela Road, Cremorne. tion as some had suggested, but to deficiency of ossification. F. E. Dawson, Esq., M.B., 1917 (Univ. Sydney), Adelong. This was the fifteenth or sixteenth case of Köhler's disease F. S. Hansman, Esq., M.B., Ch.M., 1920 (Univ. Sydney), on record, but it constituted as yet the only case on record Royal Prince Alfred Hospital, Camperdown. in which no ossification at all had occurred in the scaphoid A. R. Steven, Esq., M.B., Ch.B., 1916 (Univ. Glasgow), at so late an age as seven years. The mother was deaf Hillcrest Avenue, Gladesville. and dumb. The child exhibited no other abnormality beyond the facts that the ossification of the astragalus was also slightly deficient on the same side and the girth of the calf The undermentioned have been nominated for election as in that leg was less than that of the normal leg. Dr. Scott members of the New South Wales Branch: inferred that Köhler's disease was caused by the late ossi- David Adcock, Esq., M.B., Ch.M., 1920 (Univ. Sydney), fication of a bone which had been exposed to extra trauma. "Greenheys," Guildford. Dr. L. B. Bull reported that Bacillus botulinus had been Hugh Kirkland Shaw, Esq., M.B., Bac. Surg., 1914 (Univ. isolated by him from grain. Although frequently suspected, Edin.), Murwillumbah. its presence in Australia had not previously been positively demonstrated. The infection had been discovered in spilled grain upon a "winnowing floor" and had given rise to "forage poisoning" in horses. The organism was normally medical Societies. anrobic, but in symbiosis with certain moulds it could grow aerobically, as in the present instance. If the home THE MEDICAL SCIENCES CLUB, SOUTH AUSTRALIA. canning of fruits and vegetables developed in this community botulism would probably appear in the human A meeting of the Medical Sciences Club was held at the subject. University of Adelaide on November 5, 1920. Dr. W. Ray showed an X-ray photograph of the ventricles of the brain of a hydrocephalic infant which was taken by Correspondence. removing the cerebro-spinal fluid, one cubic centimetre at a time, and replacing it by an equal volume of air. The otherwise relatively opaque cavities were thus rendered re- MILITARY TRAINING OF MEDICAL STUDENTS. latively transparent in contrast to the surrounding tissues. It could be shown by the displacement of. air on moving Sir: Whilst commending Major A. J. Aspinall's suggestion the head that the air was able to pass from the right to the for a field ambulance (The Medical Journal of Australia., April left ventricles and vice versa. In all, 255 c.cm. of fluid had 9, 1921), I beg to suggest carrying the idea still further by been removed and 255 c.cm. of air substituted for it. The advocating the establishment of a medical officers' training photograph had been taken seven months previously and corps at each university. since then the hydrocephaly had apparently not advanced. Underlying the whole scheme of defence organization evi- Applications to numerous radiographic problems were sug- dently is the idea of unifying military training establish- gested by the members present. ment and equipment throughout the Empire, thus making Professor T. Brailsford Robertson displayed two tests for the forces interchangeable and capable of working in co- organically-combined iodine. The one carried out on a 0.3 operation and under unified command. grm. thyreoid tablet of English manufacture showed a satis- In this respect, remembering how in the organization factory content of iodine; the other, carried out on a 0.3 by the Australian Imperial Forces everything had to con- grm. thyreoid tablet of Australian manufacture showed a form to Imperial war establishments (even to the omission barely perceptible trace of iodine. The therapeutic efficiency at the commencement of the war of a divisional sanitary. of the two makes of thyreoid tablet might be expected to section), I beg to point out the prime necessity for uniform- parallel the iodine content. The values of the tablets were ity in organization. Presumably before that Imperial organi- therefore in no wise comparable. Professor Robertson dwelt zation is finally completed, any suggestions or recommenda- upon the necessity of adequate supervision and control of tions from Australia to the Imperial War Council would the distribution of glandular preparations and several mem- receive consideration. bers seconded his remarks. With regard, however, to the medical schools in Great Dr. H. K. Fry drew attention to a hallucination in a Britain, the excellent voluntary military organizations, known child cited in Le G. Guthrie's "Functional Nervous Dis- as officers' training corps, which grew out of the old volun- orders in Childhood," which apparently originated in the teer medical sta ff corps, of which some of us were mem- visual phenomenon arising from the visibility of the blood bers, will almost certainly be continued, possibly with im- corpuscles in the retinal circulation, to which Sir Joseph provements suggested by the experience of the war. Verco had drawn attention at a previous meeting. The In the Naval and Military Section at the Australasian Medi- hallucination, as described by the subject, consisted of small, cal Congress in Brisbane the suggestion of similar medi- round bodies, starting at a definite point in one corner of the cal officers' training corps at the universities was favourably visual field and traversing a definite path. In the centre received. of the field they appeared to the subject to change into The idea was the formation of a unit at each of the forms familiar to the child's imagination, such as horses, etc. medical schools. In addition to the routine training of a A further meeting of the Medical Sciences Club was held field ambulance, I had in mind a course of instruction on April 1, 1921. similar to that which medical officers received at the 2nd May 28, 1921.1 TH^ M^;DÍCÀ^ ` JÔURIVÀL OF AÚ§TRAtÌÀ.: 451

