V'ovenabcr 2. 1912. AUSTRALIAN MEDICAL JOURNAL. 755

THE LACK OF HOSPITAL ACCOMMODA- The cases of Measles and whooping-cough were TION FOR CERTAIN INFECTIOUS treated at the Children's Hospital as out-patients, DISEASES. if, during the course of treatment they- devel- oped broncho-pneumonia, -etc., an e ffort. usually CI I.AI:1,ES \ . AI.A('l<.AY. A1.1). unsuccessful, was made to obtain their admission to the_Melbourne Iospital. The usual procedure was ICI-inical Assistant to \Medical Out-Patients, AI el- for the child to be seen once in the early stages of bourneHospital; late _Medical Superintendent the disease, and the mother then instructed to re- A I elbourne Iospital ; la to Aiedical Superin- turn at frequent intervals to report progress and to tendent InfectiousDiseases Hospital.) obtain Medicine. These methods of treatment were most unsatis- 'fins paper is mainly a record of personal hospi- factory. and I vas duitc convinced at that time tal residential experience during the last six years, that a definite proportion of young children's lives with special reference to the difficulties encountered were lost owing to the absence of special hospital in dealing with cases of infectious disease. and with accommodation. 'l'he attitude of the controlling suggestions for improvement in hospital accommo- authorities of the Children's Hospital was, and, I dation. understand. still is, not to admit children to the My attention was first directed to this subject in institution suffering in ally degree from measles or 1906, when, as resident medical officer at the Mel- whooping-cough. There can be no question that bourne Hospital, I was surprised at the number of this attitude is a perfectly correct one in view of the young children suffering from whooping-cough and grave clanger involved to other children in the broncho-pneumonia who were admitted to the medi- institution. For at least the last six years, cal wards from the out-patient department of the however, there has been, a fairly large iso- Children's Hospital. I was impressed by the diffi- lation ward at the Children's Hospital which culty experienced in treating very young children in has been used for the isolation and treat- the wards of an adult hospital and by the unfortun- ment of cases of infectious disease which ate termination in many instances. It will be re- have broken. out in the medical or surgical cognised that the medical treatment and nursing wards. An extension of this principle might have of sick children, especially those suffering from been adopted so that some of the extremely severe acute infectious diseases, are, to a large extent, spec- cases attending the O.P. department could have ial branches of their respective professions, and, as been admitted. If it is practicable to isolate the such, not obtainable in a large usually crowded cases occurring in the hospital, it is surely- practic- general hospital. able to also isolate and treat the severe, compli- In the latter half of the year 1907 I was resident cated cases occurring- outside, in this way following medical officer at the Children's Hospital, perform- the example of Great Ormond-street with its spec- ing out-patient duties ; during that period, there ial whooping-cough ward. was a severe outbreak of measles in the North- During- the measles outbreak, in 1907, Dr. S. Pat- ern suburbs of Melbourne, and at the same time terson, with whom I was working- in the out-patient there were a considerable number of cases of department, computed that we saw over 400- sepa- whooping-cough. rate cases of measles, and we had the unfortunate I realised then the converse of the position and extremely unsatisfactory experience of seeing I had been in 'during- the previous year, several cases develop broncho-pneumonia and die. as, owing to the large number of children which hospital treatment and environment would who developed broncho-pneumonia during the in all probability have saved. course of their infectious disease, I was 'l'he present methods of treatment are practically continually placed in the position, of a sup- the same as those of five years ago. with the ex- pliant to the Melbourne Hospital, asking for ac- ception that the measles patients, after being sepa- commodation for these patients. This was often rated as far as possible, wait their turn, more or very difficult to obtain, and, when obtained, often less sheltered in the open air. The same difficul- too late to save life. The difficulty experienced in ties are being experienced by the resident medical treating cases of measles and whooping-cough at officers, and the extremely unsatisfactory methods this time was not confined to those requiring ad- of treatment deplored as nluclt as ever. mission to a hospital, the treatment of the out- Measles and whooping--cough are not usually patients was also most unsatisfactory. Children considered to be very serious diseases. vet their suffering from infectious diseases were segregated mortality rate, as evidenced by- statistics, is sur- as far as possible, and placed in a small consulting- prisingly large both for the State of Victoria and room, which they usually quickly filled and over- for the Commonwealth, while in nearly all Euro- flowed wherever possible. Here might be seen pean countries it is many times larger. In order cases of measles, whooping-cough, chicken-pox, that a satisfactory standard of comparison may be scarlet fever and diphtheria. 'Children suffering obtained, it is advisable to contrast the death-rate from the two latter diseases were usually trans- from these two diseases with that from scarlet ferred to the Infectious Diseases Hospital at Fair- fever and diphtheria. field as soon as diagnosed; but occasionally diffi- It must also be remembered that, as most of the culty would-be experienced if the patient came from deaths occur from broncho-pneumonia, it is very one of the non-contributing municipalities. possible that many certificat çs of death for regis-

November 2, 1912. 756 AUSTRALIAN MEDICAL JOURNAL.

tration are simply signed up as broncho-pneu- The relative death-rates for measles and scarlet nlonia the predisposing cause, measles or whoop- fever are well shown in the excellent graph in the ing-cough having occurred some weeks or months Commonwealth Year Look. previously. To show the age incidence of a disease such as The following statistics, either obtained personally whooping-cough the following figures are very in- or from the official Commonwealth Year Book, for structive. During the year 1910 the total deaths the years 1901-11, are supplied by the kindness of from whooping-cough in the Commonwealth were Mr. Knibbs, the Commonwealth Statistician, to 476, of that number 305, or 65 %, occurred in chil- whom I am greatly indebted:— dren under one year of age. For this one year in For the last five years-19o7-11 inclusive—the Australia, for which the figures are available, average yearlÿ death-rate from measles and whoop- whooping-cough takes almost equal fourth place ing-cough combined has been 13o in the State of among the scourges of infant life. -Victoria, and nearly 600 iii the Commonwealth. In A very interesting statistical record is the one Victoria, the total number of deaths from the worked out by Mr. Knibbs showing the monthly combined diseases during this period was 655. variations in the frequency of deaths from these in- DEATH-RATES FROM fectious diseases. Typhoid is thus shown to be NUMBER OF DEATHS AM) most frequent in the summer and autumn, whoop- MEASLES AND WHOOPING-COUGH, 1907-1911. ing-cough in the winter and spring, measles in the Victoria. spring, and diphtheria in the autumn and winter:— VARIATION IN DEATHS FROM VARIOUS Measles. Whooping Cough. MONTHLY CAUSES, ADJUSTED FOR EQUALISED MONTHS AND Year. Rate per CONSTANT POPULATION. Rate per 1000 No. No. 1000 population. population. Deaths per Month' per 10,000,000 of Population. 0.011 1907 39 0.0032 130 Diph- 0.006 1908 21 0.0017 76 theria 0.014 1909 4 0.0003 173 Scarlet and 0.006 Whooping 1910 27 0.0021 73 0.003 Month. Cough. Typhoid. 1Ïoasles. Fever. Croup. 1911 72 0.0054 40 January 85 200 21 7 50 9 57 492 February .. 98 217 9 Total .. 163 10 78 March .. .. 72 241 8 12 11 108 Commonwealth. April .. .. 74 216 12 17 122 May .. .. 99 140 0.259 133 1907 .. .. .. 147 0.036 1,070 June .. .. 92 118 10 16 0.059 123 1908 ...... 125 0.030 249 July .. 124 56 12 11 257 0.060 22, 12 98 1909 ...... 31 0.007 August . .. 139 48 0.109 13 96 ...... 124 0.028 476 September . 130 47 36 1910 63 ...... 206 0.046 291 0.065 October .. 105 36 36 11 1911 8 73 November . 99 80 46 11 72 Mr. Knibbs, in speaking of the graphic records of December . 95 133 27 the annual death-rates for the Commonwealth from the years 186o to 191o, makes the following The home conditions of many of the poor in the significant statement concerning the mortality northern suburbs of :Melbourne are quite unsuit- caused by measles :- able for the care of an acute case of illness, even if "On the whole, the graphs furnish clear evidence the mothers had the available time or the requisite of a satisfactory decline in the death-rate of the knowledge to adequately nurse the patient. Good- Commonwealth, a fall having taken place from all states that "uncomplicated cases of measles may 20.86 per 1000 of the population in 1860 to be allowed out of bed a week after the temperature 10.43 in 191o. The graphical representation of has become normal"—"the quarantine period is three weeks." Other authorities agree with this the death-rate brings into prominence five statement, and if this line of treatment is taken as years in which the rates were exception- high when compared with those of adjacent being the accepted one, it may well be asked how ally are the children of the poor to be cared for during years. These years are 186o, 1866, 1875, 1884 and this period, especially if lung complications, etc., 1898. The principal cause of the excessive rate of should arise? What applies to measles applies 186o was the prevalence in that year of measles, equally as forcibly to cases of whooping-cough. If, scarlatina and diphtheria ; while the high-rates of therefore, owing to poverty of surroundings, it is 1866, 1875 and 1898 were also largely due to epi- found impossible to efficiently treat and isolate cases demics of measles." of measles and of whooping-cough, then, in the in- In this connection it is very interesting to con- terests of infant life, it is essential that proper hos- trast the relative mortality rate of the four infec- pital provision should be provided for them. tious diseases under comparison for a recent term of years. During the four years inclusive from 1907 Voelcker, who describes having treated over 55o 2,052 cases in the special whooping-cough ward at the to 1910, in the Commonwealth there were Hospital for Sick Children, Great Ormond-street, deaths from whooping-cough, 1,814 from diphtheria, lays the greatest stress on general hygienic manage- 427 from measles, and 232 from scarlet fever ; while ment and prompt isolation ; he recognises the great typhoid fever, 2,609, w,as not greatly above that of difficulty in treating the disease, but is insistent on whooping-cough. November 2, 1912. AUSTRALIAN MEDICAL JOURNAL. 757

the necessity of guarding against complications and of the management Of such an institution is under pats the quarantine period clown as six weeks. consideration. At Fairfield I have seen the scarlet Both Dr. John Williams, at the Melbourne Hospi- fever ward empty for four months, and, subse- tal, and Dr. Peter Bennie, at the Children's Hospital quently, I have seen room found for over 15o cases of this city, have for many years laid stress of scarlet fever; while at other times the diphtheria on the liability of cases of measles to develop patients have numbered only 5o, and within a com- tuberculosis, and they are strongly supported by paratively short period 250 cases have been in the Holt, who states in his recent Text Book that, "as institution at one time. It can thus be seen that a predisposing cause to tuberculosis, whooping- adequate ward and nursing provision must always cough is second only to measles. In both diseases be kept ready for infectious diseases, and it should tuberculosis develop in much the same way and never be considered unnecessary because, for vary- from practically the sanie causes." This liability ing periods of times, it is not required. was well shown at the Children's Hospital after the On leaving the Infectious Diseases Hospital at outbreak of measles by the number of cases the end of 1908, I received the appointment of of tubercular meningitis seen in patients who had Medical Superintendent to the Melbourne Hospital, had measles some months previously. and was then myself frequently asked by the au- On leaving the Children's Hospital early in 1908 thorities of the Children's Hospital to admit chil- I was for nearly twelve months in charge of the dren suffering- from broncho-pneumonia and some Infectious • Diseases Hospital at Fairfield, and was infectious disease. For some time I admitted them there able to observe at first -hand the definite pro- whenever possible, but, as the adult accommodation vision which had been made for two infectious dis- became more difficult to obtain, I was compelled to eases, namely, scarlet fever and diphtheria. Every refuse them. case of these two diseases arising in the metropolis In definitely refusing to admit these patients, for which proper isolation and treatment could not whom I knew could be only a small proportion of be obtained under home conditions, was accommo- those requiring indoor hospital treatment, I was dated in_the hospital. By reason, however, of it be- strongly influenced by the fact that these young ing under municipal control, occasional difficulties children slid not do well in the wards of an old adult arose concerning the admission of patients from out- hospital ; also, that by continuing to admit them, I side municipalities or shires which were non-con- was only indefinitely postponing the time when tributing, and which had repudiated responsibility suitable accommodation would have to be provided for previous patients, these were usually settled for then elsewhere. by an appeal for a maintenance order to the Board At first, accommodation for these cases and for of Public Health. others which occurred during an outbreak on board Realising the inefficiency of the treatment of two the training ship "John Murray" was provided infectious diseases—measles and whooping-cough- by the erection of tents in the hospital grounds, but 1 could not fail to contrast the different and effec- with the increased scope of the new building opera- tual treatment reserved for the two other infections tions, these tents had to be removed. Subsequently diseases—scarlet fever and diphtheria. To account an attempt was made to place the measles cases in for such an anomalous position I could only sur- one of the hospital wards, but this arrangement mise that in the beginning financial considerations proved so unsatisfactory that it was decided not to strictly limited the original scope of the Fairfield admit any further cases. Notwithstanding this re- Hospital's operations; and that scarlet fever and solution of the Committee of Management, the ad- diphtheria were regarded much more seriously as mission department of the hospital was frequently requiring isolation and treatment than measles or faced with the problem of what to (lo with a case of whooping-cough. I think, however, that I have measles. After repeated representations to the shown that these two latter diseases are at least Board of Health authorities, and only after much equally important, and this contention is borne out trouble in each particular case, accommodation— by Mr. Knibbs' statistics, as quoted above, where acknowledged to be most unsatisfactory —was the mortality from whooping cough is shown to be • found for occasional cases at Coode Island under nearly equal to that from diphtheria, and that from the direct control of the Board. Subsequently in- measles greater than that from scarlet fever. terviews, etc., with the Government and the Board When considering- accommodation for .patients of Health, extending over two years, representing at an infectious diseases hospital, it should always the need of hospital accommodation for measles, re- be remembered that, unfortunately for the manage- sulted in nothing being clone, until the arrival of the ment of the institution, it is in this respect compar- emigrant vessel, the s.s. "Irishman," with about 40 able with no other kind of hospital. Infectious dis- cases on hoard, clearly demonstrated the inadequacy eases occur and recur in epidemics of varying time of existing arrangements. incidence, consequently adequate buildings and ade- A sum of £ i,000 having been allotted by the quate staff must always be kept up, even if cases Government for the purpose, it was decided by the are few; while in times of severe outbreaks no case Board of Public Health to build a small measles requiring admission can possibly be refused, and all •ward at Fairfield, presumably to be managed by the available resources are over-taxed in order to house, authorities of the present institution. The small feed, nurse and medically treat a sudden large in- wooden building for this purpose, which is at pres- flux of patients. This great and primary difficulty ent after many delays, nearing completion, has been of extreme periods of stress on the accommodation erected in the Yarra Bend Asylum grounds, out- is rarely, I think, fully realised when the question side the Infectious Diseases Hospital fence, and has, 758 AUSTRALIAN MEDICAL JOURNAL. November 2, 1912

I understand, been practically finished without airy small proportion of the total cases arising in the city arrangement with the authorities of the hospital as would go into hospital. Although these two dis- to. its future working. This building will accom- eases under consideration are undoubtedly very in- fectious, yet hospital accommodation is not re- modate from 16 to 20 cases, and, apart from the future difficulties of its management, both nursing quired so much to control infection as it is urgently and medical, its structure and ward space show required to adequately treat the effects of disease. that it can only be regarded as a makeshift arrange- In this connection it might be pointed out that a ment. It is intended by the Board of Health that great want in this community is suitable private this building should only accommodate oversea hospital accommodation for any severe cases of in- cases and cases of hardship arising in hotels, board- fectious disease; there is nothing intermediate be- ing-houses, etc. This attitude quite neglects provi- tween the Fairfield municipal hospital, and more or sion being made for the large number of children less effective isolation in private houses. suffering from measles and its complications who The "Australasian Medical Gazette," in a recent have to attend the Children's Hospital as out- leading article, drew attention to a similar state of patients ; while for the odd cases which might be affairs existing in Sydney. accommodated at Coode Island, the locality and the The question of proper hospital accommodation defective character of the buildings place their un- for infectious diseases has been much neglected in suitability beyond question. the past by the medical profession of this city, and a The need, I consider, both for the present and continuance of this neglect will not be creditable to for the future, is either the construction of two the high position of trust we hold in the commun- large wards at Fairfield, one for measles and one for ity. whooping-cough, under the control of the present management and in uniformity with the existing Cardiac Complications of Pregnancy. buildings (this would probably mean an extension Newell (Journ. Amer. \led. Assoc., Sept. 28th) con- cludes:- • of the present boundary of the hospital towards 1. Any organic lesion, even if perfectly compensated un- Yarra Bend). Or, for all severe and complicated der normal conditions, should arouse apprehension and cases occurring in children accommodation should call for constant watchfulness if pregnancy supervenes. 2, In case pregnancy conies as a complication when the be provided in an isolation ward, or wards, at the heart is imperfectly compensated, the uterus should be Children's Hospital, separated from the main build- immediately emptied, since a heart which has failed under ings and controlled from the out-patient depart- the ordinary burdens of life has no chance of sustaining ment ; here could also be placed, as at present, any the added burden of pregnancy. cases arising in the hospital itself. A small out- 3. When a heart which has been previously well com- pensated fails during pregnancy, an attempt must be made patient department could be attached to this build- to restore compensation by rest and appropriate treat- ing, where only cases of infectious diseases would ment, but unless the attempt is promptly successful the be seen ; this would avoid any possibility of the pregnancy should be ended. mixing together of the infectious and the non-in- 4. If compensation has failed during one pregnancy, fu- ture pregnancies should be absolutely forbidden. fectious. 5. In any case in which an organic heart lesion can be The present Infectious Diseases Hospital, as be- demonstrated, even though it may have caused no symp- fore stated, is a purely municipâl-managed hospital, toms during pregnancy, labour should be regarded with ap- prehension, and every measure should be taken to shorten although it is in receipt of a varying government the labour and thus relieve the heart of a serious burden, grant according to the year's expenses. To ask the although it may seem to be doing its work perfectly well. municipalities concerned, however, to undertake the 6. A patient with an organic heart lesion will usually capital cost of the erection of two more wards and stand an operation well if the operation is performed at a time previous to a failure in compensation. On the other to maintain them is to ask something, at present, hand, an operation after failure of compensation will often quite impossible, and if hospital treatment for these prove fatal in patients who would have stood operation cases is regarded as essential, then Government as- well at an earlier time. sistance must be asked for. 7. Any patient known to have an organic heart lesion who is contemplating marriage should be advised of the The objection has been strongly raised that, once dangers pertaining to pregnancy and labour, the prognosis there is a ward solely for cases of measles, the dis- in the individual case depending on the nature of the le- ease is so widespread that any ward would become sion, the age of the patient and her previous history as re- overcrowded in a very short time. The answers to gards the efficiency of the heart under normal conditions. 8. It is impossible to estimate accurately the efficiency this objection are, I think, the following:—If it can of the cardiac muscle in any patient in whom a failure of he shown that hospital accommodation is essential compensation has once occurred, since although compensa- for these patients in order to save life and prevent tion may have been promptly restored under treatment, future morbidity , -then it should he available ; she may die suddenly before, during or after labour, with- out warning. but if segregation and treatment of cases of 9. Labour should be shortened as much as possible in not made compul- every patient who has a demonstrable heart lesion, al- measles and whooping-cough is . sory in an infectious diseases hospital, only those though no unfavourable symptoms may have arisen. In primiparas the propriety of a caesarean section to relieve parents who urgently desire hospital accommoda- the heart of the strain of labour may be very properly tion for their children will agree to being separated considered in any case, particularly if the soft parts are from them for an indefinite period. rigid, since it is poor policy to test theendurance of a There can, I think, be no question that, if isola- given heart unnecessarily. 10. The demonstration of a mitral stenosis should call tion is not compulsory, only the severe and com- for the most careful observation. Any sign of failing com- plicated cases and those of the poorest class will be pensation should be niet promptly, and if any condition taken into hospital. During an epidemic, therefore, supervenes which is accompanied by a rise in arterial it may, I think, be correctly assumed that only a tension, the pregnancy should be terminated at once. November 2, 19I2. AUSTRALIAN MEDICAL JOURNAL. 759

auotraríanc jilleòícar journal ought to be no difficulty in seeing something of a similar character established in our own midst_, even as 2nd NOVEMBER, 1912. regarded a profitable speculation. The problem is pressing, and it is one that must INFECTIOUS DISEASES. presently be faced. In all probability the best method would be to erect it into a separate scheme For some time past it has been recognised that under the direction of a metropolitan fever hospital the hospital provision for infectious diseases in Mel_ board, with its own medical staff, working- up from bourne is not commensurate with the rapid growth junior to senior positions, and making a life study 3f population. Apart from enteric fever, which is of its special needs, as is done in similar hospitals treated in. the general hospitals, the only special in London. This much is certain, that our present accommodation for the acute infections is that pro- methods are, for a city of the size and importance vided at Fairfield. Since that institution was open- of Greater Melbourne. makeshift and muddling, ed about eight years ago the suburban population and that the cost is out of all proportion to the con- has shown an enormous increase, and although ad- venience and efficiency of existing equipment. ditions have been made and temporary extension found in time of need, it has never been entirely satisfactory. Much good work has been done, but it has always been at the cost of great effort and gotet anb Comment5. much inconvenience, to say nothing of extra expen- diture. The annual report of the Rotunda Hos- Rotunda pital is, as usual, included in the "Proe. The merits and demerits of Fairfield apart, it be- Hospital. of the Royal Academy of Medicine in Ire- comes evident that any idea of its enlargement land." of which the issue for 1912 is to should not be regarded with favour. Melbourne is hand from the publishers, Messrs. Falconer, of Dublin. The a city of wide distances, extending as it does from clinical report is signed by the Master, D. H. Jellett, and his two assistants, Drs. Solomon and Madill. During the Preston to Mordialloc, and Sunshine to Box Hill. A year 2,208 patients were delivered in the indoor clinic. single large institution for dealing with infectious Twelve deaths occurred in this number, and the _blaster diseases is open to a double objection. In the first states four were admitted moribund and died within two place, there must always be a difficulty in ade- hours, while other two were severely septic on admis- aion. It is admitted, however, that three deaths occurred quately separating a number of infections which from sepsis acquired in hospital. The most important applies in a general sense to any hospital of the change in administration was a notice issued on August kind. In a special sense the difficulty of providing 20th:—"All patients who have had a normal confinement a single institution in Melbourne is accentuated by without perineal laceration and suture may be allowed and the long distance patients must be conveyed in encouraged to sit up in bed after the first twelve hours. Further, they may get out of bed to pass water if order to reach it, a consideration involving danger they wish. After forty-eight hours they must get out of at once to the patient and to the community. With bed to pass water at least twice in the twenty-four hours some vicarrangement the present hospital at Fair- unless their general health contra-indicates doing so. Of this the sister or assistant on duty will judge. After 72 field would meet the requirements of the northern hours they may take a few steps when they get out of bed, suburbs. Additional accommodation appears to be or sit for a few minutes on a chair or on their bed, the called for by the establishment of a second institu- time they remain up being gradually increased each time tion for the southern communities, and a third for they leave bed, the general health being satisfactory." Dr. the western group. Jellett remarks he has no reason to regr t having issued the order. Caesarean section was done eight timas. The The difficulty of dealing with measles and treatment of eclampsia was continued on former lines. whooping-cough is one that becomes daily more Forceps were used in 114 cases. apparent, and Dr. Mackay makes a strong point for attempting something in the way of special accom- modation by drawing attention to the very consider- In the same volume is included a paper able mortality that attends these affections. Ob- Vaccines in by Dr. Roulette, the pathologist to the Ro- viously it would be impossible to treat any large Fuerperal Sepsis tunda Hospital, on "Vaccines in the Treat- ment of Puerperal Sepsis." Dr. Jellett proportion of cases of measles or whooping-cough had published seven cases so dealt with in the previous in hospital, but it ought to be feasible to maintain year's report, and the practice was greatly extended. In accommodation sufficient to handle dangerously all 54 cases were inoculated, but in only 39 was a bac- complicated attacks. teriological diagnosis forthcoming. The author is not in- clined to be dogmatic in any evidence so far obtained, and Faulty as the present state of affairs is with re- publishes the following categorical conclusions:— spect to public hospital accommodation for infec- Vaccines given in small doses do no harm in puerperal tious disease, there is absolutely no provision for sepsis. patients who are willing to pay for private treat- In the majority of cases they do good. ment. The Board of Public Health decrees that In many cases they produce immediate and remarkable private hospitals are not allowed to take infectious improvement. Autogenous vaccines are more trustworthy than stock cases, and where these occur among inmates of vaccines, and sometimes succeeded rapidly where the latter hotels and boarding-houses it is often exceedingly failed. difficult to find them even a suitable shelter. Anti-streptococcic serum given simultaneously increases In London a very useful private hospital for in- the effect of streptococcal vaccine. To get the best results accurate bacteriological diagnosis fectious cases is successfully maintained, and there is necessary. 760 AUSTRALIAN MEDICAL JOURNAL. November 2, lf) r2

LADY 1LB0T MILK INSTITUTE. Institute milk for 10 days or more prior to death, the death- rate amongst the "Talbot" cases was 5.64 per cent. We make the following extracts from the Annual Total cases supplied-455; total deaths-43; rate-9.45 Report:— per cent. "Talbot" cases-425; deaths amongst "Talbot" cases- The Area Supplied and the Work of the Institute. 29; rate-6.82 per cent. As previously stated, the Institute recommenced its "Talbot" cases-425; deaths amongst "Talbot" cases summer distribution of milk on 1st November, 1911, and during supply or within 3 weeks thereafter-24; ceased the same on 11th 'May, 1912. The districts in which rate-5.64 per cent. the charitable distribution was carried on were:— Bearing in mind that a large percentage of the Institute Melbourne (including North Melbourne and Carlton), cases are invalids recommended by their doctors for the ,Collingwood, Abbotsford and Ciflton Hill, Prahran, Wind- milk, the Board considers that the Institute has reason to sor, and South Yarra, Fitzroy, Hawthorn, Richmond and be gratified with the low rate of deaths amongst the "Tal- Burnley, South Melbourne and Albert Park. bot" cases. The number of cases supplied was greatly increased as The Cost of the Institute. compared with the previous season, owing partly to the work having been commenced nearly seven weeks earlier The Board is pleased to be able to report that, not- than previously, and partly to the increased recognition withstanding an increase in the prices loth for purchase by medical men and others of the value of the Institute's and delivery of the milk, the total net cost to the Institute work. per pint of milk delivered has been reduced as compared The number of children supplied with milk and ice dur- with the previous season. This is accounted for by the ing the period under review was 455, as compared with fact that more than twice as much milk was supplied and that the expenses of administration and nursing atten- 243 for the previous season. This number does not in- clude the Prahran or South Melbourne creches. These dance do not increase in proportion to the amount of milk were supplied with 33 pints per week and 18 pints per supplied. It is interesting to note that although the net week respectively, but owing to it being impossible for the cost per pint has been reduced as compared with the pre- Board to keep any reliable record of the actual number of vious season, the cost per case supplied has increased. children supplied or the deaths, etc., amongst them, the This is due to the fact that the amount of milk supplied to creches are excluded for the purpose of the statistics given each case this season has averaged about 123 pints, as compared with an average of about 100 pints for the pre- below. vious season. This the Board regards as indicating an The following table shows the number of children sup- increased appreciation of the merits of the Institute's plied in each district for the seasons 1910-11 and 1911-12 milk and consequent desire on the part of mothers to keep respectively:— their children supplied with it as long aspossible. 1910-11 1911-12 As previously stated, the total number of cases supplied Richmond and Burnley .. .. .. 53 112 (1) (exclusive of the Creches) was 455. For the purpose of Melbourne, East Melbourne, North (2) ascertaining the cost per case, the Prahran Creche (sup- Melbourne and Carlton .. .. .. 50 91 plied with 33 pints per week) is here treated as 6 cases, (3) Fitzroy .. .. .. .. .. .. .. 29 85 Collingwood, Abbotsford and Clifton and the South Melbourne Creche (supplied with 18 pints (4) per week) as 3 cases, making the total number of cases Hill .. .. .. .. .. .. .. .. .. 50 70 supplied 464. (5) Prahran, Windsor and South Yarra 26 42 South Melbourne and Albert Park .. 35 35 It will be seen by the Financial Statement appended that (6) the total expenditure for the period has been £1620 2s. Hawthorn .. .. .. .. .. .. .. .. .. 20 (7) lid., against which must be set the revenue derived from 243 455 sale of milk, £480 9s. id.; leaving a total net expenditure of £1,139 13s. 10d. Of these 455 cases 30 are not "Talbot" cases, that is to Dividing this sum by the 464 cases supplied, *Ike total say, they did not receive the milk for 10 consecutive days. cost per case is ascertained to be £ 2 9s. ld. The total Taking from the above total the 30 not `Talbot' cases, there amount of milk supplied to customers of the Institute for . remain 425 cases, in the feeding and care of which the the period under review was 57,038 pints. The total net Institute claims to have materially assisted. The deaths expenditure being £1139 13s. 10d.; if we divide this sum amongst these cases were 29, distributed amongst the vari- by the number of pints delivered, we find that, charging ous districts as follows:— the total net expenditure of the Institute against the milk, Richmond and Burnley .. .. ...... 9 the net cost per pint is 4.79 pence as compared with 5.26 Melbourne, North Melbourne and Carlton .. 5 pence per pint for the previous season. Fitzroy •• 5 Full and accurate details of all milk purchased, deliver- South Melbourne and Albert Park ...... 4 ed, returned, or used for testing purposes, of ice pur- Prahran, Windsor and South Yarra ...... 4 chased and delivered, together with full records of every Collingwood, Abbotsford and Clifton Hill .. .. 2 case supplied, have been kept in the office of the Institu•te, Hawthorn ...... - and are available for inspection if required. 29 Dr. Bull's Report. It is to be noted that the deaths recorded above include The outstanding features of the routine bacteriological the whole of the deaths of children supplied by the Insti- examinations of milk supplied by the Lady Talbot Institute tute for 10 consecutive days, whether such deaths occurred for the season 1911-1912 were as follows:- during the supervision of the Institute or not. 1. The average number of bacteria per cubic centimetre The deaths of those babies who did not die during the of milk was lower than in any previous season. milk supply and nursing supervision of the Institute have 2. As a whole, there was greater uniformity in the bac- been ascertained by reference to the records of the Chil- terial contents of the milk. A continuously low and uni- dren's Hospital, enquiry from the parents, and any other form bacterial average for the season may be taken as an available source of information, in order that no death indication that the main directions laid down by the Insti- amongst children actually supplied by the Institute might tute for the production and handling of a pure milk sup- go unrecorded by the Institute. These enquiries show that ply have been consistently and faithfully carried out. of the 29 deaths referred to above 5 children died at dates 3. The temperature of the samples received at the labora- varying from 3 weeks to 4 months after ceasing to take tory averaged 13.8 deg. C. (56.8 deg. F.), which compares the Institute's milk. • favourably with previous seasons. As each laboratory Taking the whole of the deaths occurring both during sample was the last delivered daily in the Carlton district, and subsequent to treatment by the Institute, the death- it may be taken that the average temperature of the milk rate amongst "Talbot" cases was 6.82 per cent. Exclud- supplied to customers was probably lower. The monthly ing (as the Board considers it is justified in doing) the readings were—IFebruary, 61.8 deg. F.; March, 59 deg. F.; deaths of those 5 infants who had not been taking the April, 53.6 deg. F.; May, 50.5 deg. F.