Anzac Corps School at Estaires, established by the late note that I did not accuse him of inconsistency because "he Colonel C. Mackie Begg, C.B., of the New Zealand Army did not find the `gauze pack' method all that was claimed Medical Corps, when Deputy Director Medical Services of for it," but because he demanded "more convincing data" the 2nd Anzac Corps. This school, originally under Lieu- from Dr. Forbes Mackenzie, whilst producing none himself. tenant-Colonel Irvine, Royal Army Medical Corps, then Incidentally, only two cases even supported by a little Lieutenant-Colonel Murray, D.S.O., New Zealand Army hearsay are still unconvincing and I am surprised that those Medical Corps, was afterwards re-established for the Aus- two cases apparently did not take any longer to get well tralian Corps under Lieutenant-Colonel Clive Thompson, than others treated by irrigation.

D.S_0,, M.C., A.A.M.C.. It requires a little practice to insure that one is packing All officers who attended these corps schools, I think with- and draining and not plugging the urethra, even with soft out exception, derived benefit therefrom. open woven gauze. With the establishment of an officers' training corps at Yours, etc., the universities, medical officers could both attend for and J; P. FOGARTY. Kew, Melbourne, give instruction in refresher courses. With regard to the important feature of the prevention May 21, 1921. of disease which is the prime function of a medical service, the establishment of chairs in preventive medicine at our universities is essential, if we are to keep pace with medi- Sir: Before arriving at any conclusion from the very in- . cal training in other countries. In the event of the teach- teresting statistics produced by Dr. Kenneth McLean in ing of preventive medicine being seriously extended through- his letter published in your issue of May 14, I think the out the medical curriculum, one could hardly conceive of following facts should be considered: attention not being directed to military hygiene and sani- (1) An A.A.M.C. order existed during 1918 and 1919— tation, which, to a great extent in the past, have given the under threatened heavy penalty to the transgressor—that impetus to and whose leaders have often been pioneers of all cases of acute gonorrhoea, if not cured on the eighth day civil sanitary advancement. In this respect the training of of treatment, must then be immediately evacuated to hospital. the future medical officers of our Navy and Army is of (2) In November, 1918, an A.A.M.C. order was issued to considerable importance, it now being increasingly recognized the effect that the massage pack method of early treatment that the giving of instruction and training in personal (then incorrectly termed "the massage-plug") would be used

hygiene is one of their chief functions in maintaining an to the exclusion of all others. (Nevertheless according to effective fighting force. Dr. McLean's figures nearly three times as many cases At the present time there appears to me to be an ex- treated by injection or irrigation reached hospital.) ceptional opportunity of introducing into our medical schools (3) Accompanying this order (November, 1918) were de-

an organization under the defence scheme which would tailed instructions—drafted at A.I.F. Headquarters—setting

ultimately insure a succession of medical officers who, as out how the method should be carried out, not only headed to training in times of peace, would have imbibed some with the unfortunate misnomen of "massage-plug proof the lessons which their seniors or predecessors had to cedure," but also differing from the gauze pack method (re-

learn by actual experience under conditions of war. ported by me several months earlier) in that the urethra

One lesson alone as to medical organization and correct was to be first syringed with 5% argyrol and then "plugged" channels of communication would have saved many of our with cotton wool (not gauze) soaked in the same solution.

medical officers at their initiation to active service being (4) On May 26, 1919, having heard that the specialist

placed in what Major Aspinall terms "embarrassing staff at Bulford were somewhat unfriendly towards the pack positions." or plug method—no investigation was being made into the

The general adaptability of the Australian, however, made vast difference—I, in company with Lieutenant-Colonel H. him speedily pick up the game. In some respects he some- H. Woollard, then Senior Medical Officer, Sutton Veny Area, times showed points to those either with more military ex- spent a day at Parkhouse (an adjunct to Bulford for the perience, or should one say, to those so trammeled with treatment of chronic cases). We were there shown the tradition and correct procedure that initiative and resource records indicating the type of treatment each man had had were sometimes hindered thereby. before admission to hospital and we were advised that these Yours, etc., records were based on the statements of the men them-