\OVcilll)cr 2. 1tJ12. AUSTRALIAN MEDICAL JOURNAL. 761

The principal results for the four months (February to The Board's sewers have been constructed, and are col- May), 1912, compared with the corresponding period of lecting the sewage, from Murray Road, Preston, in the 1911, were as follows:- north, to Victoria-street, Sandringham, in the South, and Table Showing Number of Micro-organisms per from Boundary-road, Nunawading, in the east, to Williams- Cubic Centimetre. town-road, Footscray, in the West. 1911 1912 The whole of the sewage, amounting to upwards of February ...... 9,000 5,300 30,000,000 gallons daily, is concentrated at the Pumping March .. .. .. .. .. .. .. . 29,600 21,200 Station, Spotswood, whence it is pumped to a height of April .. .. .. .. .. .. .. 25,400 31,300 125 feet and then flows by gravitation to the :Metropolitan Farm. .. .. .. 3,600 11,600 1Lay . . .. .. .. .. At the Metropolitan Farm, Werribee, a very large amount Average ...... 23, 800 18,700 of work has been carried out. The Farm, with a total area of 9,152 acres, is now being Table Showing Average of Micro-organisms per Cubic utilised for the disposal of sewage daily. Centimetre, after Deleting the Figures for the Sample The total cost of the farm to the 30th June, 1911, was Yielding the Highest Count Each Month. (This Table £ 461,074. gives a better idea of the bacterial condition of the The prepared blocks on the farm, are laid down with bulk of milk supplied by the Institute) :- prairie and rye grass and lucerne, on 4,742 acres of which, 1911 1912 during the financial year ended 30th June, 1911, 34,000 February .. ...... 4,400 2,500 sheep and 1,000 cattle and horses were carried; the re- March ...... 14,500 4,100 venue from grazing, including sales of wool, etc., was April ...... 20,600 8,000 £ 11,835. Slay ...... 3,600 9,900 In regard to water supply, the Board has spent during the last twenty-one years a sum of £636,002 upon con- Average ...... 15,100 5,600 struction works. The principal items upon which this expenditure has Analysis of Cost. been incurred are as follow: The following table shows the amount which each pint New mains £ 244,097 of milk delivered cost the Institute and the various head- Reticulation .. .. .. .. 197,832 ings under which such cost per pint occurred:- New reservoirs .. .. 78,141 Gross Net Improvements, Al aroondah 57,376 Gross. Not Cost Cost Cost. Cost. per per Improvements, Yan Yean . 30,045 Pint. Pint. New water supplies- Pence. Pence. Coranderrk £9,111 1489 19 0 2.930 22.061 Purchase of milk ..£696 8 6 Delivery of milk .. 291 16 3 205 5 1.2'27 .863 O'Shannassy (preliminary) .. .. 5,590 Purchase & Delivery of Donnelly's Creek .. .. .. . .. 940 0 10 99 15 - 597 .420 15,641 Nursing expenditure .. 211 . li n 119 12 is 889 .625 Secretary's salary .. 128 S u U :1 .538 .378 Improvements to channels .. .. .. .. .. 15,366 Collector's Salary .. 62 0 9 1 3 12 9 .261 .183 ice chests . .. .. 21. u 11 16 10 .090 .062 The Board's existing water supply system originates in Office expenses .. .. 6 7 8 8 17 8 9 .283 .199 two sources, viz., the Yen Yean, or northerly, supply from the Plenty Ranges, beyond Whittlesea, augmented by the .. £1620 2 11 11139 13 10 6 61 4.79 Totals Yan Yean watershed, and the Maroondah, or easterly, sup- ply from the mountainous country in the vicinity of Healesville. In both directions the most remote point 1IE77tO POUT .IN BOARD OF {YORKS. from which water commences to flow towards Melbourne is about 50 miles distant from the metropolis. The following extracts from the. Annual Report will The greatest distances water is supplied beyond the give some idea of the magnitude of the work of this Metropolitan limits are to the Werribee Farm, 25 miles, and body:- to Mordialloc, about 17 miles. Sewerage and Water Supply Works. The average daily consumption of water to the 31st De- Since the date of the Board's creation, the following en- cember, 1911, was 36,110,115 gallons, equal to 61.41 gallons gineering works have been carried out:- per head of population. 131 miles of main and branch sewers. The total cost of the water supply system up to 30th 1,183 miles of reticulation sewers. June, 1911, was as follows: - The outfall sewer to the farm, the rising mains, the Original water supply works, tank, pump- pumping station, and that portion of the Hobson's Bay ing station, etc. .. .. .. .. . £ 84,885 main sewer, extending from the pumping station to Port Yan Yean system .. .. .. .. 630,288 Melbourne, were completed by 1897 at a cost of £ 743,268, Maroondah system . .. .. .. 777,527 and in August of that year the first property was con- O'Shannassy system .. .. .. .. .. . 5,590 nected with the sewerage system. The aggregate expendi- Service reservoirs .. .. .. .. .. .. .. .. 136,280 ture upon sewerage at this period was £2,066,732. Large mains .. .. . 1,053,718 Up to the 31st December, 1911, out of 121,149 tenements Reticulation .1,325,960 available for connection with the sewers, 115,085 had been connected. The following had also been connected:- Total ...... .. .. £ 4,014,248 130.731 water-closets, 94,425 baths, 71,494 sinks, 65,929 sets of wash troughs, 31,356 lavatories, 13,087 stables, 7,653 There are two storage and nine service reservoirs, as under:- urinals, 5,481 polluted areas and paved yards, 1,782 cel- Storage Capacity lars, 938 slop hoppers, 292 latrines, 263 dairies, 70 public in Gallons. urinals, 44 public conveniences. Situation. The cost of sewerage works and house connections up Yan Yean (storage) .. 6,400,000,000* to 30th June, 1911, was £6,267,762, divided as follows:- Toorourrong (storage) .. .. 60,000,000

.. . 16,000,000 Farm purchase and preparation ...... £ 461,074 Preston No. 1 .. .. .. . .. 25,000,000 Outfall sewer and rising mains ...... 421,674 Preston No. 2 . .. .. .. 1,000,000 Pumping station buildings and engines .. . . 196,099 Essendon, No. 1 .. .. ...... 6,000,000 and branch sewers ...... 1,939,469 Essendon No. 2 .. .. .. Main 10,000,000 Street reticulation ...... 1,787,241 Caulfield .. .. .. .. Reticulation of rights-of-way 821,716 3,000,000 • • 9,000,000 House connections branches . .. . . 298,892 Surrey Hills .. .. .. .. .. Cost of house connections chargeable to Morang pipe head ...... . . 3,000,00.0 .. .. .. .. .. .. 1,000,000 capital .. .. .. .. ...... 341,507 Heidelberg ..

£ 6,267,762 Total , • • 6,534,000,000 762 AUSTRALIAN MEDICAL JOURNAL. \ E unl,er 2, I9I2.

'Of this quantity, 5,400,000 gallons are available for con- pain for at least 24 hours after operation. I much sumption. regret no P.M. was allowed to verify this unusual develop- Portions of the municipalities of Moorabbin, Oakleigh, ment. I have previously had a female with rectum open- and Nunawading have been added to the metropolis for ing into vagina posteriorly at junction of labia minora, in water supply purposes. that case one could feel the bulging of loaded rectum and cut down on it, as also another case I had in a male, but Summary. with no aperture whatever.—Yours, etc., The following is a summary of the leading features in the foregoing statement:— A. NORRIS WILKINSON, M.R.C.S. (Eng.), L.R.C.P., Inglewood. (a) The Board commenced operations in 1891, and by 1897 the first house was connected to the sewers. (b) In the meantime, expenditure to the amount of CURRENT LITERATURE. £2,066,732 had been incurred for sewerage purposes alone. (c) The most adverse financial conditions were encoun- Effect of X - rays and Radium on Silkworms. tered early in the Board's existence through collapse in Hastings, Beckton and Wedd (Arch. Mid. Hosp„ Cancer land values, failures of banks, etc. Lab.) conclude:- (d) Money had been borrowed to the extent of £3,893,580 and interest paid thereon before .a sewerage rate was 1. Fertility of Eggs.—In the case of X-rays applied to imposed. the insects in the first generation no definite result is ob- (e) Up to 30th June, 1911, the Board spent £6,267,762 tained, though there is an indication that the fertility of upon sewerage. these insects is somewhat diminished. The immediate (f) Up to 30th June, 1911, the Board expended £ 636,002 descendants of these insects, however, though not them- upon water supply. selves receiving X-rays, are markedly less fertile. If X- (g) Up to present date, loans have been floated (includ- rays be applied in two successive generations the fertility ing re-borrowings) to an aggregate amount of £ 11,234,580. of the second does not depart so greatly from the normal; The present liability to debenture holders is £ 9,331,000. but, nevertheless appears to be diminished. Borrowings are subject to the approval of the Governor- Il. Date of Hatching out of Eggs.—In every case in a in-Council. series of 13 sets of experiments acceleration, as estima- (h) The water works were transferred to the Board sub- ted by the total proportion of hatching out occurring be- ject to a liability to the Government of £2,389,934. fore a given date, is indicated in the case of eggs them- (i) A sum of £ 701,271 has been repaid to the Govern- selves subjected to X-ray treatment or the offspring of X- rayed parents; and this finding is confirmed by the results ment, leaving the present indebtedness at £ 1,688,662. (j) Differential rating was introduced in 1898-9 under of a series of experiments made or completed during the an Amending Act, and the obligation placed upon the following year. On the other hand ,a retardation is indi- Board of laying sewers in private rights-of-way, and house cated in the hatching out of the eggs of the second genera- branches. tion; while there is also some evidence that this retarda- tion can be warded off by repetition of irradiation in the (k) The present total indebtedness of the Board is second generation. £11,019,662. (1) The members of the Board (with the exception of the III. Weight of Cocoons. 'An extensive series of experi- Chairman, whose services are continuous, and are restrict- ments indicates that X-ray treatment, as above applied, in ed to the duties of the office), are unpaid, and are nomina- one generation only, stimulates larval growth, as •estima- ted by the municipal councils. ted by weight of the cocoons. (Note, however, the remark (m) The members are subject to the usual municipal as to the control figure on p. 146.) As might be expected, elections once every three years by virtue of their positions not every experiment shows increase in weight of result- as councillors, and also to re-election to the Board by their ing cocoons as compared with controls, since experimental respective Councils every three years. error may in an individual case quite well mask the indi- (n) Full details of all business and proposed expenditure vidual result; but on the whole results show well-marked are printed and circulated to members and all Councils. agreement; on the other hand, radium in the dosage (o) The Board meets fortnightly, and the committees employed has exerted a depressing effect as regards a weekly and fortnightly. weight of cocoons, while there is also evidence that X-ray (p) There are seven committees, besides special com- treatment, when repeated as above in a second generation, has a depressing influence on metabolism as judged by this mittees and conferences, as required. criterion. (q) The percentage of working expenses to revenue, viz., 20.22 per cent., is low, and compare§ most favourably with Iv. Large Doses of Radiations.--Both X-rays and radium any similar body or corporation. applied as above in large doses to larvae exert injurious and even destructive effects; there is in this series of ex- periments no evidence whatever of stimulation. As regards radium, the results of the experiments de- CORRESPONDENCE. scribed in the foregoing indicate in the main inhibitory or ••■•■••• destructive effects. Duration of the pupae stage, however, appears to be shortened. Congenital Absence of Anus. There is much evidence that X-rays, applied to silk- (To the Editor of "The Australian Medical Journal") worms in the various ways and doses stated above, can produce stimulation or acceleration of metabolic processes Sir,—Mrs. J. was confined of full-time male weighing as judged by several standards, notably by earlier hatch- about 121bs. Friday afternoon. On Saturday morning the ing out of eggs as compared with controls. There is also nurse noticed stain of meconium on napkin, so thought considerable evidence that these effects are replaced by everything was quite right, but as no motion was passed effects of a reverse order in the next generation, though it later on, decided to give the infant .a soap and water in- is possible that this reversal may be prevented by repeti- jection, but on attempting to pass rectal tube found no tion of treatment. aperture, so called me in. On examination no sign of Thus it appears that stimulation or acceleration of meta- anus was to be found, and, on pressing little finger up bolic processes may be produced by X-ray treatment car- between buttocks, no bulging of gut to be felt, but evi- ried out within certain limits, but that these are eventually dently there was some connection between sigmoid and succeeded by depression and retardation, while only the bladder or penis, as I saw meconium stain on nankin latter effects are manifested when the treatment is pushed myself. beyond these limits. Large doses of X-rays and large With the assistance of Dr. Jackson, of Bendigo, I did doses of radium have similar deleterious results. a left inguinal colotomy that night under urea and quinine local anaesthesia. The infant stood operation well, with- Fate of Dust. out. appreciable shock. The artificial opening acted satis- Sir T. Oliver ("Lancet," September 26th), in an article on factorily, but after 24 hours a spreading cellulitis started "Dust and Fume," says:— round wound, and the infant succumbed 48 hours after What becomes of dust when it is inhaled? It is a na- operation. The urea-quinine local seemed to stop all tural supposition that while some of it reaches the lungs, .\-()ecuuhcr 2, 1912. AUSTRALIAN MEDICAL JOURNAL. 76 the major part of it is retained in the nares. Saito, work- dense unyielding fibro-connective tissue. In its early ing in Professor K. B. Lehmann's laboratory in the Insti- stages pulmonary 'fibrosis is solely the result of irritation tute of Hygiene in Wurzburg, has tried to determine ex- caused by dust. perimentally the fate of dust breathed by workmen in fac- tories. In his preliminary experiments dogs and rabbits Midwife Practice. inhaled air charged with white lead dust from one hour to 33 hours. He found that the greater part of the dust was In an article in "Bulletin" of Johns Hopkins Hospital subsequently recovered, not from the lungs, as might have (September, 1912), Drs. Jeidell and Fricke write:— been expected, but from the alimentary canal. Ln five out The following are some of the practises of a few coloured of six experiments 4 to 24 per cent. of the total amount of midwives: lead dust breathed in was located in the respiratory or- 1. Treatment for Haemorrhage.—Ice held in the hand; gans and the remainder in the digestive organs. In an licking alum; a hot potato held in the hand; equal parts ordinary way the dust caught in the nasal mucous mem- of paregoric and laudanum by mouth while at the same brane mixes with the mucus which is secreted and is un- time a piece of cloth is burned in the stove; packing the knowingly swallowed. Experiments were also carried out vagina with any kind of rags that are handy in case of on man with white lead dust, the mouth and nares being post-partum bleeding. previously carefully washed. The experiments were con- 2. Treatment for Delayed Placenta.—Feathers burnt un- ducted from 10 to 15 minutes on 20 occasions, care being der the nose of the patient to make her sneeze; salt held taken by the men not to swallow the saliva. Inspiration in the hands to make them sweat while the patient blows and expiration took place through the mouth and nose into a bottle. singly and combined, with the result that, provided sneez- 3. The Use of Douches and Ergot.—In one neighbourhoor ing did not take place, 95 per cent. of the dust inhaled ante partum douches were routine. Post-partum douches remained in the body, 50 per cent. of which was primarily are quite commonly used when the placenta is not intact or retained in the nares. By processes of exclusion 12 per when the lochia have an abnormal odour. The midwife cent. probably finally found its way to the lungs, for the carries from patient to patient her own douche tip, which bulk of the lead dust-60 to 80 per cent.—was recovered she greases before using. Ergot is used by a few of the from the alimentary canal. Saito's experiments demon- white midwives to increase labour pains. strate that the principal portal of entrance of soluble dust 4. The Kinds of Pads Used.—Anything from greased into the body when inhaled is the alimentary canal and rags to burlap is used by the very poor unless the mid- not the lungs. When two such channels of entrance as the wife is in a position to furnish them with something differ- respiratory and alimentary are so close to each other it is ent. On one occasion we visited a poor Lithuanian woman not always easy to say upon which the dust has exerted who had been delivered that morning in a room contain- its baneful influence. In Laborde's experiments with ing two dilapidated beds and a broken chair. The midwife guinea-pigs exposed to air laden with fine white lead dust whom we accompanied informed us that a woman wash- the animals died within two hours. In the lungs were ing at a tub, whom we could see from the window, had found intense congestion and ecchymoses. When the ex- been confined the day before in the other bed. Our mid- posure was less intense and the animals lived longer, simi- wife not only received nothing for these confinements but lar but equally profound vascular changes were found in even supplied these poor women with clean pads. the lungs, pointing to direct irritation by dust. In our interviews we marvelled at the intelligence of Just as the ciliated epithelial cells of the trachea form several of these coloured midwives who had their training a protective barrier to dust reaching the lungs, so does onplantations before the war and who to most of our sneezing -exercise a protective function in the same direc- questions gave replies which would have been a credit to tion. When, as a result of repeated exposure of dust, this the present generation. They formed a pleasant contrast function is lost, it becomes absolutely incumbent upon men to the one who, in response to our request to see her and women, after working for a few hours in a dusty licence, amiably produced her .marriage licence. Not'With- occupation, carefully to rinse and cleanse the nostrils by standing their superstition and ignorance, the coloured warm water before leaving the factory. midwives were on thewhole a simple-minded, sympathetic ' in my own experiments I found that fine coal dust in- lot ready to trudge miles over the sandy roads in the mid- jected into the peritoneal cavity was transported through summer heat to earn their meagre fees which, in many the body considerable distances. By circuitous lymphatic cases, they never received at all. paths the dust reached the lungs and bronchial glands. Several large particles of coal dust made their way into the testes. There is plenty of evidence to show that the Acne and Sycosis. development of pulmonary anthracosis by the intestinal canal as maintained by Calmette and Petit is a possibility; Galbraith ("Prat.," September, 1912). concludes:— but that on this account the intestinal canal should be ra- From the foregoing remarks on acne vulgaris I would garded as the mode by which insoluble dust more fre- deduce the following conclusions:- quently reaches the lungs rather than by direct inhala- 1. The acne bacillus is the cause of acne in all its stages. tion, I am not prepared to admit. The engorgement of the 2. The staphylococcus is ;a surface contamination, and lymphatics in the deeper structures of the bronchi and at the most can only aggravate existing pustulation. around the blood-vessels suggests the possibility of an 3. Doses of 5 to 10 millions do not suffice to cure, unless intestinal source of infection, but the changes observed in one is prepared to go on indefinitely. The doses required the alveoli of the lung in the early stages of anthracosis range from 30 to 100 millions, according to the type of the point to irritation of the epithelial lining by direct con- disease. tact with dust. I quite admit with Calmette that it is not 4. The duration of treatment extends from three to five always easy experimentally to get either dust or microbes months in the milder cases, from six to twelve months in into the lung, and yet I have succeeded in setting up in the the severe forms. dog anthracosis limited to one-half of the lungs. Grysez 5. As there is a close relation between the opsonic index and others failed to produce pulmonary anthracosis in ani- and the amount of pustulation, the latter may be taken as mals when, by tying the oesophagus, swallowing of dust the guide to dosage and frequency of administration. was prevented. One of the strongest adherents in Great 6. Whilst it is impossible to give anything like a definite Britain of the intestinal theory of anthracosis is Sir Wil- prognosis, it may be said that marked improvement is liam Whitla, of Belfast. There is mííì. ch experimentally to brought about in the great majority of cases, and a fair show that by the alimentary canal dust and bacilli finally proportion cured, and that it is a striking advance on the reach the lungs. To the opinion expressed by von Behring older methods of treatment. The mild comedo and super- that pulmonary tuberculous of the adult is frequently the ficial pustular types are most amenable to treatment, next result of the lighting up of disease long latent in glands the pure comedo type, and last the deep indurated type. as the result of a probable intestinal infection contracted 7. I have not found an autogenous vaccine give better in childhood, I unhesitatingly add the testimony of my own results than a stock vaccine. experience. Once pathological changes due to dust are sat Sycosis.—From the foregoing remarks I would draw the up in the lungs, the tendency is for these structural altera- following conclusions:- tions to advance, the principal feature of which is the re- 1. That the staphylococcus pyogenes aureus is the causal placement of the ordinary spongy texture of the lung by organism in by far the greater proportion of cases. 764 AUSTRALIAN MEDICAL JOURNAL. rnilcr 2, i()i 2

2. That the great majority of acute cases and many of the sub-acute can be cured by a vaccine. 3firitigb ,fifiebícaY a55ocíation. That in the chronic cases—those which have lasted 3. VICTORIAN BRANCH. perhaps for years—complete cure is rare. 4. That in a certain type of case, already mentioned, a vaccine is of no use. Dr. A. E. R. White, 85 Spring-street, Melbourne, Hon. Sec. 5. That an autogenous vaccine is superior to a stock vac- cine, and that a case should never be looked upon as a failure until an autogenous vaccine has been tried. NOTICES. Extensive Resections of the Small Intestine. The ordinary Monthly Evening will be held at the Flint ("Bulletin of the Johns Hopkins Hospital,' May 19, Medical Society Hall on Wednesday, November 6th, at 1912) concludes:- 8.30 p.m. 1. As much as 50 per cent. of the total small intestine in BUSINESS: dogs may be removed without fatal results. The animals may gradually return to a condition of practically normal (1) Consideration of the request of the Hon. Staff of the weight and metabolism when maintained on the favourable Melbourne Hospital that the members of the Vic- diet under good conditions. Resections of 75 per cent. and torian Branch of the B.M.A. express their opinion re even more of the total small intestine may be survived, but the attitude of the Coroner (Dr. Cole) towards mem- such animals are not liable to show a true recovery, i.e., bers of the profession in the matter of the adminis- a return to normal weight with the establishment of a tration of anaesthetics. good compensatory process. (2) Dr. R. 1l. Downes will read a paper: "The Epiphysis. 2. At first, the animals suffer from, a severe diarrhoea, Their Structure and Clinical Significance." ravenous thirst and appetite, and loss of weight from (3) Dr. Pern: "The Need of Lime in the System, and its which they gradually recover until conditions may return relationship to Goitre." to those of a normal animal. They remain, however, ex- Dr. T. P. Dunhill will open the discussion on the tremely sensitive to unfavouralble conditions of diet and hitter paper. living. 3. Metabolic studies on such animals show that there is a marked increase in the excretion of the nitrogenous, fatty, Telephone 1434 Central. and carbohydrate elements of the food. The elimination may reach 66 per cent. of the diet content. After compen- VICTORIAN BRANCH. — Ordinary Meeting, ist Wednesday sation is established, on a rich, easily assimilated diet, in month. digestion goes on as in a normal dog, except for an in- „ Clinical Meeting 3rd Wednesday crease in the amount of intestinal putrefaction, as indi- in month. cated by the amount of indican in the urine. An increase in the amount of fats in the food may lead to an increased elimination of nitrogen and fats to a point about 25 per PEDIATRIC SOCIETY.—Second Wednesday in month. cent. above normal. The carbohydrates, on the contrary, are absorbed to a degree considerably above normal after EYE AND EAR SECTION.-4th Wednesday In Month. the compensation is established. 4. The compensatory process consists in a hypertrophy as Melbourne Hospital Clinical Society. well as hyperplasia of the remaining portion of the small (Fourth Friday in the Month.) intestine. There is no regeneration of either the villi or crypts. Computation makes it probable that in favourable cases approximately the original epithelial area of the in- operation of choice. The surgical rule has been and will testine is restored by the hypertrophie process. continue to be, a resection of the minimum amount allowed_. 5. As in animals, about 50 per cent. of the small intestine by the pathological conditions. From the met - stíic may be resected without much danger of serious conse- ies, it would seem wise to give these patie: a CriEh” and ' quences in the majority of cases. The resection of larger easily assimilated diet, poor in fats and re tive ::,..Aic'lriii amounts may, however, be followed by severe metabolic carbohydrates. .•'' disturbances, and even inanition and death. Human cases behave in general like the animals. They show similar metabolic disturbances. In one case there was distinct evidence of a compensatory process. No regeneration or GENERAL. hypertrophy has ever been reported in a human case. There are over 58 cases reported in the literature where over During 1911 no fewer than ;519 passengers aannci`e 200 cm. of the smlall intestine have been resected. The ployees were killed in railroad • accidents in the United mortality is 16 per cent., which is probably much lower States, most of then as the result of injuries received in than it should be, owing to the greater probability of suc- collisions. In the months of July, August, and September, cessful cases finding their way into the literature. according to Accident Bulletin No. 41 of the Inter-State 6. The metabolic disturbances in human cases bear no Commerce Commission, there were 1232 collisions, in definite relationship to the amount of small intestine re- which 70 persons were killed and 1923 injured. sected. Five resections of over 400 cm. have recovered, while death from inanition has resulted from the resection With regard to the question of "alcohol as a cause of of 284,289,300 and 350 cm. respectively. Profound digestive insanity," the report of the Irish lunacy inspectors states disturbances have resulted from the removal of 192 and that the facts indicate that there is practically no relation- 204 cm. of ileum. In human cases, factors like difficulties ship between the distribution of insanity and that of in measurement, the pathological condition, the total drunkenness in Ireland. Chronic alcoholism is so small in length of the intestine, and the resistance of the patient Ireland that it can have no great influence on the insanity undoubtedly modify the result, and explain the apparent discrepancies between the amount of intestine resected and rate. the subsequent metabolic disturbances. 7. The prognosis in human cases should be guarded. A milk preparation new to most Australian practitioners Apparently successful resections may, for lack of suitable has been put recently on the Australian market. It is compensation, succumb ultimately to a slow process of known by the trade name "Glaxo," and is a dried milk inanition. prepared in New Zealand. It has already established 8. The experiments and the series of human cases empha- a reputation in Great Britain, and the second edition of sise the specific function of the three segments of the Dr. R. Hutchison's work, "Food and Dietetics," points out gastrointestinal tract. Neither the stomach nor colon is that "Glaxo" is the only member of a group of infant foods able to compensate for the loss of large portions of the which contains as much fat as human milk. Further in- small intestine. formation can be obtained from \lr. C. Ea Hall, the local 9. Resection of the human intestine is almost never an agent.

--- -N. 701 Nov 1b ^r C), 1912. AUSTRALIAN MEDICAL JOURNAL. 765

lZECESSITY OF LIME IN THE SYSTEM argic habits, coarse, dry skin, scanty hair, high T. ND ITS RELATION TO GOITRE. blood-pressure, a great tendency to accumulation of fat, and the deposit of a n uicoid substance in the skin. in exophthalmic goitre katabolism is in ex- SYDNEY PERN, I.R.C.S., L.R.C.P. (Lond.). cess of anabolism; the mind is quick, the nerves under high tension, hysteria and mania may super- From close observation of many cases of goitre, vene, peripheral circulation in a state of chronic and by living in a district where they are present in dilatation, skin changes, such as clamminess, flush- great numbers; also by knowing the families and ing, pigmentation, certain eruptions, and, in marked by carefully studying the circumstances under cases, rapid wasting. which they live, the writer is putting forward cer- At the one end of the pole we can place endemic tain observations which he hopes may, in some goitre , with its resulting nivxedenca and cretinism, small way, help to unravel the great tangle of and at the other exuplithalniic goitre. events ivlcicli embrace the functions of the thyroid In both conditions, in children born of stich par- and its relationship to goitre. ents, the thyroid gland readily shows hereditary in- For all practical purposes there are two kinds of fluences: in each case there is apt to be impairment goitres—endemic and ex-ophthalmic—the rest of its functions. Alyxeclenca, following endemic goi- being stages of degeneration. The endemic goitre tre, is clue to atrophy of thyroid. 'l'he atrophy is due is admitted to be of a purely hypertrophic nature. to hypertrophy reaching a certain limit, then de- The a circumstances r ider which it is found are, generation resulting, it being no longer able to meet roughly, these :— Limestone districts have always the demands made on it. Children burn of such par- been noted for these goitres ; and where they pre- ents, with thyroids already impaired, soon fall vic- vail the people live largely on foodstuffs tims to cretinism. such as cheese and milk, which contain a great deal Children born of parents with exophthalmic goi- of lime. It used to be held that lime was the cause tre likewise readily develop goitre, but sometimes of goitre, and then that again was discredited, but one or more in such a fancily take on a mild myxe- on closer observation there may, after all, be some dematous type, going to fat, becoming slow and truth in that statement. lethargic, and, in one case, very liable to spon- People living under these. circumstances, drink- taneous thrombosis in veins. ing water saturated with line, and eating food rich The in it, must of necessity take into their bodies a great extremes of the goitres have been mentioned, but what about the intermediate conditions? From deal more 'lime than is essential for their proper myxedema and cretinism to the normal being there needs. We know that line is needed for the func- are all stages of thyroid inefficiency, likewise from tions of the body, and we can rightly assume there the normal individual tip to the exoplithaliiiic. 'Thy- is some regulating apparatus by which only enough roid inefficiency in children is shown by tendency and no more shall be used for keeping perfect to stunted growth, thickness in build, slowness of health. People living under the circumstances just speech, excessive appetite, heavy sleeping, incon- mentioned are liable to a goitre which is a. pure tinence of urine at night, mental activity not quite hypertrophy of the thyroid gland. This points to up to normal. These symptoms ivay be present in excessive work being thrown on the gland whilst all degrees, from what is palpable to the eye to what performing its proper function. - only an acute observer is able to detect. The circumstances under which exophthalmic In adults, thyroid inefficiency is usually marked by excess of goitres are found are, roughly, these :—The water fat, gross eating, sleepiness. up to supply is rain water stored in tanks, which. is prac- the extreme de- gree of ni yxcdema. Children so affected grow tically distilled water with a little CO. dissolved in rapidly when put on thyroid extract, but it it. The foods which are eaten are of the simplest mist not be supposed that every child can he grown by thy, kind, with hardly any variety : a beast is killed and roil extract. It is only children whose thyroids eaten, which means a little fresh meat occasionally, are not quite up to normal wh o respond well to otherwise it is salted. Those affected can get 'no vegetables, and rarely grow any themselves, and such treatment. In the sauce way, after much ob- servation, one is able to recognise the steps from from the constant handling of milk and the milking slight nervousness and palpitation up to the extreme of cows, they get nauseated against it, particularly degree of exophthalmic goitre. After the study of the children. In nearly all cases of exophthalmic many cases, the writer found out that adults who goitre in young people they own to never drinking came into his district did not get exophthalmic milk. These people are living under circumstances goitre, but their children did. In some cases there where a minimum of lime is taken into their sys- are three generations of exophthalmic goitres. In tems. some families there are all stages of exophthalmic In the one case, where excess of lime is in evi- goitres, big and small; some with the extreme de- dence, endemic or hypertrophie goitre, with its final gree of hyper thyroidism, and others with only an stages of cretinism and myxedema, is prevalent, and easily excited heart and slight nervousness. Ex- in the other, where deficiency of line is most mark- ophthalmic goitre has been produced by implanting ed, exophthalmic goitre abounds. thymus gland. In most cases of exophthalmic From a rough observation of the symptoms of goitre the thymus is persistent. Hence children these two cònditions, it will be noticed that one is living under conditions which conduce to exophthal- the extreme of the other, myxedema being marked mic goitre can develop goitre, because the thymus by slow metabolism, dullness of mind, often melan- gland could be brought into action more readily cholia, slowness of speech and action, sleepy, leth- Adults suddenly put under the than in adults. 766 AUSTRALIAN MEDICAL JOURNAL. November 9, 1912. same conditions, and when the thymus has long ago In fact, wherever lime is found deposited in the atrophied, can, and (lo, suffer with most of the symp- body it is an attempt on the part of the system to toms of hyperthyroidism, but do not show any en- repair damage and render harmful matter inert, en- largement, it being fully recognised that the size of velope it and strengthen it. This is seen in the fol- the thyroid has no relationship to the symptoms. In lowing instances:— fact, the younger the children and the more marked Calcareous deposits often found on old ligatures. the circumstances for producing exophthalmic Renal calculi of calcareous variety always de- goitre, often the larger goitre. The biggest posited in infected kidneys and round foreign exophthalmic goitre ever seen by the writer was in bodies, also deposited round primary calculi, epi- a child 13 years old, and who vomited if she drank thelial detritus, fibrinous deposits or blood-clots. milk, so never touched it. A lot of people who are Hydatid cysts. really suffering from hyper-thyroidism are treated Vaginal deposits from vesico vaginal fistula. for neurasthenia and irritable hearts. In aneurisms it is often found. Here there is no It is convenient here to make a few remarks about doubt that it is often of the greatest help in keeping lime, how available for human consumption, and the diseased tissues from stretching (calcium salts for what it is necessary in the body. might be given in aneurisms with advantage). Lime is found in the waters of most wells and In general atheroma there is primarily a toxin rivers. It is largely distributed throughout the which causes fatty degeneration of muscle fibre and vegetable world. especially radishes, asparagus, elastic tissue with, consequently, loss of tone to ves- spinach and the cereals, rice predominating. Milk sels. A deposit of lime forming a more or less contains more lime than line-water. Robert rigid pipe is better than loose tissue with no con- Hutchison says :—Cheese contains 6% of mineral tractible power. Some pressure can be exerted salts, chiefly line; wheat contains 1.9t fo mineral along a rigid vessel, but none along a lax one with- matter. but ordinary baker's flour only 0.5%. 'There out any power of contraction and a great inclina- is a certain amount also in neat. In fact, it is very tion to stretch. widely distributed, so much so that it would seem Foreign bodies in the bladder get encrusted with almost impossible for people not.to get a sufficiency. line. It would be a very difficult matter to estimate the Ernpyentas, which are small and undiagnosed, amount which is necessary for an adult, but Robert often get impregnated with lime salts. Hutchison states that an infant requires grs. 5 Salivary calculi and calculi in tear duct deposited daily. _A growing child would, therefore require a round some foreign natter or bacteria. fair amount. One litre of milk contains i'/a Twenty to thirty per cent. of gallstones are lime grammes or grs. 15 of lime. and bile pigments. ( Keen's Surgery.) 1 t - possible to take such a diet as will not sup- Lime deposited in old tubercles o f lung. ply the right amount to the system, particularly In ovarian cysts. when milk and fresh vegetables are excluded and All these examples tend 14) show that lime, rain water drunk. wherever deposited, is for the benefit of the indi- There is a disease in these parts affecting stock, vidual to destroy bacteria or coat over foreign when left on certain areas of country too long. called bodies. "Cripples.'' The chief symptoms are softening of A brief summary of the symptoms of exophthal- the bones and swelling of the joints. These areas mic goitre ill comparison with Addison's Disease are known by analysis to be deficient in line. Lat- will lead us to a very important conclusion :— terly, wells have been dug and windmills erected, with the result that the "cripples" have vanished Addison's Disease. Exophthalmic Goitre. yOlen this has been done. It would seem hardly Pigmentati> m. Pigmentation. possible that animals living on green food could get Progressive _Asthenia. a deficiency of lime; yet by substituting wells for Progressive .Asthenia. waterholes, the lime in -the lower strata of the soil is Breathlessness. Breathlessness. made available and the disease vanished. Experi- Headaches. I-leadaches. ments have been made by feeding animals on a diet Dizziness. Dizziness. . \uriunt. as free from lime as possible, and it was found that Tinnitus Auritun. 'Cinnitus Pulse small and feeble. Pulse rapid and ir- the bones were called upon to supply the necessary regular. calcium salts to the system. This is practically Faintness. what happens in "cripples." \V'e, however, find no Faintness. such condition in the human body, except rickets, Palpitation. Palpitation. Coldness and clammi- Clamminess & sweat- although occasionally one does come across a child ing of extremities. who is always breaking some bone or other. ness of extremities. The chief uses of lime in the body are for :- Blood-pressure greatly The growth and metabolism of bone. reduced before death. Chronic vasodilation. As a normal and absolutely necessary ingre- Chronic vasodilation. dient of the blood and of every living tissue. Nausea and vomiting. Nausea and vomiting. Gastric disturbances Gastric disturbances Lactation calls for a large supply, also preg- not following errors nancy. not following errors As a first line of defence in the repair of tissues, of diet. of diet. to strengthen weak patches in blood ves- Diarrhoea often trouble- Diarrhoea often trouble- sels, such as aneurisms, general atheroma some in later stages, some in later stages, often with vomiting and damaged valves. often with vomiting. November 9, 1912. AUSTRALIAN MEDICAL JOURNAL. 767

From a comparison of these two diseases v.ve can exophthalmic goitre, and the comparisons of the conclude that, knowing Addison's Disease to be due symptoms with Addison's Disease. led the writer to diseased adrenals, and the symptoms therefore to believe that the ergot, by raising the blood-pres- caused by a deficiency of adrenalin secretion, in ex- sure, relieved the adrenals, which were colder a ophthalmic goitre, so far, the symptoms may be due strain and not secreting sufficiently to properly meet also to a deficiency of adrenalin secretion. This is the demands made upon them. Other cases of ex- now proved to be so, and can be estimated by cer- ophthalmic goitre were then treated with ergot, and tain tests. line given to increase the coagulability of the blood. 'l'he remaining symptoms of exophthalniic goitre 'l'he -writer has since found out that Kocher has are identical with stimulation of the sympathetic made exhaustive experiments on these lines, and fibres received from the third, fourth and fifth goes so far as to say that the degree of coagula- thoracic segments of the cord. bility is in proportion to the symptoms of ex- Thus far the symptoms are entirely clue to these ophthalmic goitre. Experiments have also been two factors—adrenalinemia plus sympathetic irrita- made by Lidsky and Kotman, showing that in tion of a certain area of the cord. operative niyxedenia the coagulability of blood was l f, as has already been hinted at, lime has some increased as to time and degree. This proves con role to play in the production of this class of events, that the thyroid secretion has the power-clusively we should expect to find some alteration in the of reducing the coagulability of blood, in other coagulability of the blood. words, the less thyroid secretion the firmer the clot, Whilst attending confinements the writer's atten- the more secretion the thinner the clot. tion has been drawn to the difference of rate and Of which of the three elements that coagulability degree of the coagulability of blood. In some cases depends on is the one which meets the case best. the blood doted in great firm hard masses, which Lime is the one which fits the circumstances seem to stand up and do not spread out as usual. most thoroughly. Not only does that experiment In these cases the type has always leaned towards show that the thyroid secretion has the power of that of thyroid deficiency. Whilst attending the altering the clot, but it shows that, according as confinements of cases of exophthalmic goitre, some niucli or little secretion is entering the blood, much of the cases repeatedly had profuse post-partem or little lime is rendered inert ; also, that if there is haemorrhage, in spite of thorough emptying of the much lime coning into the blood there will be a uterus. and also good average uterine contractions; great call upon the thyroid to supply a sufficiency also observing that the blood was very slow to clot of secretion, and it would have to hypertrophy to and the clot poor in quality, the writer's attention meet the demands. vas directed to the possibility of deficiency of lime In the reverse case, when little lime is coming in, being the cause. 'l'liese cases latterly were then the normal amount of thyroid .secretion will be promptly treated yyith hyperderniic injections of in excess, because it will not be required, as only a ernutin ( P. D. and Co 's. preparation of the active little will he needed to render inert or to form principle of ergot). This danger is now prevented some inert compound with the small amount of lithe by injecting directly the baby is born. available. At this stage we must naturally assume .1 few remarks on t he effect of exophthalmic that all ductless glands have afferent and efferent goitre during pregnancy, parturition and lactation impulses, or are under hornion guidance, whereby may not he out of place here to increase or decrease their secretion as is neces- Patients suffering from the minor symptoms of sary for the well-being of the body. If there is a exophthalmic goitre usually have nothing abnormal, deficiency of lime, and only a small amount of secre- but may complain of a certain amount of palpitation tion needed. an inhibitory impulse will be forwarded and nervousness. to the thyroid, which will attempt to check the Fairly bad cases get decidedly worse, some ex- secretion entering the blood by storing it up. This tremely bad, the symptoms increasing during the is showin in cases of so-called exophthalmic goitre latter few months of carrying, and getting progres- after injury or shock, w h ich occurs with great sud- sively worse as parturition gets nearer. If. after denness. 'these cases only show irritation of delivery, they should be fortunate enough to get a sympathetic fibres of the 3rd, 4th and 5th thoracic hypodermic injection of ergot, or its active principle, segments of the cord, as can be produced experi- all is well, they enter into a new life, their recovery mentally. is rapid, they put on flesh where before they were 'I']ie facts are presumably these :—The system is thin; their colour, when before they were sallow and suffering from shock; blood- pressure falls, the anaemic. becomes healthy, and sometimes they are adrenals receive a stimulus through the sympathetic able to suckle the baby, which they had never been nerve to raise the blood-pressure; they respond to able to do on previous occasions. the best of their ability, and it is only reasonable to If, on the contrary, they had lost a good deal of suppose that at the same moment an inhibitory blood, and had received no hypodermic injection of impulse to store up secretion is sent to the thyroid, ergot, they slowly got well, kept anaemic. and often which is known to cause vasodilation, and which, if were unable to suckle the baby; but, if they could allowed into the system, would make matters do so, and did improve by the rest, after a while worse. Ilence the sudden enlargement of the thy- lactation pulled them down and the symptoms roid in certain cases of head injuries. fear, etc. returned. Thus far the thyroid secretion has been shown to be able The remarkable effect of hypodermic injections of to render inert one of the three elements causing ergot, or its active principle, on the symptoms of coagulability of blood, which, fromaforesaid evi- 768 AUSTRALIAN MEDICAL JOURNAL. November 9, 1912.

Bence, points strongly to lime ; also that at times it balance. For the same reason growth, the parting can probably be inhibited ; it is known to cause with tissue foods and getting rid of waste products vasodilation, as is shown by the administration of are under the same control. • dessicated thyroid. The question why women suffer so much more Sir James Barr, in "B.M.J.," 21st September, from exophthalmic goitre than men, may reason- 1912, in a discussion on Lime-salts, attributes the ably be answered by this. It has been shown by viscosity of the blood as being due to such. In the analysis that the menstrual flow is very rich in writer's opinion, the vasodilatory effect of thyroid line. If this is so, women living where there is extract is due to a diminution of viscosity, and not little line obtainable, and losing some each month an actual dilitation of capillary area, the blood which they can ill-afford to part with, would cer- being able to pass through the peripheral vessels tainly fall victims to exophthalmic goitre in larger with greater ease. Iodine is one of the chief ele- numbers than men. During the menses and preg- nancy the thyroid swells. Here, again, inhibition is ments in thyroid secretion: What relation this ele- brought into play, lime is leaving the system, the ment has to lime and the body generally has puzzled thyroid secretion must be stored up, or the blood- the writer for some time. It might be offered as a pressure will go clown and the adrenals be over- suggestion that, according to the theory put for- taxed. This inhibition can only be temporary, as ward this evening of the thyroid being able to get thyroid secretion does leak into the system in ex- rid of the superfluous lime, the iodine unites with ophthalmic goitre. The enlargement of exophthal- the lime, forming cal-iodide, which is the most mic goitre has appeared to the writer to be an at- soluble salt of lime, and so assists its excreation. tempt on the part of the gland to store up more and On the one hand are the adrenals and on the more of its secretion, particularly as it is not a true other the thyroid, one causing vasoconstriction and hypertrophy; the young have this ability more than the other vasodilation. In other words, the whole the older ones. of the management of the peripheral circulation is It is not necessary for the thyroid secretion to be in their hands, controlled by the vasomotor centre above normal to produce symptoms of hyperthy- through the sympathetic nerve. It has been de- roidism, but as it forms some combination with finitely proved that there is an excess of thyroid lime in which both are rendered inert, and which is secretion in the blood in exophthalmic goitre, and absolutely necessary for the proper growth and that adrenalinema exists. The thyroid secretion is metabolism of the system, so if there was not suffi- in excess or otherwise according as there is much cient lime coining into the system to balance the or little lime entering the blood. Circumstances secretion, there would be all the effects of hyper- show that in exophthalmic goitre little lime is enter- thyroidism with a normal amount of secretion. It is ing the blood, and thyroid secretion is in excess. more than probable that this is actually so in the This would produce vasodilation rapidly if it were early stages of exophthalmic goitre, as it is only not for the adrenals counteracting it. Chronic rational to presume some attempts on the part of vasodilation is now produced, which soon exhausts the body to prevent it entering the circulation. the adrenals, and as soon as the adrenals begin to Thus far the steps are these :—Insufficient lime flag the blood-pressure drops, stimuli come from the coming into the system to enter into some combina- vasomotor centre through the sympathetic nerve to tion with the thyroid secretion, with the result that the adrenals to put forward still further efforts, or there is an excess or apparent excess of that secre- blood-pressure will fall too low and death result. tion, which tends to produce a fall of blood- pressure. This constant irritation of the sympathetic nerve in The vasomotor centre in the brain sends a stimulus sending impulses to the adrenals causes one of the to the adrenals through the fibre of the sympath- two divisions into which the symptoms of ex- etic nerve, issuing from the 3rd; 4th and 5th ophthalmic goitre can be classed. The same im- thoracic segment, to keep up the blood- pressure, pulse which stimulates the adrenals also inhibits the and at the same time an inhibitory impulse is sent thyroid, hence the enlargement of the thyroid on to the thyroid. As exactly the reverse would be stimulating the sympathetic fibres from the 3rd, 4th done when the boold-pressure is too high, the and 5th thoracic segments, and, as the impulse adrenals would be inhibited and the thyroid stimu- which causes the sympathetic irritation is an effer- lated to action. Hence the true hypertrophy of the ent one to the adrenals, this is why it is limited to thyroid in endemic goitre due to excess of lime. the upper part of the body, and not an irritation of On these lines one would expect to find the adre- the whole of the sympathetic system (the impulse nals hypertrophied in exophthalmic goitre. The to the adrenals also passing through the same constant impulse to the adrenals would in time pro- channel). Thus are accounted for the symptoms duce that train of symptoms classed under the head of exophthalmic goitre as regards vasodilation, of sympathetic irritation, and would be in propor- adrenalinemia, and sympathetic irritation owing to tion as to the ability of the adrenals to keep a bal- there not being enough lime coming into the sys- ance of blood-pressure or otherwise. It can be well tem to utilise all the thyroid secretion available. seen from this that the use of the manometer is use- So far the writer has tried to show that the whole less, except to give evidence when the natural arrangement of the peripheral circulation is in the mechanism for regulating the blood-pressure has hands of the adrenals and thyroid under the con- failed. trol of the vasomotor centre. In shock, where The results of giving lime in these cases are, there is engorgement of the splanchnic pool, the roughly, these :—The lactate being used as the most adrenals and thyroid will have to adjust the right soluble and readily - absorbed salt, ro grs, t.d.s. at November 9, 1912. AUSTRALIAN MEDICAL JOURNAL. 769

first seems to aggravate the nervous symptoms. the world in whom the balance is not properly ad- Headaches and palpitation become worse, there is justed, and who suffer more or less according to sleeplessness and often dyspepsia, discomfort is felt the degree of the error. .1t the present time the in the goitre and a soreness in the throat, which, on extremes are recognised, but the intermediate stages inspection, appears red. _Many complain of the are apt to be overlooked, and patients treated constant desire to keep clearing the throat. This is symptomatically. What means have we of recog- mentioned here because there is some relationship nising an error in the balance? So far we might between lymphoid tissue, thymus, and thyroid. In find the coagulability test of some value, particu- about ten days to a fortnight -these symptoms pass larly as the whole crux of the present question is the off and improvement begins. Within a month im- amount of -lime in the system. How many cases of provement is very noticeable, the patient begins to . hysteria and mania may he due to a deficiency of put on flesh rapidly, the goitre gets soft and then lime and sympathetic irritation ; and also, again, in shrinks. melancholia with high blood-pressure, etc., the

The younger the patients are, as a rule, the more cause may be found in the thyroid inefficiency.

rapid the improvement. •'hhere are people tinder the writer's observation Recognising the way that lime seems to aggra- who yearly get thinner and less active—men in the prime of life—their hearts get shaky. What other vate the symptoms when first given, the writer results could be expected than these, if there is a hesitated to put very acute cases directly on it, so employed ergot to tone up the peripheral circula- minimum quantity of line going .into the system? The food they take will not nourish diem, because tion and take the strain off the adrenals, and then without the lime it cann o gradually introduced the calcium salts. The result t form the necessary ingre- was good, particularly in one case with acute dilata- clients to make good the waste of tissue. The heart has the most work of any organ to perform, and tion of heart. It has been observed lately that the will be the first to show degenerative changes if it acute dilatation of heart and sudden death after cannot get the best material to make good the waste diphtheria are (hie to adrenalinemia. (G. A. Gibson, products. "11.M.J.," July 27, 1912). This condition and the acute dilatation in Graves' Disease are practically In treating disease and accidents, the first care of identical. So in acute cases the treatment of adre- the medical man ought to be to see that the patient's nalinemia is the first thing to do, and is best done body is in the best working order to combat the dis- by intravenous injection of adrenalin. The ordinary ease, and have plenty of available material of the hypodermic injection acts too locally, although it best quality to replace the damaged cells. It is use- must have sonic effect on the general sympathetic less administering medicines to bodies which are system on account of its immediate action in re- unable to forni new tissues, or that function is im- IÌ^ lieving asthma. The writer has employed epinine paired. It is easy to see how disease can gain a hold —a synthetic preparation of L' D. and Co.—hypo- in a body when that function is deficient, and how dermically, and found that it has a much more hard would be the battle in the reverse order of generalised action, the patient feeling the effect of things. It is along these lines that the future of it in the body for two or three days, it also being dealing Avith malignancy will probably be carried more stable and not acting so locally. Since writ- out.

ing this a "1,.1\1. J." ,has come to hand showing that Amongst other things, the writer has found the Dr. Gibson, of Edinburgh, has had great success by employing adrenalin alone, and, when used in com- administration of lime useful in some forms of bination with lime, every case should be benefited. nienhorrhagia, asthma, general nervousness, and thinks it might be of use in hypertrophie rhinitis

The remarkable way that young people suffering with hay fever. with exophthalmic goitre grow and put on weight In fact there are very few people in whom the when treated with lime, or lime and ergot, is astounding, and balance of affairs can be said to be properly regu- is only equalled by the rapid growth of children showing slight thyroid defic- lated. It is lately recognised that the cases of heart failure in diphtheria are clue to .adrenalinemia. It is iency when put on thyroid extract. more than probable that in other diseases other of

Surely the ability to grow children and improve the ductless glands may be affected. Lot's test al- their condition generally in the extremes of thyroid ready shows the presence of adrenalinema,-the same deficiency. and excess, places in our hands a great applying to the pancreatic secretion. weapon in combating sickness and disease. There may be some children who need both, not given ne- If the body is working up to its best form it cessarily together, but alternately. This opens up a should be able to store up reserve food for times of need, as is seen in the lower animals. If an indi- new field of investigation and research, and at first vidual is unable to store up any available food sight its possibilities cannot be conceived. supply his body is not perfectly balanced. In Dr. From the remarks already made, it can be ass- Gibson's hands, adrenalin alone has done great sumeci that the thyroid secretion and lime unite to things. The writer has already cured a certain form a compound which is very essential to the number of cases by lime alone, others by employing growth and repair of tissues, including that of the something to relieve the adrenalin strain, such as natural wear and tear of the body. If one or other ergot, orally or hypodermically, and epinine (synth- of them is in excess or deficient, the natural meta- etic adrenalin), together with lime. Every case, holism is upset. There are millions of people in some 25 or more, has been so far enormously bene- 770 AUSTRALIAN MEDICAL JOURNAL. November 9, 1912.