J. S. PURDY, selves—in fact, there was no other way.

Metropolitan Medical Officer of Health. We, Lieutenant-Colonel Woollard and myself, forthwith

103 Queen Victoria Building, Sydney, picked out six men who were credited with the so-called

May 11, 1921. "plug" method and by carefully questioning them, we were

able to convince the officer in charge that all six had been wrongly labelled. We went no further. Naturally, the men themselves would PREVENTIVE MEDICINE. easily confuse a "seal" or any form of pad dressing with a "plug" or "pack." Sir: I am instructed to draw your attention to the fact Cognisant of these facts, I must submit that Dr. McLean's that at the last meeting of the Council discussion arose Bulford statistics do not in any way help us to estimate the regarding the leading article in the Education Number of comparative value of any treatment, because they would of April 30, 1921, entitled "The Public Medical . the Journal appear to have been compiled primarily from unreliable in- Services," and exception was taken to the following remarks: formation and secondarily under the false hypothesis that It is the policy of this Journal to attack the Govern- plugging the urethra with cotton wool comprised the "gauze ments of Australia until the permanent heads of the pack" method. Who, may I be permitted to ask, would departments dealing with preventive medicine are paid prevent drainage by plugging an abscess cavity with a ma- at least £4,000 a year. terial such as cotton wool and not expect inflammation, its The Council of the Queensland Branch of the British Medi- débris and its bacterial cause to take the line of least cal Association dissociates itself with the opinion expressed resistance? regarding the salaries of permanent heads of the department. Hence if Dr. McLean can let us have the types and ,per- Yours, etc., centage of complications 'ensuing on a series of cases ' R. MARSHALL ALLAN. which were definitely known to have been treated, during the acute Honorary Secretary. stage, by careful packing of the urethra so as to insure Brisbane, drainage, two or three times a day, with soft open woven May 17, 1921. gauze soaked in argyrol or protargol, no stronger than 5%,

without any syringing or irrigation; then only would his

Bulford statistics become more than interesting. "GAUZE PACK" METHOD. Yours. etc.,

J. P. FOGARTY. Sir: May I crave your indulgence to point out to Dr. J. Kew, Melbourne, W. Sutherland that if he would kindly re-read (and this May 21, 1921. time carefully) my letter in your issue of April 23 he will 452 'Mt ME•ICAL JOt1RNAt; ò^ AtJgTR;ALtA. [ May 28, 1921.

Books Received.

Branch. APPOINTMENTS. AN ATLAS OF NORMAL, LABOUR, WITH AN APPENDIX SHOWING • SYLVESTER'S AND SCHULTZE'S METHODS OF ARTIFICIAL RESPIRATION, by G. Drummond Robinson, M.D., B.S., F.R.C.P..; 1921. London: William Heinemann (Medical Books), Ltd. ; Crown All Institutes 4to., pp. 104, illustrated by 405 illustrations from photographs and or Medical Dispensaries. drawings. Price: 25s. net . Manchester Unity Independent Order SQUINT : ITS CAUSES, PATHOLOGY AND TREATMENT, by Claud of Oddfellows. Worth, F.R.C.S. ; 1921. London: Baillière, Tindall & Cox ; Demy 8vo., pp. 242, illustrated by 42 figures. Price, 12s. 6d. net . Ancient Order of Foresters. VICTORIA. THE ATLAS GEOGRAPHIES: A NEW VISUAL ATLAS AND Hibernian Australian Catholic Benefit GEOGRAPHY COMBINED ; PART III., SENIOR GEOGRAPHY ; Society. No. 2, EUROPE, by Thomas Franklin; 1921. Edinburgh: W. & A. K. (Hon Sec., Medi- Johnston, Limited; General Agents: Macmillan .& Company, Limited, Grand United Order of Free Gardeners. London; Crown 4to., pp. 148. Price, 7s. lid. net . cal Society Hall, Sons of Temperance.