fited, all put on condition, the younger ones re- First child born November 15th, 1910. In labour

sponding more rapidly than the older. about 16 hours ; d vstocia ; forceps; very profuse The writer does not expect to see the goitre van- P.P.H. She was white for days after, and the bed ish in all cases, as it is hardly to be expected ill was kept raised at the foot ; there was also _seat people who have had goitre in the family for three laceration of the cervix. Child died four mouths generations: but, as long as all the symptoms of later while the mother yvas suffering from enteric hyperthyroidism are overcome, that is all that can fever. he desired. All these cases have been advised to \Vas irregular since the birth of the child : 4-6-7 put lime in their water-tanks to prevent any recur- weeks; profuse; no pain, except across the small of rence, and it may he necessary to use well-water the back. General health fair. Troubled with pain if good enough. The Nauheim waters have of late in the back, and hands and feet sometimes swollen ; been gaining a reputation in treating cases of is far too fat. exophthalmic goitre. They contain a fairly large June 6th : About seven months' pregnant ; L.O.A. ; proportion of calcium chloride, hence the results, ac- narrow pelvis; os lacerated right across ; great deal cording to my views. of leucorrhoea. These conclusions are the outcome of some years July 9th : Difficult to feel the child ; feet in left of careful observation and reasonable deduction, side of fundus ; body lies down to the right side; and may lead to further investigation. foetal heart loudest in mid-line low down ; present- ing parts cannot.be felt. Even if, in sonic small vvav, the writer has been July 18: Transverse presentation ; head to left able to elicit any little point whereby the well-being legs to right and upward. Advised Caesarean. C.V. of the community at large is benefited, he will be perhaps 7.5 centimetres, but very doubtful, because justly repaid. of her obesity. July 24th: Consultation with Dr. Dunbar Hooper. NOTES ON A CASE OF CIESAREAN SEC- July 25th : l'rine normal, tor8; no albumen; TION AT TERM FOR COMPLETE TRANS- some phosphate. VERSE PRESENTATION AND PROLAPSE Jule 31st: Urine, s.g. 1024; distinct albumen. Fehling rapidly reduced; pus cells and many crys- OF FUNIS IN A WOMAN WITH A JUSTO tals of oxalate of lime. MINOR PELVIS. August 5th : 1024, some albumen; slight reduction of Fehling; urates. l. W. i )L.' N lt:A R HOO PER, M.D. August 12th : 1024, some albumen ; no reduction of Fehling. I am indebted to Dr. Miller Johnson for the August 19th: Exactly the same. notes of this case. for asking me to see it in con- sultation, and for his watchfulness throughout. It Treatment. is to be noted that premature rupture of From July 31st : Thyroid gr. 5 ter in die, to Aug- the membranes precluded any hope of rectifying the ust 7th, when reduced to bis. in die, as pulse was presentation. The patient's first confinement, we noted to he quick. Combined with this was Fer. were informed. was very difficult, and she and her et Am. Cit. Pot. Cit. and Nucis husband were very anxious for a living, uninjured On August 22nd she felt exceedingly well, and child. 'l'he dangers and probabilities of the the skin of the face looked clearer than for a long Caesarean section were fully explained to them, and tinge. She also wore an abdominal belt and took their consent was accorded willingly. a great deal of exercise. The great factors for success were the deliberate August 25th : Membranes broke at 9 a.m. Moved performance of the operation without the added at once to Rossmore Private Hospital. Operation risks of even one vaginal examination; and, of at 12.-5. No vaginal examination made; cord pro- course, no attempt at manual or instrumental de- lapsed at 11.30; wrapped in gauze soaked in hot livery was made. The operation, at which Dr. Tate saline solution. Large female child extracted, io/ Sutherland and Dr. Douglas Stephens assisted me, lb.; its left hand found in the vagina; iodoform was quite simple. The uterus, after extraction of gauze plug pushed through the internal os into the the child, was everted to allow the placenta to be vagina ; not much haemorrhage or shock. pealed oft and the interior of the organ thoroughly Open ether and oxygen ; vaporole of pituitary ex- cleansed with hot saline. The catgut used was that tract injected twice into buttock after closure of prepared by myself, as at ':e Mount Sinai Hospital, uterine wound in layers and at end of operation. New York. The wound ,rea was prepared with August 26th : Vomited several times; passed tinct. of iodine 2.5 per cer , The operation occupied many clots; some distension, especially of the upper . one hour from the commencement of anaesthesia to part of the belly. the return to bed. There was no need for unusual August 27th: Vomited great deal; great disten- haste. The patient nurses the infant and both re- sion of the stomach itself. Washed out with Sod. main well. Bicarb and hiborate, and in last wash-out added some Mag. Sulph. No further vomiting, and bowels Mrs. S., zet 30. Two para last period, November acted later in the afternoon and ten times next day; 19th, 1911. passed some offensive clots. Menstruated first at 14 years; never regular, From that on uninterrupted progress. \r oyenl her 9, 1912. AUSTRALIAN MEDICAL JOURNAL. 771

of late years there has been a notable improvement. 3u5tratíau Orbital. journal The only safeguard possible is that on which the Federal Commerce Act insists, that the ingredients 9th NO VEMBER, 1912. of the remedy shall be set forth on the label, and it is a pity that under State laws this requirement can be evaded. It cannot be too clearly urged that the PATENT MEDICINES. objection on the part of medical men is not directed against either the patent or the proprietorship of 'l'he recently cabled statement that a witness advertised remedies. It is against the use of secret before the London Chamber of Commerce com- iormuke, either by its own members or anyone else, plained of the restrictions on the importation of and against the fraud and cruelty involved in patent medicines into Australia is a refreshing in- promises of the cure of affections which science and timation that sales must be considerably retarded. experience alike have- demonstrated are incurable 'l'he alleged reason, that the laws were dictated by by the means to he employed. interested medical men, is so obviously unfounded and unjust that it conies at once under the old truism of advocates of a weak cause indulging in abuse of the other side. The attitude of the me- dical profession towards proprietary medicines has POte5 aub COYUUneut5. always been logical and consistent. There has never been objection raised to patented remedies, Throughout the Commonwealth medical The Maternity practitioners have recently received a merely on the ground that they are sold without a Bonus sheaf of documents in connection with the signed prescription. But the profession has con- maternity bonus. At first sight it is not sistently set its face against countenancing or quite clear why the profession has been brought into the matter at ail. It may be a political makeshift to give the prescribing any remedy, the formula of which is measure a greater air of importance. It may be a hasty secret and against remedies which are vaunted as attempt to cover some loose points in a very hastily con- cures for diseases without any sort of scientific ceived project. However it is not with the political aspect support for the statements put forward. It is a that the concern of the profession lies. The medical or midwife's certificate is apparently to ensure that the child basic article of association among qualified medical was viable. As the matter stands at present, one of two men all over the world that any remedy claimed by alternatives is created. Either themedical man or mid- any of its members shall be made clearly known, wife is asked to do something for nothing, or the bonus is reduced by the amount of a fee for signing the certificate and any claim on its behalf be open to criticism by by which it is to be claimed. Most distinctly medical men the profession as a whole. should make it clear that the signing of such a certificate is something quite apart from their ordinary attendance, The insinuation that the medical profession is and as such entitled to a special tee, whether that fee is jealous of patent medicines is too trivial to merit to be paid by the Treasury or by the parents. It is im- much notice. The consumption of these nostrums portant that the matter should receive immediate atten- is confined mainly to two classes : Those who are tion in order that a uniform and reasonable fee for such service be fixed. The maternity bonus may be a great na- not really ill at all, and those who, in despair, tional blessing, as stated by the Prime Minister, but there clutch at the specious advertisements as a drown- is no sort of reason why it should be achieved at the ing man grasps at a floating straw. In either case expense of the doctor and midwife. The doctor in par- the work of the qualified profession remains un- ticular is asked to become a referee for the Treasury offic- affected, for the balance of faith in both instances ials in certain cases, and should be recompensed suitably. comes back in the end to the proper adjustment. * But there is another class for whom the profession is genuinely concerned, made up of those for whom The recent occurrence in Sydney of two Ptomaine dangerous examples of food-poisoning there is real danger in delay, and it is to save these Poisoning draws attention to the necessity of the unfortunates from themselves that any action is utmost care in endeavouring to trace the really required from a medical point of view. And origin of such happenings. The putresence of albuminous bodies, with the resultant .formation of ptomaines, is now a in order that medical advice in such cases may be well-established pathological possibility, but it should be clearly and forcibly put it is absolutely essential kept in mind that a diagnosis of ptomaine poisoning is in that medical men should know exactly what is the the majority of such instances apt to be too readily accept- composition of the remedy in which the patient has ed. The very striking instance of the fallibility of such a diagnosis which was afforded some time ago in Prahran been led to rely. may be recalled to lend emphasis to this point, if any be The attitude of the Minister of Customs, Mr. F. needed. In that case it will be remembered that several Persons partook of a meal which included substances G. Tudor, in answering a question in the -Federal prone to produce gastro-intestinal disorder, and the very Parliament on this subject ought to have tll 41earty serious symptoms exhibited by three of the victims were support of every thoughtful member of the profes- so regarded for a time. It was only by the insistence of a medical attendant that an autopsy disclosed the presence sion. Over and over again attention has been of arsenic, and led to a criminal prosecution. Quite apart drawn to the practice of great newspapers in puh- from deliberate contamination, it is possible that foodstuffs l it:ping advertisements of a character which might contain mineral poisons by some accidental contact, amount to nothing less than an attempt to obtain and it seems desirable that in every instance this dual pos- sibility should receive the closest consideration in con- money under false pretences. It seems impossible nection with every outbreak of such a character. It is not to expect complete reform in this respect, though for a moment suggested that any mania of suspicion 772 AUSTRALIAN MEDICAL JOURNAL. November 9, 1912.

should be fostered, but merely that a diagnosis of ptomaine tain the position, though of this I have no personal know- poisoning cannot be firmly based upon symptoms alone, nor upon the simultaneous appearance of symptoms in a ledge and I can hardly believe it. As a rule, when a me- number of persons, and that especially in the case of dical man has gained a clientele through lodge practice, he tinned foods other possibilities should be minutely sought divorces himself from it as soon as possible, and cöntinues after. in the locality as a private practitioner, and this to some extent is held to justify the clubs in offering starvation terms. They regard what the young man is going to get out of "lodge practice" later as a set-off against his poor pay. But there are many who never can break free from Tt3rítt5b flieòícar a55OClatiOn. contract practice, and therefore are the servants of the societies to the end of their- days. As an instance of how VICTORIAN BRANCH. lightly "lodge doctors" are esteemed by the inhabitants of the New York east side, I was told by one of my informants that when an individual in a lodge, or one of his family, is At the ordinary meeting, Wednesday, November 5th, the thought to be seriously ill, the lodge practitioner is asked following resolution was proposed by the President (Dr. if he had not better call in a "real doctor." There are me- J. F. Wilkinson) and seconded by Dr. R. R. Stawell and dical men who engage in contract practice in New York carried unanimously. The motion has reference to the who make good incomes, but they have so many patients remarks made by the city coroner, Dr. R. H. Cole, at a that they are unable to attend to any of them properly. recent inquest on a death under anaesthesia at the Mel- bourne Hospital:— They must scamp their work. The great majority have to struggle hard to make both ends meet. "The members of the Victorian Branch of the British The root evil of the system is, of course, the method in Medical Association are of opinion that the remarks made vogue of electing "lodge doctors." The competition for the to Dr. Lambert at a recent inquest that 'there is no ne- cessity to hurry people out; human life must be respected positions is so keen that the medical candidates place themselves wholly under the thumb of the lodge leaders, even by the medical profession,' was quite uncalled for, thereby losing self-respect and the respect of their pa- and is a serious imputation on the profession generally. tients. Medical men themselves in the United States are That such remarks, if persisted in, will tend to deter well aware of this deplorable state of affairs, and, gener- surgeons and anaesthetists from accepting the responsibil- ity of operating in critical cases, ally speaking, are opposed to contract practice as now con- and may thus lead to the ducted. The conditions governing contract practice in New loss of lives that might otherwise have been saved. York supply a warning to the medical practitioners of The Branch, while agreeing that all cases of death un- Great Britain not to accept contract practice on a large der anaesthesia should be reported to the coroner, is fur- scale unless adequate pay is assured, and especially not to ther of opinion that it is unnecessary and undesirable to allow themselves to be dominated by the societies. hold a piubilc enquiry in every such case. The reporting in the public press of all such cases has a distinct ten- dency to frighten patients, and render them less fit sub- jects for anaesthesia, and thus to greatly increase the dangers of such anaesthesia; and the Branch would re- lady Ifiooko. spectfully urge the coroner to consider the matter from this standpoint." Dr. R. A. Stirling then moved—"That the same publicity "Clinical Bacteriology and }hematology." W. d'Este Emery, be given to the foregoing resolution as was given to the Lond. Lond.: H. K. Lewis; 4th Ed. coroner's remarks on the occasion noted." _ It is not ninny years since Dr. Emery's book first at- Seconded by Mr. R. Hamilton Russell, and carried tracted favourable notice and its rapid reproduction in unanimously. new editions is sufficient guarantee of its value. Of the A detailed report of the matter will appear next week. many handbooks of its kind, Dr. Emery's is easily first for the general practitioner, because of its lucid description and easy style. It is likewise a valuable guide for any laboratory course. The fourth edition is sure to be as LODGE PRACTICE IN NEW YORK. popular as those which preceded it, and is to be unre- servedly recommended to anyone seeking practical infor- mation on the topics with which it deals. A "Lancet" (October 5th) special commissioner says:— The regular rate of pay of lodge practitioners is 1 dol- "Materia Medics and Pharmacy." R. B. Bennett, F.I.C., lar yearly for an adult and 3 dollars for a married man B.Sc., London. Loud.: H. K. Lewis; 2nd Ed. and family. But the inadequate rate of remuneration is by This little book does not pretend to be more than a no means the worst feature of New York contract prac- convenient guide for medical students preparing for final tice. When it was in its infancy societies would send de- examinations and expected to know the general character legates to a medical man, requesting him to accept the and attributes of the drugs of the B.P. As such, it will position of "lodge doctor" for a fair and reasonable con- be found a reliable and judiciously arranged work. sideration. All this is now completely changed, and has been so for some time; the societies have now obtained the upper hand, and instead of the societies asking for his services, the medical man goes to the societies hat in CURRENT LITERATURE. hand begging for the work, or endeavours to curry fav- our with the leaders of the societies by more reprehensible Formamint in Oral Conditions. methods. In short, the ordinary "lodge doctor" is no A ship's surgeon ("Hospital") writes:— longer independent or self-respecting; he is to all intents and purposes the servant of the societies. In syphilitic cases my practice has been to supply the patient with a couple of dozen tablets and to direct him to This unfortunate situation is not wholly the fault of the suck one or two frequently during the day. A simple and medical man, but has been brought about, to a large ex- efficient mouthwash is made by dissolving a dozen tablets tent, by the superfluous output of medical graduates and in ten ounces of water, adding a few drops of tincture of the consequent keen competition among men. A young myrrh and a couple of drams of glycerine. If the mouth is man without money, who has just been given his degree, is rinsed out thrice daily with this solution, and a soft tooth- forced to take lodge practice, at any rate for a time, so as brush is used at the same time, no difficulty will he found to live, and the societies have taken advantage of his and in securing asepsis. The simpler and easier method, how- of his fellows' necessities to grind him and them down to ever, is to give the tablets, which may be sucked while the starvation wages. Indeed, the competition for election as sailor is on duty, and which appear to be highly efficient. "lodge doctor" has become so strenuous that candidates are stated to resort to bribery, direct and indirect, to ob- The preparation serves equally well in those cases of septic sore throat which are frequently seen in debilitated

November 9, 1912. AUSTRALIAN MEDICAL JOURNAL. 77,3 patients, especially in those who have suffered severely and loss of the child through birth pressure, elective from sea-sickness. Ordinarilÿ these cases are annoyances; Caesarean section before labour should be selected. No they resist treatment for many days and clear up only ease Should be considered as convalescent, or receiving when the patient has regained strength. The cure may be adequate attention, in which the patient after recovery much hastened by prescribing formamint, and by painting from parturition does not seek surgical advice and treat- the tonsils lightly with a weak solution of iodine. As a ment to permanently remedy the thyroid condition. The tonic the triple phosphate syrup in dram doses three induction of labour in these cases is seldom indicated as it times a day is an excellent adjuvant. Cultures made from is too slow and uncertain. The pressure of elastic bags the tonsils in such eases show usually a rich growth of increases the mother's nervous disturbance, and delivery streptococci, and it is an interesting fact that these clear of the child through a partially dilated birth canal ex- up very rapidly under formamint treatment. poses it to additional risk. In cases where degeneration I have had equally good results in the treatment of oral of the thyroid gland does not seem to be present, but an and faucal ulceration in malaria patients. It is usually increased secretion of thyroid material is formed, absolute stated that such ulceration is "malarial"; in the East, for rest and milk diet, sedatives, and the application of ice instance, a malarial sore throat is frequently diagnosed, over the gland, should be immediately employed, with the perhaps generally on quite insufficient grounds. The or- hope of improvement until the child can become viable. As ganism found in the excavated ulcers on the floor of the reported cases show, it is sometimes possible to check the mouth or on the tonsils is nearly always a streptococcus, thyroid activity by this means, and to bring the patient to a and it is probable that these lesions are ordinary strep- safe and spontaneous termination of pregnancy. tococcal sore throat, or ulceration supervening in patients whose vitality has been much lowered by the attacks of malaria. The ulceration on the floor of the mouth, gener- ally encroaching on the frenum linguae, is sometimes very GENERAL. intractable; in old patients, the thick, rounded edges and slight marginal induration may give rise to a suspicion of At the London sMedical Exhibition the exhibit of malignancy. Messrs. Burroughs, Wellcome and Co. was most interesting. After taking the usual precautions, such as removing any irritating jagged tooth or rasping tooth-plate, and attend- A recent and important addition to the list of "Tabloid" ing to the patient's diet, treating any gastric disturbance preparations is "Tabloid" Bismuth Subsantonate Com- that may be present, the treatment resolves itself into pound, which contains the well-known vermifuge santonin sterilising the mouth and promoting healing of the ulcer in the form of a stable and non-irritant bismuth salt as- by soothing applications. After cocainising the site, it is sociated with a dose of the laxative phenolphthalein. The advisable, in the majority of cases, to apply a solution of product is made with a chocolate basis, which makes it at- silver nitrate (ten grains to the ounce) or of tincture of tractive to children, and it is a capital example of scien- iodine (eight per cent.) to the ulcer itself, but even then tific modern pharmacy. Concentrated Diphtheria Anti- the ulcers take a long time to heal, and there is frequently toxin "Wellcome" is a great advance on the older anti- considerable scarring. It is in such cases that I have diphtheria sera, since it reduces the bulk of the dose by found formamint of decided value. By frequently sucking about 60 per cent. The latest "Wellcome" vaccine is a pellet, and making the formaldehyde saliva thoroughly Streptococcus Vaccine, Dental, prepared from several flush the floor of the mouth, so that it comes into direct strains of streptococci isolated from cases of pyorrhoea contact with the ulcer, a constant, mild, germicidal action alveolaris, and intended for use in that very common con- is secured which decidedly promotes healing. The patient dition. Of special interest in these days of renewed ac- should continue the use of the tablets for some time after tivity in tuberculin-therapy is New Tuberculin (W.), the ulcers have healed, as a recurrence is by no means in- "Wellcome," prepared by a process designed to render it frequent, especially in debilitated patients. at once more active therapeutically and more easily ab- There are many other oral conditions in which, on board sorbed than Koch's T.R. ship, the use of formamint is advisable, and as there are few drugs more easy to prescribe or more readily taken by Dr. J. W. Hope, the Principal Medical Officer to the patients, the provision of these tablets is almost a neces- Government of West Australia, in the annual report, says: sity for the ship's surgeon. In the tropics especially they "The hospitals of the State, for the upkeep of which the will be found available. Their frequent use in cases of Government are wholly or partly responsible, are classed "sailor's sprue," in which sometimes the condition of the as follows:-1. Hospitals under the 'The Hospitals Act, mouth almost baffles description, tends to ease the patient 1904," i.e., Perth and Fremantle, 2. 2. Hospitals, Govern- and to make him more comfortable, even though they ment departmental—Albany, Broome, Bunbury, Carnarvon, cannot be said to be curative. As a prophylactic against Coolgardie, Collie, Cue, Derby, Geraldton, Kalgoorlie, Law- influenza, diphtheria, and sore throat generally they are too lers, Marble Bar, Menzies, Northam, Onslow, Pinjarrah, well known to require commendation, but it has seemed Roeburn, Southern Cross, Wyndham, York, 20. 3. Hospi- to me that their use in the oral conditions above indicated tals controlled by local committees—Children's Hospital, is not so generally recognised. Perth; Beverley, Bridgetown, Broad Arrow, Bulong, Bus- selton, Davyhurst, Greenbushes, Kanowna, Katanning, Thyroid Disease in Pregnancy and Parturition. Kookynie, Laverton, Leonora, Meekatharra, Mt. Magnet, ait. Malcolm, Mt. Morgan, Moora, Nannine, Newcastle, E. P. Davis (Amer. Jour. Med. Sci., 1912, cxliii., 815) says Norseman, Peak Hill, Ravensthorpe, Sandstone, Sir Sam- that in examining cases of pregnancy, the condition of the uel, Wagin, Wiluna, 27. 4. Hospitals at timber mills- thyroid gland should receive attention. If this be mani- Jarrandale, :\lornington, and Yarloop, 3. 5. Consumptive festly enlarged or altered the patient's nitrogenous meta- Sanatorium—Coolgardie, 1. Total, 53. In some other bolism should be closely watched, and if evidences of lack cases hospitals are managed by local committees, to which of thyroid secretion be found, the active principle of the nothing is contributed by the Government, but the medical glands should be administered, best in small doses, 1 grain men who are under agreement with the committees are three times a day, continued for from four to seven months. subsidised by the Government. In all hospitals where the Our most reliable methods of ascertaining the patient's Government helps the finances, the care and treatment of condition, are nitrogen partition of the urine and the clini- indigent cases is insisted upon as a return for financial cal study of the condition of the circulation. Pulse ten- assistance. Assistance is rendered to 'many country hos- sion varies so greatly that it is not •a constant and reliable pitals towards the maintenance of buildings, additions and factor in diagnosis. The wishes of the parents should be repairs. Perth and Fremantle hospitals are wholly cared carefully ascertained regarding the life of the child, and for by the Government. In some of the goldfields districts the situation clearly explained to them. Where children the languishing of the industry has resulted in depopula- have bean lost in previous pregnancies, and the parents are tion to such an extent that no hospital could be considered desirous of offspring, allpossible means should be used to necessary for the needs of these places, but, being estab- continue the pregnancy, without undue risk to the mother. lished, there is a strong local feeling against their closure. If there is a history .of enlargement of the thyroid during Their continuance is more from sentiment than from a labour, with the development of unfavourable mechanism reasonable necessity, and it is based upon the hope that 774 AUSTRALIAN MEDICAL JOURNAL. \nvcinlier 9, 1912.

the mining industry there will in some way, not apparent Nrittgb at present, improve. The State is called.upon to pay enor- Alebicat ZU5ociAtiori. mously for the few cases that are treated there. A staff VICTORIAN BRANCH. must be maintained whether any patients are in the hos- pital or not. Benefactions left to charitable institutions Dr. A. E. R. White, 85 Spring-street, Melbourne, Hon. Sec. should be administered by a board of trustees, who, while carrying out the testator's or benefactor's intention, could arrest useless expenditure, conserve money, and apply it NOTICES. where it may sensibly do good. The only new hospital opened was at Moora, where the people contributed the WARNING NOTICE. bulk of the outlay. Casualty wards were put up at Lance- field and Ida H. The cost of hospital administration in Medical men are advised to communicate with Dr. A. this State is necessarily higher than in other States, owing E. R. White before applying for positions advertised by to the higher cost of living, the large number of small Bullfinch Medical Fund, W.A. hospitals, and the few cases treated in each—the cost is decreased proportionately to the numbers treated. Hospi- tals are established much closer to each other than in Telephone 1434 Central. other States. This may be influenced by the districts which are being opened up having a scattered population, who are putting all their money into their land, and do VICTORIAN BRANCH.—Ordinary Meeting, 1st Wednesday not possess the accommodation at home to look after any in month. sick. „ Clinical Meeting 3rd Wednesday "Cost of Treatment.—The cost of treatment of each pa- in month. tient in all Government hospitals during 1911 was £ 8 16s. 4d., equal to 75. 8%d. per patient per day, as compared PEDIATRIC SOCIETY.—Second Wednesday in month. with-1910, £ 8 14s. 6d., 7s. 8d. per day; 1909, £ 8 17s. 6d., 7s. 7d. per day. Assisted Hospitals-1910, £ 13 6s. 11'/2d., 16s. 7%d. per day; 1911,. £20 15s. 3d., £1 2s. per EYE AND EAR SECTION.-4th Wednesday in Month. day. State Contributed-1910, £4 Os. 11%d., 5s. Old. per day; 1911, £4 6s. 9d., 4s. 9d. per day. The per capita cost to the State of the maintenance of hospitals aimounted in Melbourne Hospital Clinical Society. 1910 to 3s. 11d.; in 1911 to 4s. l%d. The expenditure in (Fourth Friday in the Month.) other States in this direction shows that in the care of the sick, calculated upon the number of beds available and the cost per head, this State is ahead of the others, with N.S.W. Branch.—Last Friday in month. Queensland the exception. New South Wales, 3s. 8d., 4254 Queensland Branch.—Last Friday in month. beds; Victoria, 2s. 8d., 3,727 beds; Queensland, 5s., 2,472 S. Aust. Branch.—Last Thursday in month. beds; South Australia, 3s. 6d., 758 beds. A considerable W.A. Branch.—Third Wednesday in month. difficulty has been experienced in keeping up the staff at hospitals, through the greater number of women choosing Private to hospital nursing." males and females, by an addition of almost exactly eight years to the expectation of life at age 0, the increase in the The secretary to the Prime Minister's department (Mr. case of each sex being slightly less than four years be- M. L. Shepherd) is actively at work in making prelimin- tween 1881-90 and 1891-1900, and slightly more than four ary arrangements for the Congress in Australia in 1914 years between 1891-1900 and 1901-1910. The female ex- of the British Association for the Advancement of Science. pectation at age 0 exceeds the male in each decennium by Each of the States, except Western Australia, has appoint- practically the same amount, the excess being 3.645 years ed a local committee. Negotiations with Western Austra- in 1881-90, 3.679 years in 1891-1900, and 3.637 years in 1901- lia have been delayed, owing to the Government of that 1 State misunderstanding the proposals made for the stay of the delegates in the different capitals. Every State is anxious to entertain the visitors for as long as possible, PERSONAL. but they can be absent from their duties in Great Britain only for a certain time, and it is impossible to yield fully Dr. G. Cuscaden has been elected unopposed to the Mel- to the desire of all the States. It is anticipated that, when bourne City Council in succession to Alderman Burston. the Western Australian Government understands the posi- tion its arrangements will be pushed on with. For pre- liminary expenses, the Federal Parliament has voted Dr. F. Antill Pockley has returned to Sydney and re- £2,000. Half of this will be paid in salary and expenses sumed practice. to an organising secretary, who will be appointed from one of the universities. He will receive a salary at the rate of £400 .a year, and will be required to go to England. The wedding of Dr. Konrad Biller and .Dr. Buriel Da- vies was quietly celebrated on Wednesday, November 6th. Mr. G. H. Knibbs, Commonwealth Statistician, has com- piled figures from which he deduces the following con- Dr. Nicoll, who was appointed lecturer in Bio-chemistry clusions:--(Fhe expectation of life at any given age, ac- at the Tropical Diseases Institute, Townsville, has left cording to a specified mortality experience, is the number England'for Australia. of years on the average which the persons reaching that age will live beyond it. Thus, according to the figures given above, if the rates of mortality experienced in Aus- Dr. W. E. O'Hara has resigned his position as clinical tralia during the decennium 1881-90 remained in opera- assistant at the Alfred Hospital. tion throughout the lifetime of any group of males, the average period lived beyond age 30 by each of those who reached age 30 would have been 33.642 years; that is, the Dr. A. G. Black, of Carlton, who has been on a holiday average age at death of those who reached 30 would have trip to Europe, has returned to Melbourne. been 63.642 years. The corresponding expectations for the experiences of 1891-1900 and 1901-1910 are 35,110 and 36,520. The results obtained indicate that the improve- Dr. A. McCormick and Dr. G. E. Rennie will act as co- ment in mortality rates in the twenty years between the examiners for the M.D. and M.S. examinations in the Mel- decennia 1881-90 and 1901-1910 is represented, both for bourne University. November 16, 1912. AUSTRALIAN MEDICAL JOURNAL. 7(5

" °YROID FEEDING IN MENTAL The favourable cases lose weight quickly, but DISEASES. gain as rapidly owing to increased appetite, with the mental improvement. The following are the notes on the cases treated :- G. NAYLOR, F.R.C.S.E. 1. M.N., et 23, single. Admitted 4- 10- 10, suffering Officer, Hospital for Insane, Ararat.) from stupor ; was quite helpless and had to be tube- fed at first, and afterwards spoon-fed. This state aving used thyroid extract for several years, continued for a year, when thyroid treatment was while in private practice, with a fair amount of begun. In two months she began to converse, and success in cases of myxoedema, idiocy, obesity, and rapidly improved in all the intellectual faculties. latterly in cases of ovarian and uterine disease, I She was allowed home, and reports of sustained have been anxious to try it in cases of insanity, improvement continue. especially after reading of the success obtained by 2. A1.C.G., et 3o, single. Admitted 14-6-09; a Dr. Lewis C. Bruce in an article by him on the case of primary dementia Of catatonic type. She subject. appeared hopeless and used to assume cataleptic Since I came to this hospital 1 have used it in postures, remaining in one position for hours; would twenty cases, and have had 12 cured, 3 slightly im- not speak and had to be spoon-fed. Thyroid begun proved for a time, and 5 apparently uninfluenced 9-2-10; improved slightly in three months, but by the treatment. would not speak, although she worked well all clay. A month after this, after menstruating, she began The cases were all under 48 years of age and to converse quite sensibly. Was sent home, and some had been inmates here for io years. has remained well to date. Thyroid, as is well known, has, even in small 3. M.A.H., yet 28, single. Admitted 12-4-07; a doses, a very marked action on the system, as evi- case of mania. She has been for years the most denced by the increased blood pressure, and raised violent and refractory patient in this institution, and temperature and rapid absorption of the sub- was a source of danger to both patients and nurses. cutaneous fat; that .larger doses would cause a On two occasions she dashed out the brains of cats greater re-action has, in my series of cases, proved against the wall, and was regarded as quite incur- more than an assumption, and to this greater re- able. On 20-4-10 she was given 6o gr. daily; in-two action I attribute the mental improvement. In the months was greatly improved, and was considered cases which have shown no re-action to thyroid, no fit to work in the laundry. On 1-8-10 was not so mental improvement has resulted from the thyroid well, and on 15-8-to was given a second course of or other methods of treatment. thyroid; in two months was greatly improved, was Seeing that certain cases respond and others of able to do any kind of work, and was quite rational. apparently the same mental condition do not, the As she had no hone to go to, we kept her here till exhibition of thyroid would appear to be a valuable 15-9-12 for further observation, and during this time diagnostic aid. The much discussed term "De- she worked at my house. Her sister took her on mentia Precox" might well be reserved for the lat- trial leave, and got her a situation in this town as a ter class, and the more favoured "Primary Demen- servant, in which capacity she is doing splendidly. tia" for the former. 4. J.M.C.P., et 20, single. Admitted October, The method adopted in the administration of the 1902 ; primary dementia ( ?) . T'hyroi'd begun 28-3-II, drug was :- but up to this there has been no change and there The patient is put to bed and given gr. 60 Mag. was no re-action to the drug. Sulph. The next clay 15 gr. of 11.W.'s extract is 5. M.A.M., æt 31, married; primary dementia ( ). given three times a day after meals; this is repeated Thyroid begun 2-4- 12. No effect and no change in for four days, then the close is increased to 20 gr. her condition. t.d. for five days; the thyroid is then stopped, and 6. AI.A.I3., let 21, single; primary dementia, cata- the patient given plenty of nourishing food and tonic type; very restless at times. Started thyroid kept abed for a further 14 days. For a week he is 19-3- Io; improved slightly by 25 -5- I0; discharged

kept recumbent in the open air, and then allowed 25 - I - 11. to resume his usual mode of life. 7. I.P., æt 32, married; chronic melancholia. Was For the first three or four days there is head- treated for 2/ years for melancholia before being ache, pulse is full and quick, and the temperature sent here. Thyroid begun 10-9- 1o; on 14-11-10 im- rises to from 99 to lot° F. Some get very excited, proved slightly, but has no confidence in herself and it is difficult to keep them in bed. In one case and is not well enough to go out. the excitement was so great that the thyroid had to 8. S.A.S., æt 28, single. Admitted 27-12-09; be stopped after third day, but in a fortnight she primary dementia. Thyroid begun 9-2-Io; greatly became quite rational and was discharged, although improved by 4-3-Io. Sent home on trial and dis- prior to the treatment appeared hopeless. charged 1-4-II. There is no danger in the use of the extract, pro- 9. F.A.F., act 37, married; acute melancholia; vided the cases are watched carefully. The only was very suicidal. Thyroid started 6-10-09; im- period for care is the week after the drug is stopped, proved slightly by 12-12-09, and was able to work as in some palpitation is troublesome, and fainting in the flower garden. Sent on trial leave 2-4-Io, and is liable with the slightest exertion. discharged 25-I-II. 776 AUSTRALIAN MEDICAL JOURNAL. November 16, 1912.

to. D.I.B., 2et 42, married. Admitted II-5-09; months after treatment she brightened up consider- delusional insanity with marked sexual delusions; ably and took notice of things about her; her weight she was very troublesome, and no man dared go increased, but after six months she relapsed, and is hear her or speak to her. Thyroid administered on now quite demented. II-6-09; slight improvement followed, the sexual 20. factor becoming less marked; this state continued M.I.N., Let 23, single. Admitted 4-10-04; de- for months, and on 29-5-IO her mental state justified lusional insanity tending to dementia; thinks she is her being sent home; discharged 1-4-II. a boy and makes love to the nurses. Thyroid begun 1 3-3-09; had no effect on temperature, but towards 11. K.R., eet 45, single. Admitted 23-2-09; de- the end she had palpitation very severely, and had lusional insanity; is inclined to be violent at times. to be kept in bed for some time; brightened up a Treatment begun 24-3-09; improved temporarily little and was fit to go on trial for a month, but was and conversed quite rationally (on reception was returned, and is now quite demented. morose and silent), but in about 6 months she went back mentally, and is now hopelessly demented. Conclusions. 12. M.R., let 3o, married; primary dementia. Ad- mitted 26-11-08. Treatment begun 14-3-09. F'roni a Those cases which did not improve showed no re- action to the drug, while those that showed the state of lethargy, with disinclination to speak, she greatest increase of blood-pressure showed the became active and talkative; remained thus till greatest improvement ; this would 6-9-IO, when she improved enough to be allowed on seem to suggest that an increased nutrition of the brain cells results trial leave, and was discharged 25-I-II. from that increased blood supply, obtainable, I 13. M.M., iet 32, married. Admitted m-11-08; think, from the large doses only. primary dementia. She was dirty, and had to be All recent cases under the age of 48 years of age spoon-fed and was unable to attend to herself, and should be given a appeared to be in a hopeless condition. Thyroid course of thyroid, a treatment begun II-3-09; 6o gr. daily ; after second day be- which, I feel sure, would be reflected in an increased recovery rate. In melancholia, before the , came very excited, and it was so hard to keep her brain in bed that after third day thyroid was stopped, and cells give evidence of degeneration, the results are she was allowed to get up. By 25-5-09 marked im- very gratifying. provement was shown; she put on nearly two stone The series of cases is small owing to the com- in weight. On 9-6-09 went home on trial and was paratively small number of receptions in this hos- discharged I1-2-Io. pital. 14. N.F., æt 23, single. Admitted 4-9-07; prim- ary dementia (?) . Thyroid begun II-3-09; no effect; present state is one of dementia. A CASE OF RUPTURED AORTA. 15. A.I,.W. , et 3o, married; acute puerperal in- sanity with delirium. Admitted 15-10-08. Had to D. P. GREKNlL\\I, AI.B., elb. be spoon-fed or tube-fed for some time while weak (House Physician St. Vincent's Hospital.) mentally and at times violent. Thyroid begun (Under the Care of Dr. Alex. Lewers.) 23-3-09. This case had to be kept in bed for several weeks as palpitation was troublesome. No cardiac stimulant was used. On 15-7-09 she improved a I\1.L., Let 6o, labourer, was admitted to hospital at great deal, and was sent home on trial; discharged 12 midday. He had been in excellent health and 7-2-Io. had followed his usual occupation until that morn- 16. A.M.R., Let 44, married. Admitted 5-I-I I ; ing, when he was suddenly seized with excruciating delusional insanity. Put on thyroid 20-I-II, but pain in the chest. At the moment of onset he was after two clays it had to be discontinued owing to a stooping clown cleaning his boots, and pain was so temperature of 103° F., which turned out to be intense that he immediately carne to the hospital. typhoid. As soon as she recovered from this, she Previous to this he had had a few stabbing pains in went down hill quickly and is now quite demented. the same region, but had never experienced any- 17. I,.J.P. , Let 23. Admitted 5-4-II ; puerperal in- thing like the present attack. sanity. Was bad for some months after admission, Had not suffered from indigestion and had always and had to be tube-fed at times. Put on thyroid been a hard-working, temperate man. 4 8 I1 ; by I-IO-I I had improved a great deal and Somewhat troubled with constipation, but no putting on weight. Sent home on trial I I-IO-II, and urinary complications. has since then been discharged. Denied all venereal taint. 18. E.G., Let 35, married. Admitted 15 - io-ii. Was very excited and violent at times. Put on thyroid On Examination: T. 98, P. 8o, R. 28, D.P. 128. 22-10-11 ; improved slightly by 26-10-11; for a few Patient was a robust, muscular individual, and clays after this—during menstruation—was not so when first seen pain was so severe that he could not well, but improved again in a few weeks. Sent lie clown quietly, but rolled about in bed and got home on trial 11-2-12 and discharged 3-5-12. most relief while sitting up. 19. E.H., Let 22, single. Admitted I-II-04; adol- Tongue was coated, breath offensive, and there escent mania. Secondary dementia was on-corning was marked gingivitis. when thyroid was exhibited 10-3-09. For a few Pain was chiefly located posteriorly • low down November i6, t912. AUSTRALIAN MEDICAL JOURNAL. 777 between the shoulder blades at about the level of probe could be passed down along the descending the 7th dorsal vertebra, although there was no aorta between the middle and outer coats for a dis- spot of superficial tenderness in this region. tance of several inches. A careful physical examination of the chest re- There was absolutely no primary dilatation of the vealed nothing unusual to a man of that age. aorta at the sight of rupture, but the outer coat had been slightly stretched before it gave way through a Heart. —Apex beat 5th interspace in nipple line; no impairment of resonance to right of sternum. fair-sized rent into the left pleural cavity. The Mitral area clear with good muscular first sound, arch and descending aorta showed a typical intense aortic clear, but second reduplicated. syphilitic atheroma. All the other organs were fairly normal. Lungs. — Emphysematous. There was a small abnormal area of dulness situated chiefly behind the Remarks' by Dr. hewers.—The case pre- sternum, but also extending slightly to the right of sented some unusual surroundings which are of it at the level of second costal interspace. No mur- interest, and I have asked Dr. Greenham to publish mur could be detected over dull area, and there was his notes. My own knowledge of the case was as no thrill present. Radial pulses were synchronous follows :—On the evening of September 22nd, Dr. and equal. Tibial and radial were also synchron- Douglas, who was in temporary charge of the ous. There was no tracheal tug. medical wards, asked me to see the patient as he felt in some doubt as to the nature of the pain. I Abdomen. — Marked tenderness and rigidity of epigastrium. Liver slightly enlarged and gall blad- found a big-framed, well-nourished man lying bent almost double in an attitude of acute pain. When der not palpable. asked where the pain was he referred it vaguely to Reflexes.—Knee-jerks—equal but diminished ; the epigastrium and lower thorax by sweeping his plantar—flexor in type. Pupils dilated but equal hand round in a circle with the lower end of the and react to light and accommodation. sternum as a centre. Dr. Douglas, on admission, Urine. — Reaction acid, S.G. 1025; no abnormal had regarded the case as anginal in character, but constituents. the patient had since twice vomited and appeared Late in afternoon of day of admission the posi- extremely tender in the epigastrium, to which site tion of pain changed and became entirely abdom- the pain was now referred. inal. However, at all times there was an indefinite- On examination, the patient complained of ness about its localisation, and even when in agony general abdominal tenderness and flinched to pres- he could not lay his hand on any superficial area sure, but there was no maximal point. The liver and say the pain was under it. Subsequently it ap- was not enlarged. The arteries at the wrist were peared to bé chiefly epigastric, and the tenderness thickened. The heart sounds were clear. No ab- and rigidity in that region were so marked that to normal area of dulness was made out. The pulse- anyone seeing him for the first time a perforated rate was 84, regular and sustained. The case was ulcer would at once have been suspected. tentatively regarded as at all events not due to any Throughout the next three days he was much acute abdominal crisis, and morphia gr. % was more comfortable. Pain was practically constant, given, with hot foments. but was not so severe as before, except for occas- On the following day the pain was still present, ional sharp twinges which did not last more than though it had been much relieved and patient was a few seconds. It was still abdominal and seemed comparatively comfortable. The physical signs to be relieved by the application of hot fomenta- were as noted, except that the pulse-rate had quick- tions to the epigastrium. ened to 104. The next morning the condition was The bowels were costive, but were kept open by much the same. Dr. Greenham, who had carefully the use of aperients and enemata. observed him, felt convinced the pain was thoracic in origin, but personally I confess to thinking it Early on the fourth morning, while sitting up to would turn out to be abdominal. Acute pain, as take a drink, he suddenly complained of severe pain the result of a dissecting aneurism, is, of course, in the left side of chest, fell hack on the bed and well established, but it is doubtful if the diagnosis (lied within a few seconds. is ever confidently made. The feature of interest Post-mortem findings :—The whole body was ex- here was the close simulation of some crisis in the tremely pale, there being no colour even in the upper abdomen and at autopsy the distance for mucous membranes. On opening up the thorax the which the arterial coats were separated. left pleural cavity was found to be full of blood consisting of huge clots; there was also haemor- rhage into the mediastinal tissue. ABSTRACTS FROM THE FIRST REPORT ON Heart: Slight hypertrophy of left ventricle; THE FACTORIES ACTS IN TASMANIA. valves all healthy and muscle good. There was some slight dilatation of ascending (By J. S. PURDY, M.D., Chief Medical Officer.) aorta, and just beyond the left subclavian artery there was a rent in the inner and middle coats The object of "The factories Act, 1910," was which almost completely surrounded the aorta. The mainly to improve the conditions under which all rupture had commenced in an old atheromatous workers, including women, young persons, and ulcer, which had weakened the vessel walls. A children, were employed in factories. 778 AUSTRALIAN MEDICAL JOURNAL. November 16, 1912.

The object of "The Wages Boards Act" was to and Wages Boards Acts, if such were to prove either maintain at, or, as in the amendment, raise workable and attain their intention. Of these the standard of wages to a fair and reasonable level, amendments, "The Factories Act, 1911," came into whilst at the same time enabling employers and force on the loth January, 1912, whilst "The Wages employees, through accredited representatives, to Boards Act, 1911," was made effective on the 14th adjust any differences without causing a general or September, 1911. By the amendment the word local economic disturbance, Although similar as to "factory" was more clearly defined. The omission their provisions to those in the other Australian of the words "working at, dealing with" cleared up States, the Tasmanian Acts were made applicable much ambiguity. The use of special motive power, to the whole State, and not limited to districts or unless such exceeds one horse-power, is no longer areas proclaimed, as in New South Wales, Queens- sufficient irrespective of the number of employees to land, and -Western Australia; or, as is the case in constitute any place a factory. Works for the Victoria, confined as to their operation to cities, generation of gas and electricity are now specifically towns, and boroughs, with the power of extension mentioned as included under the definition of fac- to shires or parts thereof. The original Act, which tory—an important point which it is realised that provided for the registration of all factories within the registration fee for every factory in which not three months after the Act came into force, was more than six persons are employed, and for which only limited as to its application by the special the motive power is obtained from a factory already exemptions from the somewhat drag-net-like defini- registered, is 2s. 6d. ; in contradistinction to los. tion of a "factory." wrhen the motive power is obtained from premises Any building, structure, premises, or place, in- unregistered. cluding any laundry, in or in connection with which By the non-registration at first of gasworks and four or more persons (including the occupier—or, in power-stations the fee of 25. 6d. could not be ac- the case of the Chinese or other Asiatic race, any cepted from small factories obtaining power there- one or more persons) were or was employed, direct- from, whilst in cases where tos. had been paid, ly or indirectly, in working in any handicraft, or in when such power-supplying factories were shown preparing, working at, dealing with, or manufactur- to be registerable, 7s. 6d. had in some cases to be ing articles for or in connection with any trade, or returned, necessitating extra and complicated book- for sale, was a factory. keeping. In addition to every bakehouse and every clay-pit By the amendment exemption was given to or quarry worked or used in connection with and "smelting- works or any works" within the meaning occupied with and occupied by the occupier of any of any Acts relating to mines and mining. pottery or brickyard, the use of any motive power Exemption was also given to any building in other than manual in preparing, working at, dealing course of erection or any temporary workshop or with, or manufacturing articles for trade or sale, or shed for workmen engaged in the erection of such packing them for transit, brought any building, building. The effect of these amendments must be structure, premises, or place within the definition remembered in contrasting the records of factories of factory. The term did not include any prison, registered for 1911 reformatory, industrial school, or home for erring and 1912. women, any charitable institution, ship, mine, dairy, Benefits Sought to be Conferred by the Acts. or premises used for pastoral, agricultural, or hor- ticultural purposes when the last-mentioned were The legislation enacted has provided for better situated outside cities or towns. supervision as to sanitation in factories by prescrib- Although the words "working at, dealing with" ing by regulation that the minimum amount of might have been construed to include ordinary re- cubic space for each person employed shall be 400 tail shops, it was obvious, from the other sections cubic feet, and that premises shall be ventilated so dealing therewith, that such was not intended. as to render harmless (so far as practicable) all the gases, vapours, dust, and impurities generated With regard to the exemptions, it was found that therein that may be injurious to health. P,y regu- certain smelting works came under the Act, where- lation it is prescribed that for each worker there • as others did not. shall be inlet and outlet ventilation, each equal to 12 Threshing-machines were registerable when situ- square inches. These regulations, together with the ate in towns; not in the country. Certain chemists provision that heating appliances in factories, whe- had to have premises registered, in addition to those ther used for warming persons therein engaged or of wholesale manufacturing chemists. Dentists for a manufacturing process, shall be provided with using an electrical machine of one horse-power or a flue of such size and construction as has been less also came under the Act. As the result of the prescribed, are of special importance when it is rea- first few months' working of the Acts, and in view lised how the absence of such provisions, together of some obvious defects, omissions, or anomalies, as with long hours of employment in factories, affected well as interpretations by the -Solicitor-General of the health of the workers, more especially women certain clauses (more especially those referring to and children, in large manufacturing centres in the definition of "factory"), the fact fhat no offence more closely settled countries with old-established was committed by non-payment of the minimum industries.' This fact is illustrated by occupational wage and the retention of the "reputable employers" mortality statistics. clause, necessitated amendments of the Factories Provision is also made for satisfactory privy and November 16, 1912. AUSTRALIAN MEDICAL JOURNAL. 77 9 urinal accommodation for each sex, proper appli- Medical Examination. ances for the extinction of fires, sufficient means of With regard to medical examination, before corn egress in the case of fire, and the efficient lighting is required as to-mencing work a medical certificate of factories with natural light where reasonably fitness of persons under 16 for employment in practicable. foundries, manure Any building or place which at any time after aerated water works, breweries, "The Factories Act" carne into force, or which after works, and bonemills. a period of disuse is about to again become a fac- It is interesting to note that under "The Federal tory, must be certified to in writing by the Chief Compulsory Service Act" all boys at 14 years of Inspector as suitable for a factory, and comply with age have to submit to a medical examination, and the requirements prescribed for new factories, again at i8 years of age to a more stringent medi- which are such as to ensure satisfactory construc- cal examination as to fitness for military service. tion and maintenance for the various purposes of different trades. Education of Girls Employed in Factories. Limitation of Hours of Adult Workers. There is no such uniform examination for girls, A week of 48 hours has been fixed as the working who also do not receive the other advantages of week, which in the case of adults may be exceeded, physical training and discipline such as boys now provided that not less than time and a quarter rates receive. This suggests that when the school age is be paid for such overtime. Work beyond 10 hours raised to 14 years. in conformity with "The Fac- a clay, or for more than five hours continuously tories Act," the provision of evening continuation without an interval of one hour for a meal (break- classes for girls from 14 to 16 years is worthy of fast, dinner, or tea), is not permitted, except in the consideration. Training in cooking, domestic econ- case of a worker getting up steam or making pre- omy, infant nursing, physical culture, and kindred parations for the work of the factory. A half-holi- subjects, if special compulsory provision were made day (almost universally observed on Saturdays) is therefor, would counteract to some extent the compulsory for all factory employees. acknowledged unhealthy effect of factory life pn girls, especially those of poor physique; and at the Employment of Children in Factories Prohibited. saine time add to national efficiency, which so much Under the 1911 amendment, by altering the defi- depends on the physique and training of girls, the nition of `child" to mean a person under the age of future mothers of the best immigrants to Australia 14 years, the age permitted for commencing em- —children born and bred in the land. ployment in a factory was raised from 13 to 14 At the end of June, 1912, there were 938 factories years. At the same time it was enacted (without registered, with 7851 employees, 6251, or 79.62 per the reservation which in the original Act contem- cent., of whom were males, and 1600,- or 20.38 per plated the possibility of permission being obtained cent. females. Thus, there was a slight relative pro- from the Chief Inspector) that "No child shall be portional increase of male- employees for 1912, employed in any factory." partly accounted for by the fact that no female chil- dren under 14 were returned as employed in fac- Children Employed. tories in 1912 : whilst there were eight females, or .5 The registrations for 1911 showed that there were per cent. of females employed, or .13 per cent. of 44 males and 8 females employed under 14 years of all employees, in 1911, and still 23 male employees age in factories in Tasmania. 'raking the number under 14 at the beginning of 1912 employed in con- of all employees under 14 years of age this worked travention of the Act. out at .67-per cent. of all factory employees. Of fe- At the time of issue of the application forms for males employed under 14 years of age the per- registration for 1912, the new abstracts had not been centage was .5 of all females employed, or .13 per printed and circulated drawing attention to the cent. of all employees in factories. Of male em- amended clause prohibiting the employment of any ployees under 14 years there were .71 per cent. of person under 14 in a factory. Whenever attention all males employed, or .57 per cent. of all employees has been drawn to this breach of the Act the chil- in factories. The largest number of boys under 14 dren have been discharged. It was not found that in any one trade in 1911 was eight in the printing, any of the 23 children received less than the mini- bookbinding, and stationery trade. Consequently mum wage. In the most recent case to come under

the alteration, by the amendment of "The Factories • the notice of the Department—that of a boy and a Act," by which the age of commencing work was girl, each under 14, employed in a woollen mill— raised to 14 and child labour prohibited in factories, the weekly wages up to the time of discharge were although affirming an excellent principle, did not 9s. and 8s. respectively. As notices in each case affect to any great extent employment in this State. sufficed to secure discharge, and representations Whatever may have been conditions as to child. em- were made to the effect that the change in the age ployment previous to the introduction of "The Wo- of commencing employment had not come under the men and Children Employment Act" (now re- notice of the occupier, it was considered unneces- pealed), either factory occupiers at the time when sary to take proceedings. "The Factories Act" took effect did not seem to have made any great demand for such labour, or *Presidential Address, Public Health Section, Austral- parents did not encourage their children to take up asian Medical Congress, Sydney, 1911,—"Australasian factory work at that age. Medical Gazette," October, 1911,

780 AUSTRALIAN MEDICAL JOURNAL. November 16, 1912.

effect of a week of comparative detachment from 2uStrattan fliebtcat journal the whips and scorns of time is incalculable. Its anticipation might well sustain a spirit through z6th NOVEMBER, 1912. weeks of solitary existence on sun-burnt plains and wind-swept wastes, or in the endeavour to win a footing from the forest primeval ; while its realisa- THE SPIRIT OF CARNIVAL. tion carries back to the same environment a never- failing mine of mental reminiscence : nor is the To the professors of political economy may be change of mental occupation less actual to the left the discussion as to the effect upon the wealth majority of inhabitants of the cities and towns. The of the community produced by a period of pleasure first week of November in Melbourne represents a and frivolity such as is represented by the "Cup" festival that is probably unique in national gather- week in Melbourne. Even if it be somewhat in- ings, and in any estimate of its influences for good conclusive, it is not an uninteresting speculation as or evil the far-reaching mental stimulation of popu- to the possible effect on the health of the com- lar carnivals in general, and This in particular, is a munity, and it is probable that the findings would feature worthy of more than cursory examination, be of a less pessimistic nature than those which and one that almost certainly lifts the national bene- force themselves upon the minds of the followers of fit on to a plane that is altogether beyond the vision Adam Smith. of critics, by whom the spirit of carnival is coldly condemned. If it should be objected at the outset that there is too much to eat and too much to drink at such a season, let the obvious fact of temporary hyper- alimentation be granted. If it should be urged that the hours of sleep are unduly curtailed, let such a POteg anb (Comments. palpable truth be accepted without protest. These, after all, are but minor costs to pay for a general The resolution of protest passed by the benefit, if such there be discernible. What is the Death under Victorian Branch against the attitude of real significance in the spectacle of staid and sober Anaesthesia. the Melbourne city coroner at a recent in- quest, although somewhat over-burdened, citizens suddenly and simultaneously ceasing to was temperate and dignified. The medical profession have any interest save in the discussion of the rival of Victoria has never found fault with the prin- merits of horses of which a few days ago they had ciple of coronial investigation of deaths under anaesthesia, although its practice has sometimes been pointed out as never heard and in a few clays more will have en- actively objectionable. tirely forgotten ? And even those to whom With the suggestion which has been made, that all the racing spirit and practice are anathema, seem deaths occurring within an hour of operation or anaesth- willing to catch something of the prevailing air of esia, be reported, there need be little sympathy. It would detachment from every-day affairs and to give be almost as useful to require that all deaths happening themselves up to within an hour of taking a dose of medicine be investiga- temporary distraction after their ted. There is no logical reason why the arbitrary period own manner. of one hour should have more value than one minute or one Almost without question it is in this detachment month. From the point of view of the anaesthetist, the claim is scarcely entitled to be considered. The anaesthetist is from the daily round that the aggregate benefit to only present to enable the surgeon to perform what the the community is derived in the case of a general latter thinks is requisite. If the surgeon is satisfied that pleasure-seeking of this character. The monotony of what he considers advisable has been done, or left undone, living becomes at times insupportable in the ag- and the patient has recovered consciousness, the anaesth- gregate, as well as the individual, existence. The etist has no further responsibility. The case belongs again wholly to the surgeon. It would be an altogether festivals of all peoples, savage or civilised, are not insupportable position for the anaesthetist to be allowed merely animal orgies, born of a reversion to a for- to report such cases apart from the surgeon. It is right mer lower existence. They represent in part, at that an anaesthetist should take an interest in his work, least, a psychical demand for large emotional im- but it is equally desirable that he should not become a pressions, by means of which the depressing influ- busybody dealing with matters that are not his concern. ences of monotony are dulled or dissipated. Too * * * * sustained concentration on individual tasks leads The provision of radium by the govern- inevitably to irritation and breakdown. Too pro- Radium ment appears like a good many other poli- longed continuance in individual routine produces at Hospitals. tical intrusions into technical matters—to have begun with large promises and to be apathy and inferiority of effort. The same is true of likely to end with poor performance. The matter has been toil in the aggregate. Intense public concentration under consideration for more than a year. A committee of eventually relieves itself in violence, either of words hospital representatives reported against any large ex- or deeds. The wearing repetition of daily per- penditure on radium, and considered that about £ 1,500 worth at one or more hospitals would best meet practical formance calls aloud at times for frank frivolity. requirements. Now it is stated that the Premier is only Doubtless there are some features in all saturn- willing to give radium to a single hospital, and to what alia that are deplorable. Such may be left to the amount is not set forth. Such a proposal should be un- hesitatingly condemned by the profession. Government moralists. Possibly it is true that all such manifes- assistance to charitable institutions must be impartially tations are economically unproductive. The econ- distributed. There can be no singling out of particular omists may be covered with confusion by the as- instances. If a certain hospital be given a government sertion that 'all work" makes a dull boy. In radium monopoly to-day, it will be some other exclusive support that will be demanded to-morrow. If the govern- such a land a s our own' the stimulating mental ment is going to supply only one amount of radium, it November i6, 1912. AUSTRALIAN MEDICAL JOURNAL. 781 should be placed in working in a separate institute and Mr. Atlee Hunt, Department of External Affairs, asked apart from all existing hospitals. It is against all medical for the views of Council re the position and rights of the custom and tradition that hospital surgeons or physicians Chief Medical Officer in connection with inmates of the desiring radium treatment for their patients should be Port Moresby Hospital. Council decided that patients en- asked to place them under the staff of another hospital for tering hospital who are in a position to pay private hos- that purpose. pital fees should be charged fees by their medical atten- dant. Dr. Andrew Honman, on behalf of sub-committee, read a report giving further data upon which intermediate hos-hos- Jfirítta Aieàíco.Y gtocíatfon. pitals could be established. VICTORIAN BRANCH. EXTRACTS FROM REPORT OF INSPECTOR-GENERII, PROCEEDINGS OF COUNCIL. OF INSANE, VICTORIA. Council meeting held on October 30th, 1912. During the year the numbers of the registered insane Present:—The President (Dr. Wilkinson), and Drs. Mol- rose from 5,349 to 5,449—an increment of exactly 100— lison, B. Smith, Boyd, Hiller, Laurie, Lewers, Anderson, which compares favourably with the increment of 1910, Syme, Honman, Stawell, Kenny, Fetherston, Ferguson, i.e., 149, and is also below the average annual incrment Stephens, Wood, and White. of the last seven years—approximately 113. New Members Elected:—Stanislaus E. A. Zichy-Woin- The numbers in the State hospitals have risen by 60; of arski, Chas. A. Stewart, Phillip 'Aloysius Parer, Andrew S. those on trial leave the numbers have risen by 42; there Young, J. A. C. Welshman, Henry W. J. Cook, Martin W. has been a decrease of 3 in the number boarded out, an Ratz, Wm. W. McLaren, James I. Rowan, James J. Nicho- increase of 7 in the private licensed houses, and a decrease las, Wm. M. Clayton, Alfred Fay Maclure, Percy Denton of 6 in the number of those out on trial leave from the Fethers, Jas. J. 'McEniry, Keith G. Colquhoun, Aylmer E. latter institutions. The net result of these changes is .a B. Gaffney, F. E. Hutchinson, Alex. Sandison, Norman L. total increment of 100 for the year. G. Wilson, J. Jamieson Black, Albert H. Hughes, John L. An improved recovery rate and a slightly increased Atkinson, John G. Mackenzie, Joseph H. Wolfenden, God- death-rate are elsewhere commented upon, but it is un- frey E. Garde, Godfrey U. Taylor, Lionel B. Daly, Mary fortunately necessary to point out that the ratio of the Glowrey, Margaret H. W. Robertson, Harry F. Green, insane to population is now 1 in 245. Thomas Roberts, Andrew J. Brenan, Ulrick A. Daly, David Murdoch, David P. Greenham, Harrie B. Lee, Robert Oliver Mont Park. Douglas, Henry J. Williams, Frances J. Burns, Walter F. The acquisition of the Mont Park and Strathallan Es- Brownell. tates has given the Lunacy Department a magnificent pro- Canon Godby wrote accepting, on behalf of the commit- perty of 1200 acres for the purpose of erecting a new tee of the Cotham Road Intermediate Hospital, the sug- instiution or series of institutions. The land is situated gestions made by Council, but suggested that the wording beyond Heidelberg, and lies between the Upper Plenty- of Rule 9 should read, 'The Hospital Management shall be road and the Greensborough-road, and is but 9 miles from satisfied as to the circumstances of every applicant . . . the General Post Office, Melbourne. It is reached by train and will not admit, etc., etc.," Accepted. either from Regent or McLeod stations, the latter station Dr. Edwards, resident medical practitioner of Bullfinch, bordering on the property. A railway siding has been con- W.A., telegraphed a "warning notice" against medical men structed from Mcleod, by which goods are now delivered accepting a position from the Bullfinch Medical Fund. at a private station in the heart of the property, and it is Dr. R. H. Todd, of N.S.W., has received a letter from the hoped that this 'private line—some three-quarters of a mile "organiser" of the LoyalOrder of Moose proposing to dis- in length—will shortly be available for passenger traffic pense with medical benefits for the "order." also. Dr. E. Brooks, Hon. Secretary of the Tasmanian The land is, generally speaking, of excellent character, Branch, forwarded a resolution that the Federal Govern- and well adapted for asylum farming, and a good area will ment be asked to grant £ 10,000 yearly to endow original be available for sewage irrigation. Gardens and orchards medical research in the Commonwealth. Referred to the will be possible on quite an extensive scale. Federal Committee. The water for domesticpurposes will be from the Dr. Hornabrook forwarded a "true copy" of a letter re- Metropolitan Board's supply, and a 6-in. pipe has been laid ceived from the resident medical officers of the Mel- from the Yan Yean aqueduct to a site at the top of Sugar- bourne Hospital, stating that they were appealing to the loaf Hill. Here provision is being made for a storage re- Melbourne Hospital Committee for a full enquiry into the servoir which will give at least three or four days' supply statements made by Dr. Hornabrook at the coroner's court for a 'population of 3,000 people. By this means an excel- on 24-9-'12. Letter received. lent pressuz'e will be obtained for fire extinction purposes. Every effort will be made, however, to conserve and make Dr. Hiller, Hon. Secretary to the Hon. Staff of the Mel- use of all roof water. bourne Hospital, forwarded the following resolution passed by the staff:—"That the Victorian Branch of the B.M.A. Two neat cottages for resident officers have already been be asked to consider the attitude of the coroner, Dr. Cole, erected, and four more are in process of erection. They with regard to the giving of anaesthetics by the members are all pleasantly situated on the Upper Plenty-road, and of the Association." Council deemed it advisable to have in the immediate vicinity of the new farm buildings, the this matter discussed at the next ordinary meeting of the first block of which is practically complete. This block which is designed for 160 patients of the class that are Branch. usually employed in the farms and gardens, is built of Mr. G. T. Allen, Secretary to the Commonwealth Trea- concrete, and consists of a group of four cottages, each of sury, wrote, by direction of Mr. Fisher, asking this Asso- which will contain 40 patients. These cottages are placed ciation to kindly draw up a circular containing advice round a central block which is made up of an office in which would be useful to women before or after the time front, with waiting-room, recreation-room, and quarters of the confinement, which could be published by the Go- for staff. Behind this is a large dining hall, with kitchen, vernment. Referred to a sub-committee to draw up the scullery, and stores. This block will be lit by electricity, proposed circular. which will be supplied by a Lister-Bruston set, which ap- \lr. T. W. Holmes, Secretary to the Public Health De- parently acts quite automatically, and needs but little partment, asked Council to nominate a medical man of supervision. The principal supply for hot water will be standing to represent the Government of Victoria at the from a large "Ideal" boiler. Attached to each cottage is a Australasian Medical 'Congress at Auckland in 1914. Pro- properly-connected sanitary spur, consisting of lavatory, fessor H. B. Allen, Dean of Faculty of Medicine, was water-closets, dressing and bath rooms, the latter being nominated. supplied with both plunge and spray baths, 782 AUSTRALIAN MEDICAL JOURNAL. November 16, 1912.