A TEXT-BOOK OF GENERAL PATHOLOGY FOR THE USE OF STU- East Melbourne.) Order of St. Andrew. DENTS AND PRACTITIONERS, by J. Martin Beattie, M.A., M.D., M.R.C.S., L.R.C.P., and W. E. Carnegie Dickson, M.D., B.Sc., Australian Prudential Association Pro- F.R.C.P. ; Second Edition, 1921. London:_ William Heinemann (Medi-. prietary, Limited. cal Books), Limited; Royal 8vo., pp 496, illustrated by 232 figures. Price, 31s. 6d. net . Mutual National Provident Club. A MANUAL OR SURGERY FOR STUDENTS AND PHYSICIANS, by National Provident Association. Francis T. Stewart, M.D. ; Fifth Edition, .1921. Philadelphia : P. Blakiston's Son & Company; Royal 8vo., pp. 1,086, with 590 illustrations. Price, - $10.00 net. ATLAS DE SYPHILIMETRIE: Les Conditions expérimentales de l'extinc- QUEENSLAND. tion de la Syphilis, par Arthur Vernes, Directeur de l'Institut Pro- Australian Natives' Association. phylactique de Paris; 1920. Paris: Imprimerie A. Pradier, P. Boll, Brisbane United Friendly Society In- successeur; Royal 8vo., pp. 121, with 100 graphs. Price, Fr. 35 net. (Hon. Sec., B.M.A. stitute. A MANUAL OF MIDWIFERY FOR STUDENTS AND PRACTITIONERS, Building, Adelaide Stannary Hills Hospital. by Henry Jellett, B.A., M.D., F.R.C.P.I., L. M., and David G. Madill, Street, Brisbane.) 1 \ B.A., M.B., B.Ch., B.A.O., L.M.; 1921. London: Baillière, Tindall & l Cox; Demy 8vo., pp. 1,200, with 20 plates i M oued .70 figures in the text. Price, 42s. net . SOUTH AUS- Contract Practice Appointments at TRALIA. Renmark. medical Appointments. Contract Practice Appointments in (Hon. Sec., 3 North South Australia. Terrace, Adelaide.) Dr. N. L. Cass (13.M.A.) has been appointed District Medi- oal Officer and Public Vaccinator at Meekatharra, West- ern Australia: WESTERN AUS- . The appointment of Dr. H. W. Ward (B.M.A.) as Medical TRALIA. Officer of Health to the Cunderdin Local Board of Health, Western Australia, has been approved.

(Hon. Sec., 6 Bank All Contract Practice Appointments in

of New South Western Australia. Wales Chambers, St. George's Ter- medical .Appointments UACaitt, etc. race, Perth. For announcements of medical appointments vacant, assistants, locum tenentes sought, etc., see "Advertiser," page xxiii.

University of Adelaide: Professor of Zoology. NEW ZEALAND: Public Service Board, Sydney: 1 Male Medical Officer; 1 WELLINGTON DIVISION. Female Medical Officer; 2 Male Dental Officers. Friendly Society Lodges, Wellington, Lever's Pacific Plantations, Solomon Islands: Medical Officer. New Zealand. (Hon. Sec., Wel-

lington.)

medical }appointments.

Diary for the month. IMPORTANT NOTICE.

June 1.-Vic. Branch, B.M.A.. Medical practitioners are requested not to apply for' any June 3.-Q. Branch, B.M.A..

appointment referred to in the following table, without having June 8.-Melb. Paediatric Society (Vic.).

first communicated with the Honorary Secretary of the Branch June 10.-N.S.W. Branch, B.M.A., Clinical.

named in the first column, or with the Medical Secretary June 10.-Q. Branch, B.M.A., Council. of the British Medical Association, 429 Strand, London, W.C.. June 10.-S. Aust. Branch, B.M.A., Council.

June 14.-N.S.W. Branch, B.M.A., Ethics Committee.

June 14.-Tas. Branch, B.M.A..

Branch. APPOINTMENTS. June 15.-W, Aust. Branch, B.M.A..

June 16.-Vic. Branch, B.M.A., Council.

June 21.-N.S.W. Branch, B.M.A.: Executive and Finance

Australian Natives' Association. Committee. Ashfield and District Friendly So- June 23.-Clinical Meeting at the Hospital for Sick Children, cieties' Dispensary. Brisbane. Balmain United Friendly Societies' Dis- June 24.-Q. Branch, B.M.A., Council. NEW SOUTH pensary. June 24.-N.S.W. Branch, B.M.A.. ' WALES. Friendly Society Lodges at Casino. June 28.-N.S.W. Branch, B.M.A.: Medical Politics Commit-

Leichhardt and Petersham Dispensary. tee: Organization and Science Committee. (Hon. Sec., 30-34 Manchester Unity Oddfellows' Medical Elisabeth -Street, Institute, Elizabeth Street, Sydney. EDITORIAL NOTICES.

Sydney.) Marrickville United Friendly Societies ' Dispensary. Manuscripts forwarded to the office of this Journal cannot under any circumstances be returned. North Sydney United Friendly Societies. Original articles forwarded for to publication are understood to he offered People's Prudential Benefit Society. The Medical Journal of Australia alone, unless the contrary be stated. All communications should be addressed to "The Editor," Phoenix Mutual Provident Society. The Medical Journal of Australia, B.M.A. Building, 30-34 Elizabeth Street, Sydney. (Telephone : B. 4635.)

Library Digitised Collections

Title: Medical Journal of Australia 1921

Date: 1921

Persistent Link: http://hdl.handle.net/11343/23184

File Description: Medical Journal of Australia, May 1921

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