On one side of the property, sand and gravel pits were for the maintenance of patients, and for fines, sales, etc., a found, and along the Darebin Creek a good quarry was net weekly cost of lls. 7 1/2d, is shown. The weekly cost for opened, from which blue metal is being obtained for the 1910 was 11s. 1 1/2 d., and for 1909 11 s. id. per patient. making of roads and also for the concrete work in con- The Master-in-Lunacy collected £ 17,974 8s. 5d. for the nection with the first block. A road has been made run- maintenance of patients in the various institutions, and ning through the centre of the estate from the entrance on £994 4s. 4d. was received from the various hospitals for the Upper Plenty Road across to McLeod Station, with a the Insane for fines, sales of produce, etc. branch leading off in the direction of Heidelberg. These The work of the Lunacy Department during 1911 has been roads have been largely planted with plane trees on either in no way lighter than in preceding years; in many ways side, and around the margins of the estate extensive pine it has been heavier; the increased admission rate with an plantations have been made. increasing accumulation of incurable cases demanding The second block of buildings has been commenced, and more accommodation which, owing very largely to build- should be completed before the end of 1912.. It consists ing difficulties, is becoming almost impossible to com- of a central office block, with a kitchen and dining hall plete. behind. There are four patients' blocks provided-two on Continual efforts are being made to improve the sani- either side of the central block. The total accommodation tary arrangements in the various hospitals, and it is a of this portion will be for 140 patients, and it is intended great pity that we are unable to do everywhere what has to use it principally for those patients who contribute the been done successfully at Ballarat, i.e., install a water- greater part, if not the whole, of their maintenance charge. borne sewage scheme with irrigation and cultivation of It may be necessary, in the first place, to utilise the whole land with the effluent. New sanitary spurs containing block entirely for female patients, but this will depend properly constructed closets, lavatories, and baths are be- very largely on the demands made on the Department for ing erected at Kew, Sunbury and Beechworth. At Bal- additional accommodation. larat, the old mess-room for the attendants has been con- Plans are being prepared for the erection near the rail- verted into a dayroom and dormitory for male patients, and way terminus of a large central administrative building, good sanitary accommodation has been added; on the fe- which will contain offices for the :Medical Superintendent, male side, water closets opening out of the dormitories Secretary, and clerks, with waiting-room and quarters have been added for night use. But, unquestionably, if above for the Medical Officer and a resident clerk and Kew is to remain the important receiving institution it messengers. Behind this building, and directly attached to now is, a complete water-borne sewage scheme should be the railway platform, will be built a central stores block undertaken there; it is the more possible now that a main in the basement of which will be cold storage tellers. Next 'Metropolitan Board of Works drain runs through the Hos- to this block will be the workshops, with a coal store at- pital grounds, as it would be very easy to make the neces- tached; and, further still, provision is being made for a sary junction. large central laundry which is being planned in such a During the year your Government gave permission to manner that only so much as is absolutely required for Dr. W. A. T. Lind to go to Europe to advance his know- immediate needs will be built, as the plan will permit of ledge in the pathological side of insanity, in order that on extensions being :made from time to time without inter- his return he might take up the work of Departmental fering with the work in the portions already erected. Pathologist. Steps have been taken to outfit the labora- All these buildings, which have been started and plan- tory at Royal Park, which will be the headquarters of the ned, should be ,finished in 1912, although it must be con- scientific work of this Department. A library has been fessed that the difficulty in obtaining labour in this area started on our special subject, and it is hoped that we has been very considerable in the past. shall be able to store there all the principal modern works An excellent site has been reserved for the erection of and magazines dealing with insanity and its allied sub- the main asylum, which will give the necessary accom- jects. I have to acknowledge the enthusiastic help of Drs. modation for 720 patients of the more troublesome and un- Hollow and Callander in this direction, and I cannot help satisfactory character. It will consist of twelve pavilions, mentioning the excellent workwhich is being done by arranged en echelon—six for each sex. On either side, the latter gentleman in his inquiries into the heredity causal factor. two will contain 40 patients, two 60 patients, and the outermost two in each case will contain 80 patients. In all An elaborate investigation by Dr. Catarinich has been probability, hospital wards will be constructed later in undertaken at Sunbury into the prevalence of tubercle connection with this block. The administrative portion amongst the patients at that institution. He has used the will consist of a small reception ward, operating theatre, Von Pirquet reaction in 825 cases. The results contained visiting rooms, dispensary, messrooms, and a main kitchen, in his paper, which was accepted at the Triennial Congress arranged in one straight block dividing the two wings of of 1911, seem to prove that institutional life of the best the echelon. The kitchen will be a special feature, and character, i.e., where there is no overcrowding and excel- will have attached to it a large bakehouse. It is thought lent ventilation, does not tend to produce tubercular dis- that by providing •a kitchen and bakehouse we shall be ease, nor does it render the inmates especially liable to the able to obtain a greater variety in the dietary. bacillus tuberculosis. It is estimated that this large block will not cost more Taken on the whole, the year's work has been of a satis- than £ 130 per bed. It will probably take three years to factory character, but one cannot feel that as much atten- complete, and it is hoped that when it is erected it will tion should be paid to the prevention as the cure of in- be possible to entirely shut up Yarra Bend, which, having sanity. The problem of the feeble-minded, which is exer- started in the earlier days of the colony, may be considered cising the minds of alienists, philanthropists, and econ- to have earned an honourable repose. omists in other countries, is coming before the public so much more clearly that it is certain that it must engage The usual tables showing the expenditure of the De- the attention of the legislators also in a very short time. partment are appended. These tables show that the ex- The right understanding of the problems of heredity, and penditure for the year exceeded that for 1910 by £5,095 the putting into practice of the knowledge so gained, will 2s. 11d., the expenditure for the year under review being have as powerful an effect effect in producing a sound and £ 174,269 4s. 3d. Nearly the whole of the additional ex- healthy stock as will the improvement of our environ- penditure was for salaries. As was anticipated in last ment. In my first criticism of the Lunacy Act I pointed year's Report, further concessions to the staff as regards out (Annual Report for 1905) the necessity for separate salary and leave have been made. Additional leave hav- legislation for defective and feeble-minded children; I now ing been approved for the attendants and nurses, it was see that it would have been wiser had I used the term necessary to make additional appointments on the staff, "feeble-minded person ' which resulted in a considerable increase in the salary s." 1 am more and more convinced that the feeble-minded woman, and what one may also payments for the year. The other items of expenditure call the high-grade imbecile, the chronic inebriate, the de- have not varied to any appreciable extent as compared with former years. generate ne'er-do-well, are all of a class more dangerous to the nation from a eugenic point of view than any other The average weekly cost for maintenance of patients is class of person. I am fairly sure that the increasing wave shown in Table XXIII. For the year 1911 the weekly cost of accumulated insanity, which is the result of more than a was 13s. 1%d.; deducting from this the amount received century's abortive attempts at cure merely, will only be November 16, 1912. AUSTRALIAN MEDICAL JOURNAL. 783 diminished when the three principal sources of supply are large mononuclear cell and enters. It then becomes .mo- attacked. These are (1) the evil of defective inheritance; tionless, grows bigger, and develops a distinct mantle of (2) the prevalence of venereal disease; (3) intemperance. protoplasm around itself. The development goes on with- The special education of the feeble-minded children is, in and at the expense of the protoplasm of the mononu- in my opinion, highly desirable, not only that they may be clear cell, the nùcleus of the cell always remaining intact. made more useful and happy, but that, as a prelude to The degenerated protoplasm forms an envelope around the permanent segregation, they may be separated from those sporozoite, which has to be gradually increased in size who are merely backward from accidental causes. according to the growth of the parasite. The sporozoite then divides. As far as I can make out each half forms a large non- granular staining mass. This mass, on the one hand, ap- CURRENT LITERATURE. pears to become vacuolated and transformed into an ir- regular coil; and, on the other hand, to leave the cell and Eye Strain. become extracellular. The coil later is found to be thicker Stephenson (Med. Press and Circ., Oct. 9th) says:— in some parts than others, and the ends seem club-shaped. At the base of the coil, lying just above the nucleus of the Speaking generally, the pain due to over-taxed eyes is cell, but in the protoplasm of the mononuclear, are some in the frontal region, often immediately over one orbit or rod-shaped bodies, which stain better than the strands of both (Head). Thence it tends, when severe, to radiate the coil. The coil, which now appears to be extra-cellular into the temples, or, for that natter, to become general. because the protoplasm of the mononuclear is so degenera- The ocular headache is generally most marked, as might ted, becomes broken up into irregular, short wavy bodies. be expected, towards the close of the working day, al- From these short, thick, and wavy bodies the delicate, long, though in a recent communication by Mr. Percy Flem- and corkscrew-shaped body, the spirochaeta pallida, deve- ming stress is laid upon the diagnostic importance of a lops. This is the microgamete, or adult male gamete, "morning headache" The patient wakes with the head- which has no more necessity to divide than a spermatozoon. ache, which improves after breakfast, and may be absent In some coils there appear to be circular masses, with during the day if the eyes are not much used, but will be spirochaetae corning out of them. increased or brought about by using the eyes for near So much for the development of the adult male in the work. Dr. R. W. Boyne, on the contrary, says: "It is very sexual cycle. The female development appears to be quite rare for ocular headache to persist after sleep, and the distinct from the male after a certain point. The other fact that it does so throws grave doubts upon the ques- half of the sporozoite mentioned above, and which is now tion whether the eyes are the cause of headache in that extracellular, becomes crescentic and then spherical. This particular instance." Dr. James Hinshelwood, again, spherical body is the perfect female or macrogamete and states categorically that ocular headaches are generally is now ready for fertilisation. absent in the mornings, an observation that agrees with The act of fertilisation I have never seen, but it is highly my own experience. Under any circumstances, however, probable that the spherical body forms a "cone of recep- it would probably be unwise to lay much, if any, stress tion," which is touched by the microgamete; the micro- upon the question of "morning headache" as a diagnostic gamete must then penetrate the macrogamete until its pro- feature. It is, I think, going altogether too far to say, as nucleus reaches the female pronucleus. The forms met Mr. Flemming does, that unless a headache is frontal or with in the next stage are rather difficult to distinguish situated above each orbit, and is present on awaking in the from the macrogametocyte. A clear membrane appears morning, "a surgeon should hesitate about correcting a over the whole surface of the zygote, and then the sporog- half or quarter D of hypermetropia or astigmatism." A ony runs its course. The zygote divides into two and more rational attitude, as it seems to me, is that adopted again into four; these four masses are the sporoblasts. by Dr. Leonard Williams in his useful book on "Minor Each sporoblast then becomes oval in form and goes on Maladies and Their Treatment" (1906). That. accomplished dividing to form numerous sporozoites, one of which starts physician writes:—"Neither the distribution of the neu- the cycle again. This completes the spore stage, or sporo- ralgia (except that it is generally cranial) nor the type of gony. If what I have described is correct the syphilitic the headache, affords any indication that it is the eyes parasite belongs to the order sporozoa and to the subclass which are at fault, so that it is all the more important to telosporidia, since the spores are formed at the end of the keep constantly reminding ourselves of the now well-estab- cycle. An appropriate name for the syphilitic organism lished fact that where either of these symptoms cannot be would be leucocytozoon syphilis. The infection is probably traced to any obvious cause, eye-strain is, in all proba- conveyed by the sporozoite, or, as I have called it, the in- bility, the main factor in their production." fective granule, and not by the spirochaeta pallida. The It is unfortunate that, by the very nature of things, we bodies visible in the sections are, I think, the sporoblasts are often precluded from adopting the most certain test at and possibly the macrogametocytes. The reason I think our disposal as to the ocular origin of this or that symptom some of the bodies are spores is because they persist in —namely, by the application to the patient's eyes of a weak spite of treatment with salvarsan. Possibly the recurrent solution of atropine sulphate By paralysing the ciliary syphilides, meta- and para-syphilis, are due to the presence muscle, that drug, of course, places the eyes temporarily of these spores, which can in loco start a new life cycle. at rest, and if under its continued use a chronic headache, or "neuralgia," or what not, disappears, we are justified in concluding that the symptom was due to eye-strain. It is unfortunate, again, that in myopia, where the remedy CORRESPONDENCE. causes a minimum of discomfort, manifestations of. eye- strain should be relatively uncommon, and that in hyper- opia, where the manifestations of eye-strain are common, The British Medical Association and Dr. Cole. atropine gives rise to maximum discomfort. In that (To the Editor of "The Australian Medical Journal.") condition, when the eyes are under the influence of atro- Sir,—I notice that in the daily press Dr. Cole, in reply pine, reading becomes, of course, out of the question, while to an interviewer, who asks him how he regards the re- even distant sight is blurred in direct correspondence with solution adopted by the Branch, while declining to discuss the degree of error that exists. Still, I repeat that the the matter, states: "As a public officer I have my duties most valuable and conclusive proof as to the ocular origin to perform. The Coroner's Act sets out those duties." It of this or that symptom is to be found in the use of a would be interesting to know to which particular section solution of atropine for a few days. I may add that the of the Act the coroner refers to. In the Victorian Statute strength of the solution need never exceed one grain of the Laws, the law of the Coroner's Act is a very short one, sulphate salt to one ounce of sterile water. reference being made to the fact that the English Act ap- plies here. The law is only explicit as to the holding of an Life Cycle of Spirocheta Pallida. inquest, which must be held in cases where death has been (J. E. McDonagh ("Lancet," Oct. 12) says) :- due to violence or unknown causes, but in other cases it is The commencement of the cycle is with a sporozoite or left to the discretion of the coroner whether an inquest infective granule. By means of its progression, since it is need be held, and he merely certifies in such cases that motile (I think it has flagellae), the sporozoite reaches a he does not consider an inquest necessary, and gives the 784 AUSTRALIAN MEDICAL JOURNAL. November 16, 1912.

probable cause of death. Unless the circumstances under Which the death occurs demanded it, there need be no in- jOritiO AfiCbiCAr quest. As I have already stated, this requires great judg- ZWiluCiatiun. ment and discretion on the part of the coroner. It becomes VICTORIAN BRANCH. all the more important that the coroner should have re- ceived •a medical training and had some experience in that Dr. A. E. R. White, 85 Spring-street Melbourne, Hon. Sec. profession; he could then be in a position and competent to form a correct judgment of what to do in the matter. Before the Coroner's Act of 1887 became law—I am here NOTICES. referring to the English Act, every sudden death was pre- sumably one for reference to the coroner, who might claim to hold an inquest in every one of them. But now, if WARNING NOTICE. the cause be known, an inquest is often uncalled for, and Medical men are advised to communicate with Dr. A. reference to the coroner in many of such cases must be a E. R. White before applying for positions advertised by courteous formality rather than a legal obligation. Again, Bullfinch Medical Fund, WA. if there is no reasonable cause to suspect that a death is unnatural an inquest need not be held. To decide these questions implies a course of medical training, strengthen- Telephone 1434 Central. ed by subsequent experienced and right judgment. It will be observed that a medical experience is of more impor- tance than a legal one, for it will not be disputed that all VICTORIAN BRANCH.—Ordinary Meeting, 1st Wednesday the law necessary for a coroner to acquire could be learnt in month. in a day.—Yours, etc., „ „ Clinical Meeting 3rd Wednesday LOUIS HENRY, M.D. in month.

The Feebleminded Census. PEDIATRIC SOCIETY.—Second Wednesday in month. (To the Editor of "The Australian Medical Journal.") EYE & EAR SECTION.-4th Tuesday in Mouth. Sir,--(In compiling the returns in our census of the feebleminded in Victoria, I find that some excusable doubt has existed in the minds of medical men as to whether we MELBOURNE HOSPITAL CLINICAL SOCIETY.-4th Fri- want only children of school age enumerated, or all day in the Month. feebleminded persons. In the circumstances, my com- mittee thinks it well that all should be included. May I therefore trespass on the good nature of those who have already made returns omitting those beyond school age N.S.W. Branch.—Last Friday in month. to give me particulars also of the elder ones? Queensland Branch.—Last Friday in month. In conclusion, may I urge once more those who have S. Aust. Branch.—Last Thursday in month. have made no reply to the circulars to send a return in W.A. Branch.—Third Wednesday in month. even at this eleventh hour? A sheet of notepaper would do if they have mislaid the form.—Yours, etc., J. SANDISON YULE, Hon. Sec. for Victoria. PERSONAL. 151 Collins-street, Melbourne. Professor Anderson Stuart was entertained at dinner by a number of colleagues on his return to Sydney. The GENERAL. chair was taken by Sir Normand MacLaurin. Congratula- tory speeches were delivered.

We have received a copy of Messrs. Burroughs, Well- come and Co.'s "Photographic Exposure Record and Dr .Daish, formerly of Melbourne„ has commenced prac- Diary" for 1913. It is in useful pocket-book form, and tice at Burwood, Sydney. makes a suitable gift about this season of the year. Professor J. T. Wilson, of Sydney University, has obtain- ed leave of absence and will visit Europe. Professor Penne in a recent number of "Filosofia della Scienza" records his experiences with marabouts in Tripoli. He was able to arrange for a demonstration in the presence of himself, of three professors, and others interested. Six Dr. "Cox" Robinson has sold his practice at Horsham to marabouts arrived at the appointed hour. After some Dr. Black, and purposes paying a visit to England about prayers and a consultation among themselves, one of them the end of the year. took a dagger, put the blade in his mouth, and brought it out through his left cheek until half the blade was ex- It is with great regret we record the death of Dr. John ternal to the skin, without losing any 'blood or showing any Tremearne, which occurred somewhat suddenly on No- sign of pain. With another dagger he transfixed his right vember 14th, although he had not been in good health for cheek, with a third he pierced his throat, and others he some days. The late Dr. Tremearne arrived in Victoria in thrust into his forearms. Everyone was able to observe the early "seventies" and was at once appointed resident that the daggers really pierced the flesh, and that on their surgeon at the Creswick Hospital in succession to the late removal they left no external mark beyond slight ecchy- Mr. J. H. Webb. Here he built up an extensive practice, moses. Another marabout ran a dagger through his abdo- and patients sought his opinion from all parts of the men with no apparent ill-effects, and then ate an extra- States. Owing to failing health he relinquished active ordinary quantity of nails of all kinds and sizes. He was practice 1902, and established himself in Collins-street as asked how he would get rid of these, and replied that he a consultant. He had an exceptionally wide experience of would know no more about them, as once they entered his hydatid disease and contributed occasionally to the litera- mouth they became like water. Among other feats one ture of the subject. Dr. Tremearne leaves a widow and broke a glass flask and masticated and swallowed the three sons. The eldest, Major A. J. N. Tremearne, was one fragments as though they had been chocolates. When of the officers of the 1st Victorian contingent to the Boer asked to reveal the secret of their powers the reply was war, and has since published several books dealing with that the would-be initiate must undergo a long training the natives of Northern Nigeria. Messrs. J. E. and F. B. with penances, fastings, and fearful trials. Tremearne are well-known Melbourne press-men. November 23, I912. AUSTRALIAN MEDICAL JOURNAL. 785 TE} EPIPHYSES: THEIR STRUCTURE, joint, "to the elbow, from the hncc," so that the ' • ' a FUNCTION AND INJURIES. elbow joint epiphyses unite before those of the ^^ 50.114 shoulder and wrist. We may take it that the latter C azoKupi;WI M. DO\\' \ RS, M.D., M.S. do so at twenty years of age. The upper humeral (y'iical Assistant Melbourne and Children's epiphysis originally consisted of three centres of :( ^ , F i Hospital ossification, for the head and great and small tuber- osities; these fuse together early in childhood, the t7 V t ^Q large resulting epiphysis joining the shaft later in n this paper I intend to consider, firstly, the life; that is, according to the rule that if there are anatomy of the epiphyses, both macroscopic. and several centres in an epiphysis, these first fuse with microscopic, and their function in so far as these one another before joining the shaft. At the lower subjects concern the composite injuries known as "separation of the epiphyses." This will involve end of the humerus the lateral epicondyle, the some description of the manner inwhich they capitellirni and the In)chlea are formed Iron separate centres which, after fusing, join the function in the growth of bone and the age period at which their especial function is lost through shaft at 17 ; the medial epicondyle is a separate fusion with the diaphyses. Secondly, I would centre and joins the shaft a little later, or at 18 years. 'l'he upper epiphys bring before your notice some of the facts concerned is of the radius and ulna join on at i(), while their lower centres do not in the pathological anatomy, incidence, clinical pic- ossify till ture, treatment, and prognosis of these injuries. 20. In plain language, this means that after the age of 18 an injury at the elbow joint is For my purpose I have made free use of Poland's probably not an epiphyseal separation, while at the immense monograph on this subject. shoulder and wrist this injury occurs till above 20 The existence of some process of separation of years. Each metacarpal bone and phalanyx has the epiphyses seems to have been known from one epiphysis, which ignites at 20. ancient times, for a fable ascribes to the Amazons In the lower extremity following the rule it will the custom of separating the epiphyses of the male be those epiphyses at the knee-joint that unite children so as to endow the female with physical superiority ; but the fahle does not go on to state latest, and we may state roughly, then, that the lower epiphysis of the femur and the upper epi- how they induced more than temporary impair- ment by this method, for the conditions governing physes of the tibia and fibula unite to their diaphy- ses at 20 arrest of growth after epiphyseal separation are far years. For the upper end of the femur there are separate epiphyses for the lesser trochan- from clear to us even at the present time. One sen- ter, great trochanter and head, whose dates of tence from Hippocrates has been thought to refer to fusion run 17, 18, and this injury, but the interpretation is by no means 19 years. From the ankle region we have the sequence of 18. 19, 20 for the certain. Various references appear in medical and lower tibia, lower surgical literature of the past centuries showing the íll.ula and k.iec epiphyses. The meta tarsal and phalangeal epiphyses also unite at recognition of the condition and also the denial of 20. its existence, but it is only for the last forty odd

years that the condition has been generally admit- According to the situation of the solution of con- ted, and accurately described, since as late as 1861 tinuity of the tissues, epiphyseal separations are Coulon stated that these injuries did not occur divided into three varieties:—('1) in the majority of cases the line of separation is between the cartilage because the diaphysis and epiphysis were directly continuous. - and the shaft, with some spongy bone remaining adherent to the cartilage. [Dr. Downes then gave a detailed description of the development of the long bones and their longi- (2) The separation is along a similar line, but no tudinal growth from the epiphyses, and noticed spongy bone remains adherent. This is a rare form. Macewen's views on the formation of bone.] Obviously, in the diagnosis of the nature of a These two varieties would therefore be more cor- rectly described as diaphyseal separations, for there lesion in the region of a joint, it is of importance to know at what ages the different epiphyses fuse is no separation of the epiphysis itself from its car- with their shafts by the disappearance of the tilage.

epiphyseal cartilages. It is difficult to determine (3) In very rare cases the separation takes place any fixed time for the joining of each epiphysis, for through the substance of the cartilage itself. there seems to be a wide range of variation in the As a rule the injury is not a pure separation, but dates, as is evidenced by the disparity of the figures consists partly of a fracture through the diaphysis. in many text-books. It would serve no purpose (rarely through the epiphysis), and in part of one of were I to deal exhaustively with these variations, these three varieties of separation—usually the but rather I shall try to take a mean age for each first. epiphysis from the different figures of varying writers and to put them into some form which In any case the periosteum is frequently stripped extensively from the diaphysis, but remains at- makes the memorising of them less difficult. Union takes place at a slightly earlier date in fe- tached to the epiphyseal cartilage, so that the ten- males, and the upper limb as a whole tends to dency to displacement is much reduced. It is in reach maturity before the lower. In the sipper compound separations that the greatest perosteal limb the nutrient arteries run towards the elbow stripping occurs. There are numerous cases, there- fore, where separation occurs without displacement, November 23, 1912. 786 AUSTRALIAN MEDICAL JOURNAL. so that the seriousness of the injury is not recog- It has been found experimentally that pure traction nised, and, owing to want of efficient treatment, will only produce separation in infants, and that follow. hyperextension with torsion most readily produces arrest of growth May this injury, especially in older children, in whom the In addition, there is that class of injury known ligaments are more resistant. The periosteum, as juxtaepiphyseal strain, where, after an injury, no which is freely stripped off the shaft and is only displacement or separation has occurred, but there lacerated when displacement occurs, is a great is a stretching and molecular separation of the agent in preventing separation, and, also, it may be spongy bone of this region. Though difficult to remarked, in masking the real nature of the injury recognise, such a phenomenon usually causes pain when no displacement has occurred. Wilson show- on movement of the limb, and so loss of function, ed that a weight of 55olbs. was required to detach and, in some cases, is followed by arrest of growth. an epiphysis in infants with the periosteum intact, In regard to the particular epiphyses most fre- but only i 19lbs. after its removal. quently affected, it is found that those in relation Clinically epiphyseal separations are produced by to large joints with free mobility are more often in- forms of violence which are similar to those that volved, and that the incidence is greater in the produce dislocations in adults—the analogues of upper extremity. The lower end of the femur, the separations—such as falls on to the extremities upper humeral epiphysis, and the lower extremity from heights, catching a limb in the spokes of a of the radius are many times more often affected wheel or in revolving machinery, violent lifting of than all the others and in this order of frequency. the body by a limb, catching a foot in a hole in the From my own experience at the Children's Hospital, floor, or a fall over a picket fence, with the foot and the statements of others, I should have thought caught. These injuries occur more readily in that the lower end of the humerus was most fre- those bones affected by some constitutional condi- quently the seat of epiphyseal separations, and in tions, especially rickets and syphilis. The juxta- Poland's cases, if separation of the epiphysis of the epiphyseal strains previously mentioned are brought internal epicondyle be included, it is so. But this is about by such means as produce tearing of the liga- an injury of rather small importance compared to ments of the joints in adults, and are readily pro- the separation of the whole epiphysis. Moreover, duced in rickets ; they are apt to be a determining I think many fractures of the lower end of the hu- cause of the incidence of tubercular or pyogenic merus are loosely called separation of the epiphysis inflanlìnation at these points. They are also one of when the epiphysis is quite unharmed, and if a the causes of "growing pains." skiagram is not taken the correct diagnosis is not Although separations of the epiphyses in chil- made. It is interesting to note that as many as i 1 found in this dren correspond to dislocations in adults, yet it different kinds of separation are must be remembered that in some cases dislocations situation. are found in children, especially at the elbow, and in Statistics of patients' ages show that the favourite very rare cases the two injuries are combined. period is from i1 to 18 years, which is the time 'l'he clinical expression of this injury is largely when injury is most likely to be encountered. similar to that of a fracture in the same situation Authentic cases are known where intrauterine sepa- through the presence of pain, loss of function, un- ration has followed a blow to the mother, but are natural mobility and swelling. But the swelling is very rare, and many have occurred during parturi- rather more marked, and crepitus, when ob- tion, though some doubt exists as to whether these tained, has a peculiar soft feeling unlike. that were not mostly in diseased bones. Experimentally of bony friction, or of the eroded cartilaginous the lesion is most readily produced in infants, but surfaces found in some of the conditions classed as in this period the particular kind of violence that rheumatoid arthritis. Sometimes the conical shape produces this result is not common. At the other of the end of the diaphy sis or the epiphyseal frag- extreme, though separation is an unlikely occur- ments may be palpated. The age of the patient, of rence after the loth year, yet cases have been known course, is of pre-eminent importance. When no dis- at 24 years, and some epiphyses have been found placement has taken place the diagnosis is difficult, ununited at 3o years, so that separation is theoreti- and a sprain is so mimicked that the true nature cally possible in them. may be overlooked until arrest of growth has per- These injuries are found to occur far more fre- haps manifested itself, or an acute epiphysites or quently in males than in females : in Poland's col- arthritis appears after the tenderness and disability, lection the figures being 247 and 42 respectively ; of clue to the injury, have begun distinctly to dis- these 42 female cases all but 3 occurred at or be- appear. Suspicion of such a lesion should always fore puberty, partly due, no doubt, to the fact that be felt when, without alteration of the contour of a after puberty the female leads an existence less ex- hone or crepitus, no attempt is made to use the posed to violence than the male. limb and tenderness, bruising, pain on movement It is not any particular kind of violence that and its partial limitation are present. solely causes epiphyseal separations, for they may Treatment can only be dealt with on general be due to direct violence or muscular action, but in lines, for each particular epiphysis will require its the great majority of cases indirect violence has special method. The deformity must first be re- been the factor, and it is more effective when acting duced, and wherever possible an anaesthetic is ne- in a direction either obliquely or at right angles cessary both for efficient diagnosis and treatment. to the long axis of the bone, than as a direct pull. In some cases reduction may be extremely difficult November 23, 1912. AUSTRALIAN MEDICAL JOURNAL. 787 if the broad diaphyseal end has pierced the perios- probable that in all cases there is a temporary teum and is gripped tightly by it in button-hole arrest of growth which escapes notice. This idea is fashion. If reduction is impossible by manipula- further born out by cases where some arrest has tion, then it is imperative that an open operation be followed pure diaphyseal fractures; here it is as- performed, reduction effected and maintained, if sumed that the nutrient artery has been blocked. necessary by wiring, with the strictest aseptic pre- We are, however, more concerned practically with cautions. When dealing with small epiphyses, it is the cases where the arrest of growth is more than often difficult to get good reposition, and the ques- temporary, and consequently with the method of tion of operation may also crop up here. Having production of this arrest. corrected deformity, the main indication is to guard We know from pathology that the process of re- against arrest of growth, and this is carried out pair following on injury is the final stage of an in- chiefly by greater attention to absolute fixation of flammatory reaction, and so inflammation must be the joint, and to make sure of this by keeping the present in all cases. Where this inflamma- child in bed ; also, by effecting reduction as early tion becomes excessive the cartilage may be as possible. Skiagrams should be taken afterwards partially or completely destroyed. The in- to confirm the presence of a correct position of the flammation is increased if movement between fragments. Two photographs Hurst be taken in the fragments takes place, and this seems directions at right angle to each other before we can to be the chief causative factor as a rule, for be quite sure that displacement is absent, or the it follows late immobilisation and imperfect fixa- stereoscopic method may be employed. A shorter tion in the majority of cases in which it occurs, and period of fixation is required than in a correspond- rarely occurs after immediate reduction. Oilier ing fracture, but the same difference of opinion as puts the question succinctly in the remark that any to the correct after-treatment exists as in fractures. injury in the epiphyseal region may be followed by Some surgeons favour no passive motion at all, arrested growth ; if the separation passes through while others would have fairly early movement and the middle of the cartilage (a very rare form), ar- massage. Poland does not begin passive motion rest of growth will follow. Hutchison and others till the tenth day, and it seems advisable at any rate thought that arrest of growth only occurred when not to adopt this procedure from the beginning be- periostitis followed the separation, but this has been cause of the risk of causing arrest of growth. shown to be incorrect, though it especially follows Compound separations are treated on ordinary suppuration consequent on the injury, and some- surgical lines. When deformity of the forearm has times is found after an epiphysitis unconnected taken place owing to destruction of an epiphyseal tvith any injury. cartilage of the radius or ulna, the corresponding Stripping of periosteum as would he expected cartilage of the sound bone may be removed, so from Macewen's experiments, seems to exercise no that any growth in the injured bone tends to reduce direct influence, and many cases are known where no the deformity, though the forearm will then be permanent damage has been caused by severe in- shorter than its companion. Alternatively an osteo- jury, with marked displacement. Delore in 200 tomy may be performed on the injured hone, the cases of separation of the lower femoral epiphysis deformity corrected as far as possible, and an ap- for genu valgum had no case of arrested growth. propriate piece of bone transplanted into the gap It appears, then, that the presence of inflamma- remaining. This method will only be applicable tion aggravated by movement is the main cause of when the sound bone has reached its adult size, or this phenomenon, and that it is controlled best by if the sound cartilage is removed simultaneously; immediate reduction and immobility, and that it will in the latter case a further operation may be neces- occur in those rare cases where the lesion involves sary if the damaged cartilage has not entirely ceased the centre of the cartilage, and sometimes after a to grow. suppurative epiphysitis.. The actual process is in The method of drilling the diaphysis of the in- the nature of a fibrosis, and not a premature ossi- jured bone close to the epiphyseal line has been fication. employed with the object of stimulating the re- It is rather curious that obvious arrest of growth mains of the cartilage to activity, but is rarely of should occur only in such rare cases when we re- much value. member that epiphyseal separations are far from The question of prognosis is of interest, not only uncommon. This is partly explained by the fact academically, but sometimes financially owing to that most of these injuries occur towards the period actions for malpractice. It is good in the vast when the growth of bones is complete, so that very majority of cases, but the occasional had result, little deformity is produced by an arrest of growth which cannot often be foretold, makes it advisable and may escape notice. If it happened in early always to warn parents of what may happen in the childhood the result would be far more marked. way of arrested growth. When a fracture occurs Again, if it does not make its appearance in those partly through the juxtaepiphyseal region as a con- epiphyseal regions, which are of chief activity in tinuation of the separation—the most usual arrange- the longitudinal growth of the bones, it may escape ment—the callus then formed in repair will partly notice. block the vascular supply from the diaphysis to the When one of two parallel bones has the activity cartilage and so cause arrest of its proliferation. of one of its epiphyses arrested, for example in the When this callus absorbs, the vascular continuity forearm or leg, the result will be a lateral deviation is regained, and so growth goes on, Thus it is towards the injured side from the continued ^

788 AUSTRALIAN MEDICAL JOURNAL. November 23, I9I2.

growth of the sound bone, which will go on till its The gastro-intestinal tract and brain appeared to cartilage ossifies. be healthy.

Sometimes the converse takes place, especially There was present a full-sized thymus gland. after a fracture of the shaft, and by means of the No obstruction of the larynx was present. marrow or periosteum the cartilage is stimulated in- In the absence of any other cause sufficient to stead of being irritated, so that increased growth. account for death, I put clown the case as one of and lengthening of the bone follows. Apart from those rare ones occurring in an adult in whom the this question of alteration in normal growth, non- thymus had not atrophied normally. union may occur and generally follows imperfect fixation, as when the injury was thought to be only The examination was conducted single-handed in a sprain, but permanent deformity due to imperfect a little badly-lighted room, on the floor, so I could reduction is more often seen. It must be remem- not make it as complete as I should have liked bred that there is always some enlargement of the under the circumstances. The important points diaphyseal end after repair, which disappears in a seemed to me to be the presence of the thymus, few years in most instances. large spleen, fatty liver, early nephritis, and fluidity of the blood; the latter and careful examination

negativing the probability of embolism. PERSISTENT THYMUS IN AN ADULT: According to Hewlett [Pathology : General and Special, p. 207], the cause of death in such cases has SUDDEN DEATH. been ascribed to (t) suffocation from pressure, (2)

intravascular clotting, and (3) toxaemia. Now, the CHAS. E. DENNIS, M.1)., Ballarat. first two can in this case be almost certainly ex- cluded, and the state of the liver, kidneys and blood

seem to be in favour of the toxaemia theory. About a month ago I was asked by the police to About two years ago I macle a post-mortem on make a post-mortem examination on the body of a the body of a strong healthy-looking man of about young married woman who had died suddenly whilst 35 years of age, who also possessed a full-sized at a Glance. There were no suspicious circumstances thymus, but he had died by strangling himself with connected with the case, and the following was the a belt from the foot of a bed, evidently after drink- available history :- ing. Unfortunately I have forgotten exactly the

A.J., Let 20 years, married, with two children, the p.m. appearances in his case as I kept no note, but youngest being eighteen months old and just being it would have been worth while noting the size of weaned. his lymph glands and spleen. Deceased had seen a doctor in Ararat a month or The important bearing of such cases on the ad- two previously, who said she was "suffering from a ministration of anaesthetics and their rarity makes misplaced womb, and.was run clown." it important that they should be recorded, and that As a child she had suffered from chest trouble, is my excuse for doing so. but not recently. On the clay of her death she com- plained to a friend of pain below the left breast, but it was not severe enough to prevent her attending a Blood-pressure in Scarlet Fever. dance that evening. Whilst (lancing she suddenly J. D. Rolleston (Brit. Journ. Chil. Dis., Oct) says:— gave a gasp, dropped to her knees, and fell back (1) In a series of cases of scarlet fever the blood-pres- apparently quite dead. sure was found to be subnormal in 25 per cent., the extent and duration of the depression being as a rule in direct The post-mortem examination showed that the relation to the severity of the initial attack. body was that of a well-nourished woman of small (2) In the great majority the highest readings were stature. Rigor mortis had set in. There was milk found in the first week; there was also a predominance of the lowest readings in the same week, but in a large min- in the breasts and a discharge from the vagina of ority the lowest readings were found in the second week. menstrual blood. The normal tension was usually reestablished by the fourth week. On opening the chest, the heart appeared to be (3) In the majority of cases the blood-pressure was normal in size, the right side containing more blood lower in convalescence than in the acute stage. than the left; it was not enlarged, the muscle ap- (4) In 48.4 per cent. of the convalescent cases the read- peared healthy and the valves clean. No clots were ings in the recumbent and erect positions were the same, or the recumbent was higher than the vertical record un- present, and the blood was dark and fluid. til convalescence was firmly established (hypotension of The right lung was scarred at the apex from old effort). healed trouble, and was adherent to the chest-wall (5) With the exception of nephritis complications had little, if any, effect upon the blood-pressure. from an old pleurisy. No recent trouble was dis- (6) In only a minority of the nephritis cases-12 out of covered in either lung, but there was slight enlarge- 33—was the blood-pressure above normal, and the hyper- ment of the glands at the sulcus. The liver was tension was never extreme nor of long duration. somewhat pale and friable. (7) Sphygmomanometry in scarlet fever, as in most of the other acute diseases, is of little practical importance in The spleen was about twice the normal size, fri- the acute stage, but in convalescence may give some in- able and engorged. There were signs of slight in- dication of the severity of the renal lesion which may be flammatory change in the kidneys. The uterus was of value in subsequent treatment of the patient. very large and retroverted, and there were no signs (8) Pronounced arterial hypotension, especially if accom- panied by other signs of acute suprarenal insufficiency, of recent pregnancy or abortion, should be treated by adrenalin or suprarenal extract. NOVCmbcr 23, i 1 ) i 2. AUSTRALIAN MEDICAL JOURNAL. 789

that while such enquiries as he has just brought 21uEtrartan fillebtcai journal( about are desiraible, they should not be made in public. With that we are in entire dis- 23rd NOVEMBER, 1912. agreement. Lt cannot be too strongly laid down that in every case in which enquiry is desirable, it is equally desirable that the THE ANAESTHETIST AND HIS DUTY. proceedings should be held in public. What may be fairly urged is that far wider discretion should be employed as to the need for public enquiry, and far The action taken by Dr. Hornabrook in reporting greater restraint be exercised in the conduct of pub- a case of death after operation is such an unusual lic enquiry. If such were observed, there need be professional proceeding as to call for some extended neither public panic nor professional irritation. notice. Dr. Hornabrook is an 'honorary anaesthetist at the Melbourne Hospital. In that capacity he was Allowing Dr. Hornabrook every credit for the called upon to administer an anaesthetic to a patient genuineness of his advocacy of his own ideas, it suffering from a perforated duodenal ulcer, who was must be pointed out that the methods of endeavour- operated upon by I)r. Zwar. The case was an ex- ing•to give them effect which he has selected are ceedingly desperate one from the surgical point of open to grave objection. Desirable professional re- view, and the patient died of shock within an hour forms, or contentious professional topics, are best of being returned to bed. Dr. Hornabrook thereupon discussed in professional council. Even if they be took it as a duty devolving uponhimself, in lieu of coldly received, the impatient author cannot claim to any other initiative, to report the death to the coro- be allowed on that score, or any other, to urge them ner. There was no suggestion that anything was through the public press. l n the course of his evi- wrong either with the anaesthesia or the operation. dence concerning the case of Walter Leighton, Dr. The report was made by Dr. Hornabrook as a con- Hornabrook is reported to have said: "He desired cession to his own doctrine that all deaths occurring the public to know that the work of the anaesthetist within an hour of anaesthesia should be inves- was in no way secondary to that of the physician or tigated. surgeon." Dr. Hornabrook may be reminded that the desire to let the public know is one which all mem- It has been before remarked that the selection: of bers of the medical profession are called upon to one hour as an arbitrary time limit is so obviously resist with penance and fasting, and that no amount absurd that no justification for Dr. Hornabrook's of altruistic aspiration will atone for disregard of claim can he based upon it. It is quite conceivable professional usage. that, under such a conventional procedure, the very cases in which investigation, might prove valuable would be omitted. The lofty ground assigned for the selection of a one-hour interval is that of enab- ling the anaesthetist to learn his own errors of technique, and it is scarcely supported by such a Pote5 anb Conunent. time limit. It rather suggests a refuge for any anaesthetist anxious to let the galled surgeon 'l'he fly season is -now beginning, and it is wince, and show his own withers unwrung.. Flies and probable that the supposed connection be- Disease. tween flies and contagion will be more or The further position which follows as a necessary less prominently before the public. In the "Second Report of the Government Bureau of Micro corollary to the acceptance of Dr. Hornabrook's con- - tention is, that an anaesthetist is to be allowed to biology," Dr, Burton Bradley, in a joint communication on Typhoid fever with Dr. Tidswell, says in conclusion: — take the responsibility of reporting cases quite apart "Scientific men seem sometimes to be in the thralls of from the operating surgeon. It does not require that mysterious disease "fashion," a fact which is strik- very prolonged reflection to see that such a proposal ingly evident in the perusal of the literature of the sub- is insupportable. The anaesthetist stands in very ject. Once, the dominant note of the investigations was water, writ in very large capitals. Again, it was oysters much the sane relation as a consultant. He is and shellfish, but of late it is spelt "carrier," and few seem called in for a specific purpose, and that purpose to bother to think that a carrier is only a source of infec- being accomplished, he has no further duty or re- tion, by itself no more completely explaining a spread sponsibility. For an anaesthetist to claim that by than does a typhoid case. A little while back quite a wave of enthusiasm spread amongst English and American virtue of having administered an anaesthetic he has authors upon the fly hypothesis. To-morrow, what?" And a prospective interest in; the patient for an hour, or finally summarises as follows: a day, or any time at all, is tantamount to a consult- "The fly hypothesis, involving a food infection, must be ant claiming the right to call upon a patient, seen accepted with some reserve, though the bacteriological with a colleague, at any interval he deems advisable evidence is strongly enough in favour of its possibility wherever sterile food, milk, etc., are the secondary ve- after his prescription has been given,, in order to see hicle of infection." how it works. That any surgeon, or body of sur- From the aesthetic point of view, the vigorous 'domestic geons, would consent to .anaesthetists reporting campaign against flies may be enthusiastically upheld. cases of death after operation on•the off chance of The scientific aspect of direct food infection by means of learning their own errors of technique, is extremely flies is, however, one that should only be taught with -due improbable, and, it may also be remarked, supremely reserve. Any sweeping and positive generalisations which have to be subsequently withdrawn are not con- undesirable. Dr. Hornabrook professes to believe ducive to the maintenance of public confidence. 790 AUSTRALIAN MEDICAL JOURNAL. November 23, 1912.

it was undesirable that there should always be a public jßrtttfib ,ifiebtcaY azzoctatton. inquiry, with reports in the press. The effect of this on pa- VICTORIAN BRANCH. tients who were going to be submitted to operation was exceedingly harmful. It was for these reasons that it was felt that the Branch should express a dignified opinion ORDINARY MEETING, WEDNESDAY NOVEMBER 6. with regard to the matter, and he therefore moved:— "The members of the Victorian Branch of the British The President (Dr. J. F. Wilkinson) said that the first Medical Association are of opinion that the remarks business arose out of a communication sent on to the made to Dr. Lambert at a recent inquest, `that there is no Branch by the staff of the Melbourne Hospital, in which necessity to hurry people out; human life must be re- the staff requested the branch to consider the question of ro fession spected even by the medical profession,' was quite un- the attitude of the coroner towards the medical p called for, and is a serious imputation on the profession in relation to the administration of anaesthetics. This generally. That such remarks, if persisted in, will tend an inquest which was held recently matter arose out of to deter surgeons and anaesthetists from accepting the on a patient who died while being subjected to anaesthesia responsibility of operating in critical cases, and may thus roner, holding a puib- at the Melbourne Hospital, and the co lead to the loss of lives that might otherwise have been lic inquiry into the case, saw 'fit to make remarks not saved. only with regard to the methods of administration of anaesthetics as practised at the Melbourne Hospital, and "The Branch, while agreeing that all cases of death un- criticise and make certain recommendations with regard der anaesthesia should be reported to the coroner, is fur- to the hospital in particular, but he also made a remark ther of opinion that it is unnecessary and undesirable to which was really a serious imputation on the profession hold a public enquiry in every such case. The reporting generally. The hospital staff had dealt with the matter as in the public press of all such cases has a distinct ten- far as it concerned the Melbourne Hospital. The coroner's dency to frighten patients, and render them less fit sub- remarks were sent on to the Premier, and the Under jects for anaesthesia, and thus to greatly increase the Treasurer was instructed to write to the various hospitals dangers of such anaesthesia; and the Branch would re- in reference thereto. The other hospitals dealt with the spectfully urge the coroner to consider the matter from matter in their own way, and the Melbourne Hospital Com- this standpoint." mittee referred their side of the question to the staff, and Dr..Stawell, in seconding the motion, said that it was a the staff sent a report which was accepted by the Commit- matter in which, he thought, little comment should be tee, and sent on to the Premier, and, according to the made now. The President had given an admirable, grave, press, was accepted by the Premier. The President did not and dignified account of the attitude of the Council in re- think that that phase concerned them, but the Melbourne gard to the matter, and they all knew, as well as he, that Hospital staff referred the remarks of the coroner, and his there was no desire more deep-rooted in the profession general attitude in regard to the administration of anaes- than to see that the efficiency and safety of anaesthetics thetics, to the branch, and the Council thought it was a should be maintained at a very high level. He therefore proper subject to bring before members generally. Mem- definitely and gravely seconded the proposal. bers would of course recognise the position the coroner Dr. Stirling moved:—"That the motion which was passed held in this matter. He had to protect the public from be given the same publicity as the adverse comment that anything in the nature of careless and incompetent work, was made by the coroner." It was no use, he said, passing and they all recognised that his position was one of con- a stereotyped motion like that, unless it was published far siderable difficulty, but they also knew that members of and wide, and given the same circulation as the comment the profession were quite seriously alive to the risks and on anaesthetics and the coroner's opinion of the medical dangers that patients must necessarily run in being sub- profession. mitted to operation, especially in serious and critical Mr. Russell, in seconding the motion proposed by Dr. cases, dangerous from the point of view of the operation Stirling, said that he thought the matter should not be and it was and from the point of view of the anaesthetic, allowed to stop absolutely at this resolution, that either felt that anything which would tend to make the patient now or in the immediate future the Branch should carry unduly anxious or nervous or susceptible from fear and the matter a little further and raise the whole question of fright to the effects of anaesthetics was exceedingly harm- the wisdom of the law as it now stood. Personally, he ful from the point of view of the patient, and anything was strongly of opinion that the law as at present consti- that would tend to weaken the confidence of the surgeon tuted reacted very unfavourably upon the public interests, and of the anaesthetist in undertaking the risk of, per- and he thought that was the almost universal opinion of haps, an exceedingly critical case was also exceedingly the profession. The abject of the coroner's inquest was to deleterious to the patient's best interests, and anything protect the public. That is to say, that in any case that might deter surgeons or anaesthetists from perhaps of death from other than natural causes, by means of the taking that risk might lead in many cases to lives being coroner's inquest, the fault, if any, could be sheeted home sacrificed, which might otherwise have been saved. Sur- to the person at whose door it lay. But in all the hund- geons and anaesthetists could not help feeling that the reds of coroner's' inquests he had heard of he had never publicity which was given in the public press to these heard of a single instance in which the fault was sheeted cases, when unfortunately an accident did happen, must home to the administrator, of the anaesthetic in the shape tend, and if it continued, would tend to make men hesitate of carelessness. He thought this matter might be brought to take the responsibility in critical cases Which they before the law-makers, and it might be suggested to them otherwise would take, and which might, if they did take it, that they should consider whether a revision of the law lead to the saving of the patient's life, which would other- as at present constituted would not be in the public wise be lost, and it was felt that the Branch should put this position before the coroner. The suggestion that was interest. thrown out by the coroner, that medical men were not suf- Dr. Hornabrook said that he thought within the last ficiently careful of patients' lives, when he said, "There year or two there was a certain tendency to slacken up in is no necessity to hurry people out; human life must be reporting cases, and he thought that was why public in- respected even by the medical profession," was a very quiry was doing a great deal of harm. The coroner, he serious imputation indeed on the honour and integrity and thought, was right in this way, that he had the law to carry devotion to duty of the profession generally, and if such out, and the law said that all cases of death being due to remarks were persisted in and allowed to go unchallenged, any other natural causes must be reported to the coroner. it must necessarily tend to make men hesitate before ac- Though he quite agreed that the remarks made were un- cepting the responsibility of grave and serious cases. This called for, he did think they owed something' to the coroner. was one of the matters to be brought before members. He had his duty to perform. He thought it would have The other matter, perhaps more important still, was the been more courteous of the Melbourne Hospital staff to question of the continuous public inquiry into these mat- have referred the question of anaesthesia to the anaesth- ters. I,t was agreed by all that every case of death under etists of the hospital. anaesthesia should be reported, to the coroner. It was Dr. Agnew asked whether Dr. Hornabrook was speaking the law, and it was a right and proper thing that the with definite knowledge as to non-reporting of cases. If coroner should be able to make inquiry, but it was f.lt that not, such a statement should not be made.

November 23, 1912. AUSTRALIAN MEDICAL JOURNAL. 791

Dr. Ramsay Webb said Dr. Hornabrook should either states that the osteoblasts are epiblastic in origin and not give definite information or withdraw such a statement. mesoblastic. That was entirely new to Dr. Downes, and Dr. W. R. Boyd thought such a statement ought to be different to the statements in the ordinary text-books justified or withdrawn. which he had looked up since. In regard to the overgrowth of bone which Mr. Russell mentioned, after a fracture The President pointed out that the matter did not affect through the diaphysis near the epiphysis, he believed that the resolution, and it was allowed to drop. was usually put down to some stimulation of the cartilage The President, in putting the motion, said that he had by means of an extra flow of blood to it, so that the stimu- the same feeling as expressed by \lr. Russell, that all lated cells proliferate rather more freely than usual, these inquests were practically futile and did very much Whereas if the injury was practically in the epiphyseal more harm than good, and he thought the Branch Council cartilage, the result was to irritate the cells too much, so might very well consider the suggestion made by Mr. Rus- that fibrosis occured, and the cartilage was destroyed. Dr. sell, and he would undertake to see that it was considered. Sutton had said.something on the subject of rickets, but he He gathered from the applause that the suggestion had had carefully stated 'beforehand that he was only dealing met with favour from the members of the Branch present. with injuries of the epiphyses, and not with their diseases. Dr. R. Downes read a paper on "The Epiphyses: their In any case, he did not •think he could throw much light on Structure and Function." the subject of calcification. He thanked Mr. Russell and \1r. Russell said he was much interested to hear the Dr. Sutton for their kind remarks. paper. The whole subject of bone as it was met with in Dr. S. Pern read a paper on "The Need of Lime in the surgery was always very perplexing to him, and he had System, and its Relation to Goitre." been immensely struck by Sir William Macewen's investi- Dr. Dunhill said that when he was asked to open the gations, the most striking feature of which was that he discussion he did not think that it was going to cover so denies that periosteum is osteogenic at all, and that conse- much ground. He thought that the first feelings that arose quently we have been labouring under an error in sup- in one's mind were of appreciation that a man living far posing that periosteum did throw out bone. He noticed away from the stimuli that were usually considered ne- that Dr. Downes in his paper did not accept fully Pro- cessary had thought out such a great body of work, and fessor Macewen's experiments, and perhaps it was wise given it to them in a way for which he himself felt very that he did not do so. Mr. Russell said he was quite un- grateful. There were some aspects that he could not able to explain .why in some cases of surgical injury or quite clearly follow, but that was natural, because one had disease growth was arrested, and in other cases, apparently not put the amount of thought into it along the lines on of a similar nature, growth would not be arrested, but which Dr. Perri had worked. One would like to feel that stimulated. With reference to the treatment of epiphysial the problem was as simple as had been expressed, and yet injuries, he was one of the surgeons who rejected passive one could hardly think it was so. Dr. Pern had been able movements altogether. He would go further and say that, to gather a mass of evidence, and he thought his remarks in the absence of gross displacement of the fragment, or were therefore worthy of deep thought. Some of the prob- fragments, it was impossible to get stiffness of the joint lems that arose in his mind made it difficult for hint to ac- in epiphyseal injuries, unless passive movement was per- cept all Dr. Pern's conclusions, but that did not prevent formed. One other point he wished to refer to was this. them from being of great value. In one family living a He had noticed that there was a great tendency nowadays. certain distance from Melbourne, he had found that one to treat epiphyseal injuries of the elbow joint by a method daughter had Graves' disease extremely badly. A little of apparent great simplicity, by binding the arm to the later, a brother came along with a type of goitre not chest in a position of acute flexion. He would like to utter exophthalmic, which did not cause much trouble at first, a warning that this method is not such 'a safe method of but did later. The next member of the family had a goitre treatment as it is usually thought to be. He had seen of the type which had become quite definitely exophthal- within the last 12 months two cases of ischaemic paralysis mic, true Graves' disease. The last one who came for due simply to elbow injuries being put up in that way. treatment (there were still others of the family to come) Dr. Harvey Sutton said he would like to congratulate had a large retrosternal adenoma of the thyroid, which Dr. Downes on his paper. There was one interesting side- made him exceedingly ill, was practically smothering him. light when he was dealing with the 'physiological aspect. They had the most widely diverse 'types of thyroid tumour, He mentioned the difference of opinion that seemed to while all partaking of the same food and drink and all liv- exist among observers as to the date of appearance of ing in the one home. About the question of lime in the body, ossification in separate epiphyses. It was interesting to note there was a great deal in that question, and, indeed, men that quite recently X-ray examination had to a great ex- were working at it pretty hard in many 'parts of the world. tent solved that question, as shown by Dr. Rotch. It had A series of investigations made by McCallum and Voegth- been shown that very often a marked difference between lin showed that in dogs after parathyroidectomy the blood the birth age of a person and their anatomical and physio- contained 50 per cent. less calcium salts than it contained logical age was apparent, and that many boys were 'per- under normal conditions. Then it is known that - brain haps two years behind in their whole physical and mental tissue is extraordinarily sensitive to deficiency of calcium, development to others, and yet those boys eventually and it is also known that the severer symptoms of tetany reached quite a normal standard. X-ray examinations may be relieved almost immediately (frequently) by the could determine their state of ossification, and one could administration of calcium salts. Children who suffer by this means obtain more definite information as to their from tetany invariably show lesions of the parathyroid real or anatomical age. He would have liked Dr. Downes (birth haemorrhages). These investigators regard the to have made some observations on the question of calci- parathyroid as governing calcium, metabolism and excre- fication and rickets. It was extraordinary how rapidly de- tion. Parathyroids which have been injured at birth may calcification occurred in bone, and the rapidity with which do their work efficiently until some added strain (gastro- it returned health. This might explain what Macewen's intestinal or other ) is added, when tetany may follow. work, quoted by Dr. Downes, had also brought out the Tetany does not occur unless there has been parathyroid 'remarkable way in which the bones were moulded by the injury. The work was very complicated, and much had condition of the soft tissues around as, e.g., the lower jaw still to be done, but while men were experimenting in by the tongue. laboratories he thought it was of great importance that Dr. Downes, in reply, said that he was afraid he had practitioners should be working as Dr. Pern was working given Mr. Russell a rather wrong idea of not agreeing with here. The clinical evidence should be gathered side by Macewen. His book, as he had read it, seemed to him side with the experimental evidence. Experimentalists absolutely to prove the case. The one point that was open found the explanation of many things which clinicians to discussion in his work was the origin of the osteoblasts, observed. There were many problems which he would and in the "B.M.J." of a few weeks ago, there was an ac- like to discuss, but would not owing to the lateness of the count of how Professor Geddes had attacked his views on hour. He trusted that the 'discussion would elicit much this question. Macewen says that in the process of de- that would be Mull of profit to the Society and gratifying to velopment and repair, 'bone is produced from cartilage, Dr. Pern. and that the osteoblasts result from division of cartilage Dr. Harvey Sutton said he would like to raise the ques- cells, Professor Geddes says that must be wrong, and he tion of the etiology of exophthalmic goitre, about which

792 AUSTRALIAN MEDICAL JOURNAL. November 23, 1912.

Dr. Pern had given such an interesting experience, for which he must compliment him, particularly on raising the BENllIUO 1)1VISION. point of the intermediate stages. People refused very often to make a diagnosis unless the patient had reached A meeting was held at the Bendigo Hospital on Thurs- an extreme degree. Among school children, many of these day, 14th November. Those present were the President intermediate cases occurred. First of all, the sex factor (Dr. Penfold), in the chair; the Vice-President (Dr. T. E. had been very obvious. It occurred more commonly Green), and Drs. Catford, H. Cordner, Ffrost, F. C. B. among he girls than among the boys. He had seen one Gaffney, Ker, Lyons, William's, Willis. Dr. E. Cordner was case of exophthalmic goitre among the boys, about 1,000 present as a visitor. of the ages of 14-18, and his colleagues had seen twenty or Dr. H. Cordner showed a case of congenital hypertrophy so cases among the girls. They had found cases of goitre of the pylorus in an infant aged 9 weeks. Vomiting had in children under puberty, and some of them began to get been less since treatment (washing out of stomach) had a rapid pulse, so that the menstrual theory did not seem been commenced. to apply in these cases. He thought the hereditary theory Dr. Lyons showed a case of persistent haematuria in a was very interesting. Undoubtedly, he thought an here- boy aged nine. ditary factor in the production of these thyroid lesions had been shown in the case of endemic goitre in cretinous dis- Dr. Ffrost showed a case of (?) congenital wry-neck in a tricts such as the Val a'Aosta. With regard to the calcium girl aged nine. The clavicular attachment of the sterno- theory, the condiion did seem to be largely confined to mastoid on the contracted side was fibrous. similar districts to the one in which Dr. Pern had worked, Dr. Green thought the condition due to myositis with e.g., Omeo and Sale; but Professor Osborne not very long subsequent contraction. ago pointed out that one of the redeeming features of the Dr. Willis showed a case of progressive muscular Australian vice of drinking tea was that in the tea we get atrophy. just those things which are deficient in our water supply, A discussion on progressive muscular atrophy namely, the saline constituents. He thought Dr. Pern in- and acute cluded in his paper a reference to the fat, sleepy child at anterior polyomyelitis followed, in which Drs. E. Cordner, Catford, Williams, Green and Willis took part. school ; many of these who were not under, but above, the average in intelligence were really due to disturbance of A letter from the I.O. Rechabites was read and discussed. pituitary, and not thyroid, secretion. Dr. Pern could, he A letter from Dr. Norman Wilson was discussed. thought, by putting his experiences on a statistical basis A letter from the Ballarat Division was read and re- and elaborating the question of heredity render a lasting ceived with regard to the proposed rules of the Victorian service in the investigation of this condition. Branch for the restriction of medical advertisements. The action of the Bendigo Committee in favouring the restric- Dr. Stawell said he could not let the evening close with- tion was approved by the 'meeting. out congratulating Dr. Pern on the work done by him. In common with the other speakers, he had felt somewhat overwhelmed by the amount of material Dr. Pern had brought before them and the originality of a great deal of his work. He had, indeed, tackled two of the hardest prob- CORRESPONDENCE. lems known to medical men, calcium metabolism and the relation of one ductless gland in its action on another. Dr. Stawell felt with 'Dr. Sutton that it would be an extremely The Maternity Bonus. interesting contribution to medicine to collect, say in (To the Editor of "The Australian Medical Journal.") South Gippsland, evidence of the presence of so-called en- demic goitre (without any theories as to how it was pro- Sir,—Your sub-leader in the "Australian Medical Jour- duced), first to collect statistics as to its distribution, and nal" of November 9th, on the Maternity Bonus, raises a then to collect statistics as to family pre-disposition or point which it would be desirable for the 'Council of the inherited disposition to genuine type of Graves' disease Association to express its opinion on. throughout the same kind of district. Whatever criticism !So far I have only received one application to sign the might be advanced as regards Dr. Pern's views, there certificate, which is supposed to be signed by either "doc- could be no difference of opinion, he thought, among mem- tor or midwife." I sent back a message that "my fee for bers who had heard Dr. Pern's paper, that he should be signing was 10s. 6d.," and, having heard nothing further, I encouraged to go on carrying out a genuine type of inves- presume the nurse was exploited instead of nie. tigation. Among the heap of documents which this vicariously The President said he would like to add his congratu- generous Labour Government favoured me with was one containing a clause to the effect that "where a doctor at- lations on a paper which would cause a very great deal of tended, only his signature would be accepted," while an- careful thought, and perhaps lead them to try some experi- other contained the expression "doctor or midwife." One ments in treatment they had not tried before. is at a loss to know what the law really is. Dr. Pern, in reply, said he had to thank those who had I have advised the nurses in this district to demand a spoken for the nice things said. Regarding Dr. Dunhill's fee of 5s. for their signatures.—Yours, etc., remarks, he himself had observed unique cases in a family EDMUND H. LINDSAY. where the majority showed the exophthalmic type, and one Bealiba. had the reverse type altogether. Dr. Sutton had remarked about the pituitary gland. He had purposely left that out, but he had ideas on it, and would very likely say some- Skiagraphy and the Public. thing about it another time. As regards endemic type of goitre, he had only come across two such cases, which had (To the Editor of "The Australian Medical Journal.") responded to treatment by thyroid extract, and, curiously Sir, Recently a patient of mine was sent to a radio- enough, one had marked exophthalmos with slow pulse; grapher—a well-known medical man. I have no fault to she was put on exophthalmic treatment without result, and find with the latter; but I beg to use your columns in then on thyroid extract, and the condition cleared up. which to express my surprise when I learnt that it is Every case he had treated on these lines had one and all usual to send the photo to the patient. Latter did not go responded to treatment. He had been astounded at the re- to the radiographer on his own initiative, but was sent sults, more than anything by the extraordinary way in there by a surgeon. Seeing that it is not an easy matter which children grew, particularly the young ones; some for trained medical men to "read" 'these "graphs," I very had been growing at the rate of one inch a month. As re- much question the sense of allowing patients to try their gards the age, he knew of a child with exophthalmic apprentice eyes on them, backed up by no acquaintance goitre five years old, and her sister of ten years of age had with anatomy at all. the biggest goitre he had ever seen. In fact, all the family !Thanking you in anticipation of a little space.—I 'am, had it. RUS. November 23, 191 2. AUSTRALIAN MEDICAL JOURNAL. 793

Prevent the rectum from being filled with 'scybala, requir- e Tg00k5. ing straining for their expulsion. Prescribe an aperient P w pill at night, to be followed by a saline aperient in the morning if the pill is not enough, and if this combination "The Principles and Practice of Medicine." W. Osier, M.D. does not empty thebowel, let it be washed out with half New York and London: Appletons. Sydney: Angus a pint of cold water. If the margin of the anus is sore to and Robertson. 8th Ed. the touch, advise the patient to wash the part after de- faecation, instead of using paper. And instruct the patient To review "Osler's Medicine" at this date is almost if a pile protrudes and remains outside the anus after de- equivalent to saying that London is a large city. There are faecation, to at once replace it by pressing it up with lint few students within the last twenty years who have not or a clean rag, smeared with vaseline or benzoated lard. looked into the work, even if they have not chosen it for Iif this is regularly done, serious trouble will not arise. If systematic reading. All that can be said is that there are the piles should become very swollen and painful, so that few better text-books, and that the 8th edition is in some they cannot be replaced (a condition that I have only seen respects a new work. Prof. Osier has revised and re- quite at the end of pregnancy), it will be better to deal arranged it, and new matter has been added. Dr. McCrae with the pregnancy and induce labour a few days before has taken charge of the directions for treatment. The use term. When the patient has been delivered, the condition of a new type is also an improvement. That the revision of the rectum will quickly improve. is quite recent is shown by the inclusion of the ophthalmic reaction in typhoid, to take a single example. If there is Varicose veins in the legs—or rather, the condition of any qualification to be made in Sir Wm. Osler's work, it is vascular tension which in pregnancy produces varicose that for the student, there is too much information. The veins—often lead to oedema. The only way of preventing article on typhoid fever is an admirable summary, but this is the wearing of some support; an elastic stocking, might prove bewildering to those in search of firm land- an indiarubber bandage, or a non-stretching woollen marks for recognition. On the whole, however, the book is bandage, such as the "lanoid." These things, well one of the best of many excellent text-books of medicine in applied every morning, and kept on all day, will prevent the English language. the leg from swelling. But most women prefer slight swelling of the legs to the discomfort of these appliances. When the oedema lasts long, the exuded serum becomes "Psychotherapy," including the history of the use of men- organised into fibrous tissue, so that the effect of many pregnancies is often (but not always) to make the ankles tal influence, directly and indirectly, in healing, and permanently thicker. A generation ago medical men used the principles for the application of energies derived from the mind to the treatment of disease." James J. often to have to advise pregnant women not to wear gar- Walsh, M.D., Ph.D. New York and London: D. Apple- ters; at the present time stocking susp.,nders are so gene- ton and Co.; Sydney: Angus and Robertson. rally adopted that this recommendation is usually unneces- sary. The author gives the testimonies of men in all periods of the world's history who have written of the influence of the mind over the body. From this he goes on to speak of most of the chronic medical affections—and some of the Luetin Reaction. surgical—giving with each, with much elaboration of de- Noguchi (Journ. Amer. Med. Assoc., October 5) con - tail, information as to the way in which the mental atti- cludes:- tude of the patient may be influenced for good. The book consists of material gathered ,for a series of lectures for 1. The luetin reaction is specific for syphilis. medical students. This makes it very diffuse, but also very 2. 'The reaction is present in the majority of cases of readable, and it really constitutes a text-book of Psycho- tertiary, latent and hereditary syphilis. therapy. It is a good book to be in any library, and it will many a time give the practitioner timely assistance in 3. It is less constantly present in secondary untreated and primary cases. dealing with intractable cases. T.P.D. 4. In treated secondary cases the reaction is present in most instances. 5. In general paralysis and tabes dorsalis the reaction is CURRENT LITERATURE. inconstant, but a positive reaction was obtained by Moore and myself in about 60 per cent. of cases. 6. In certain cases of tertiary and hereditary syphilis Varicose Veius in Pregnancy. there may be a considerable inflammatory reaction at the G. E. Herman ("Polyclinic") in an article on Hygiene site of injection of the control fluid, and the reaction may sometimes be as strong as that produced at the luetin of Pregnancy says:- inoculation site. Jn pregnancy there is a rise in vascular tension, one The condition of the skin which gives the luetin re- effect of which is enlargement of varicose veins in the 7. lower half of the body. This is not a simple result of action remains but little influenced by the antisyphilitic treatment, although a positive reaction can no longer be pressure, because it occurs before the uterus is large enough to press on any vein. Cases have been observed obtained in some cases which had been thoroughly treated in which the patients made for themselves the diagnosis and believed to be cured. that they were pregnant because the veins in their legs 'The relation between the Wassermann and the luetin re- began to swell. Similar varicosities do not accompany actions may be defined here in order that the fullest pos- ovarian or uterine tumours of the size of the pregnant sible benefit may be derived from the use of both reactions. uterus, or even much larger. From this it results that The Wassermann reaction is more constantly present than haemorrhoids often trouble women during pregnancy. The the luetin reaction in cases of primary and secondary question may arise, should haemorrhoids or varices of any syphilis, especially when only a slight amount of treatment kind be treated by operation during pregnancy? I think or none was given. On the other hand, the luetin reaction not. We know that the condition will certainly get much is more constantly present than the Wassermann reaction better, if not quite well, by the time the lying-in is over. in cases of tertiary and latent syphilis. Besides, in cases There are occasionally unforseen and unpleasant results in which the Wassermann reaction and clinical manifesta- after operations even by the most skilful surgeons. When tions of syphilis are very marked and the luetin reaction the condition the surgeon is dealing with is one which negative, an energetic treatment can reverse the situation largely is dependent upon the pregnancy, it is difficult for completely. Thus, through the treatment the Wassermann him to judge how much it is requisite to do. These vari- and clinical symptoms gradually are made to disappear, cose hemorrhoidal veins as a rule only give trouble when while the luetin reaction becomes more distinct and the they are forced down outside the sphincter, and so grasped condition that gives the reaction to the luetin persists by the sphincter that the return of blood from them is afterward, probably until a cure is effected. From the hindered, and they become swollen, painful, and sore. The above-cited facts it may be concluded that the luetin re- better way is to avoid the production of this condition. action possesses a greater diagnostic value than the Was- 794 AUSTRALIAN MEDICAL JOURNAL. November 23, 1912.

sermann in tertiary and latent syphilis, and also a decided prognostic value which the Wassermann does not. rtttob Olebttar atizoctatton. While the application of the luetin reaction is simple VICTORIAN BRANCH. enough to be within the reach of any physician, on must not underestimate the technical precautions necessary for obtaining reliable results, because all kinds of irregularity Dr. A. E. R. White, 85 Spring-street, Melbourne, Hon. Sec. of the reaction can be obtained by a neglectful and faulty technic. Besides, it is important to 'become quite familiar with the reactions before one can recognise the milder form of positive reaction and avoid a misinterpretation. In NOTICES. short, as in the case of everything else, one has to have a certain amount of preliminary training in order to utilise the luetin reaction properly. WARNING NOTICE. [A description given by Dr. W. A. Wood will be found Medical men are advised to communicate with Dr. A. on page 659 of "A.M. Journal."—Ed.l E. R. White before applying for positions advertised by Bullfinch Medical Fund, WA.

Telephone 1434 Central. GENERAL. VICTORIAN BRANCH.--Ordinary Meeting, 1st Wednesday Whisky. in month. „ Clinical Meeting 3rd Wednesday Dr. Stodart Walker writes:— in month. A high standard of purity in the matter of alcoholic drink is more easily and more cheaply obtainable in the PEDIATRIC SOCIETY.—Second Wednesday in month. form of whisky than in any other form. These facts are commonplaces of both medicine and EYE & EAR SECTION.-4th Tuesday in Month. popular opinion. At the 'present time Scotch whisky is not only the drink of Scotland, but the standard drink of the British Isles. It has passed into popular favour from MELBOURNE HOSPIT:IL CLTNIC.IL SOCIE'T`Y.-4tlt Fri- many causes, chiefly on its own intrinsic merits as a liquor, day in the Month. partly from its cheapness, and to some degree through the persistent advocacy of the medical profession. The public must realise that spirit, to be at all suitable N.S.W. Branch.—Last Friday in month. for consumption, must mature for several years; and, rea- Queensland Branch. —Last Friday lising that, they must also be told frankly that they must in month. pay •a percentage more than they do at present for the S. Aust. Branch.—Last Thursday in month. whisky they drink. Considering the extremely small in- W.A. Branch.—Third Wednesday in month. creased cost of high-class Scotch whisky over vague im- mature spirit bearing that name, there should be no hesitation in the matter. This is not a question of mere opinion, but one of corroborated fact. Nearly 2,000 persons were killed by wild animals, chiefly The agitation of scientific men in regard to the whole tigers, in British India during 1911. In 1910 the figure liquor question must turn on this, as one of the vital points was 2,382. The total mortality from snake-bite rose from 22,478 in 1910 to 24,264 in 1911, Bengal heading the list begging the question. If liquor is to be drunk at all, it with 9,344 deaths. must be good, unadulterated and mature; and, considering the fact that the majority of people cannot afford, or ought not to afford, to proportion a large share of their income to their liquor bill, they are more likely to get purity and Suicide as a social phenomenon shows the same re- quality in dealing with whisky than with wine. The drink gularity as births, marriages and deaths. An especially bill of this country is something over £150,000,000--an striking phenomenon is the regularity in the increase of astounding and a criminal sum. A large proportion of that suicides. The number of suicides in Prussia has risen figure is spent on the consumption of inferior wine manu- since 1878 from 180 to 207 for a million of population. factured abroad. Within the empire of Germany, the number of suicides in There is another important point upon which it is ne- Prussia takes a medium position. In this respect Prussia cessary for the unprejudiced observer to warn a gullible is exceeded by states outside of Germany: by France with public. Readers of the advertisements in many of the 238; Switzerland with 228 and Denmark with 220 per mil- London and provincial newspapers may have noticed that lion of inhabitants; while the number of suicides is 55 in certain firms are continually advertising what they call Norway; 90 in England; 29 in Ireland and 20 in Spain. "All Malt" whisky, and endeavouring to 'persuade the pub- lic that that commodity alone is the one that meets the of common sense. A recent wants both of science and Dr. Alexis Carrell, of the Rockefeller Institute of New leader in the "Edinburgh Medical Journal" emphasised York, has been awarded the Nobel Prize for Medicine for the fact that an "all malt" whisky is contra-indicated in 1912 for his work on the suture of vessels and the trans- nearly every case. The 'digestive powers of the average plantation of organs. The value of the prize this year individual are not capable of assimilating such a spirit, amounts to about £ 7,800. and, despite, the popular opinion, a blend of malt with grain in the proportions is the safest and best. The cry for "all malt" is from the lips of a few interested parties. The medical staff of the Melbourne Hospital have made a Let, therefore, the public disregard this shibboleth, and re- recommendation to the Committee that all reports of member that the main principle at stake is the one of age. deaths made to the coroner shall in the first instance be It is on this question of age that the dishonest merchant the duty of the Medical Superintendent, who shall also cheats the public. Old matured spirit is expensive and dif- notify the Secretary of his action. ficult to procure, hence the importance of buying only the brands of high-class, old-established and distilling firms who have a reputation to lose—some of these firms being Dr. Burnett Ham will recommend to the Board of Public of ancient standing, one, in particular, going back as far Health that an inspection of boarding-houses and hotels as the Jacobite rising of '46. at seaside resorts shall be made. November 3o, 1912. AUSTRALIAN MEDICAL JOURNAL. 795

H/EMATURIA. is able to pass urine, the first of which is bloody and the rest progressively clearer. JULIAN SMITH, M.D., M.S., 13.Sc. But traumatism produces its gravest effects on the bladder. Serious injuries of the pel- (Clinical Lecture Delivered at St. Vincent's vis, including fracture, always raise in our Hospital.) minds the question of bladder rupture. The simplest way to clear up the diagnosis is to In crystallising our ideas on this subject, it is pass a catheter into the bladder under strictest anti- necessary to know and to remember that any part of septic conditions. The withdrawal of clear urine the urinary tract from kidney-cortex to meatus may shows that nothing is amiss. If any considerable - bleed, and that the same causes will be operative amount of bloody urine comes away there is pro- here, as elsewhere, in the body in bringing about the bably a renal lesion, though it may be a case of result. bladder bruising. If nothing but a little pure blood Thus we must review in our considerations of conies there will be grave suspicion of bladder rup- the case injury, inflammation (tuberculous and ture. Should sterile fluid fail to return when in- other), tumours, and also the general diseases liable jected, peritoneal rupture is certain, and nothing to cause haemorrhage. but the most prompt operative help will save the As a rule, so far as injury is concerned, there is patient's life. Many of these severe pelvic crushes very little difficulty in deciding upon the source of develop progressive haematoma above the pubes or the bleeding. Take, for example, the case of the in the perinaeum and the exact injury is not discover- little girl of eleven admitted to the surgical ward a ed until the operation is performed. I cannot too few months ago. She fell, as you remember, from strongly urge you to remember these possibilities an upstairs window into the back yard. To our of injuries to the pelvis, and that quickness in relief astonishment, she neither was stunned nor did she is the whole story. Of course we should carefully break any bones. She complained only of pain in try to decide how full the bladder was before the the left loin. She was tender there, and the muscles accident. were on guard. Her urine- was deeply and uni- Disposing thus of violent external trauma, our formly tinged with blood. She was given calcium attention naturally turns . to stone, which produces lactate and kept very quietly in bed and was haematuria by a milder process of erosion and ulcer- watched closely for signs of peritoneal in- ation from within the urinary passages. Typically, volvement on the one hand, and on the other for the bleeding is not profuse. It is lessened, as one increased resistance, swelling and dullness in the would expect, by bodily rest, and is increased by loin. None of these appeared, however; her general heavy exercise or any other severe jolting. Prac- condition remained good, and in ten days the urine tically always other signs or symptoms put one on had become quite clear and her tenderness had dis- the right track. Thus the patient may give the his- appeared. We concluded, therefore, that she had tory of having passed a stone some time ago. The sustained a severe bruising of the left kidney or, at conclusion is, that he has another. If he has aching the most, only moderate laceration. The same type in one loin the opinion is strengthened. If the of case is met also in men in hunting accidents and aching gives place to colic, often terribly severe, be- in similar falls from a height. The injury is so se- ginning in loin and extending downwards to groin vere in some as to lead to very copious haematuria, and genitals, the opinion becomes stronger still, and so great as to fill the bladder with clots and to the presence of crystals of one sort or another in the cause great suffering from that alone. The extent urine brings suspicion well nigh to a certainty. It of the haematuria here is a clear guide to the gravity will remain for the radiograph to finally confirm of the kidney injury ; and much dullness and swell- the opinion, because occasionally it happens that ing develop in the loin from extravasated blood and no stone is shown on the most carefully prepared urine; the general condition is serious and operation negative. Such cases of crystals in the urine and imperative. associated colic without definite stone form a de- Again, there is no difficulty in deciding on the finite clinical entity. They respond well to urinary origin and site of the haematuria when a bullet or flushing and alkalinisation and are typically found stab wound traverses the kidney region. amongst plethoric men in the prime of life whose In other cases the history of the injury and the good appetites receive every gratification, both solid present site of pain will direct our attention to the and liquid. bladder or urethra. Thus we may, recall the brick- The haematuria in these is not at all marked ; in layer who was brought into the out-patient depart- fact, is usually only recognised microscopically. ment recently with blood oozing from the urinary 'There are to be seen in the centrifugalised specimen meatus. He told us that he slipped and fell astride discrete red cells scattered about amongst the uric the scaffolding. He could not pass water, but acid, or oxalate crystals. This method of examina- showed no signs of extravasation of urine. A tion of the urine is one of great value in obscure catheter could be passed into the bladder and was cases, and should always be kept ill mind. It is left in for a couple of days, after which he urinated particularly valuable in putting us on the right normally. We are not always so fortunate. The track in certain puzzling cases. Certain loin and urethra is sometimes torn right across and a cath- lateral abdominal pains, pains along the course of eter cannot be passed. Operation becomes neces- the ureter and some ill the pelvic region, are ex- sary. Per contra, some cases are not so serious. asperatingly obscure, and the presence or absence of There is bruising of the urethra only. The patient red cells may be the additional piece of evidence

796 AUSTRALIAN MEDICAL JOURNAL. November 30, 1912.

turning our attention to this or that organ. I recall whether it is confined to one kidney, and, if so, whe- the case of a woman who had pain in the right ther the other is present and functional. Rational "ovarian" region; she also had some slight fre- treatment is impossible without this, and the cysto- quency of micturition, and her symptoms were scope alone can supply it. ascribed to systic ovary (which was slightly en- Speaking of haematuria generally, the cystoscope larged), and she was treated accordingly. She did may be of twofold use. It may not only disclose the not improve. Armed with this knowledge, the ne- site of the bleeding, but it may also disclose the cessity of a proper investigation was seen. Red cause. In some instances it is the only means of cells were easily found in the urine and a stone low diagnosis. down in ureter suspected. [Remember a stone low 'fake the case of the man of 5o admitted to the down produces frequency of micturition.] An X- ward a month ago. I-f e gave a history of good ray picture confirmed the presence of the stone. On health until six weeks before admission. He then removal all the trouble cleared up promptly. experienced nothing more than slight bladder dis- I remember another woman who had several comfort from time to time, and began to pass blood gynaecological operations without relief. When I in urine intermittently. A careful study of his case saw her she had red cells constantly. The X-ray left one quite in the dark. His stream had become showed no stone, and the urine was inconclusive, slower of late years, and his prostate felt above nor- except that it directed attention to the urinary mal in size, so it was offered as a suggestion by one tract. Later investigations showed the presence of of you that a congestion of his enlarged prostate had tuberculosis. I could tell you of many similar resulted in rupture of one of its veins. This is un- cases. In order to give a true perspective, how- doubtedly a cause of haematuria in many a case ever, I must remind you that microscopic blood in even when no attempt at catheterisation for relief urine may he caused by influences primarily out- has been made. But in this case it was not so, for side the urinary tract and affecting it by spread. So we found that he had multiple palpillomata of the that you see it is just as comprehensive a symptom bladder. At the operation five of them were re- as naked-eye haematuria, and may arise from any of moved and their bases cauterised, the patient leav- the causes giving rise to the latter, and be on oc- ing the hospital in a month, relieved for the time at casion just as obscure. any, rate. In this patient the haemorrhage was never at any time excessive, but it is papilloma Before leaving the consideration of stone, I must mention bladder calculus. The haematuria result- nevertheless that typically produces those copious, ing is usually slight and typically is seen as a few often alarming, haemorrhages which leave the pa- tient anaemic to a degree. The bleeding is some- drops in the terminal urine. If the stone has not times referred to as a "symptomless" haematuria, caused cystitis to any extent, there will be frequent íicturition when the patient is up and about, which implying, of course, the absence of pain or other is relieved by rest. Pain is referred to the glans symptoms which might aid in diagnosis. penis, and careful questioning sometimes elicits the The papilloma, then, is typically the cause of fact of sudden stoppage in the course of micturition. symptomless haematuria. The bleeding is copious, Of course the investigation of most cases of coming on without apparent cause and ceasing also in the same way. It may just as easily recur or con- haematuria involves routine cystescopy, and if a tinue whilst the patient is in bed resting. But this stone is present in the bladder it will be at once quality should rightly be regarded as a symptom discovered. and, in addition, the very definite symptom of a You have all seen the cystoscope at work, and sudden stoppage during micturition may be met have come to recognise its great value in the elucida_ with and is clue to the valve action of one of the tion of genito-urinary disease. A certain amount »f papillomatous filaments. The occasional passage discretion is advisable, however, as to the stage of of one of these as a fragment reduces the matter to a the investigation in which to employ the instru- certainty. ment. A careful survey of the whole case should, Another cause of haematuria that the cystoscope of - course, first be made, and if a reasonable cer- discovers is bladder cancer. It is usually some- tainty is reached without cystoscopic examination, where about the bladder base, and may be felt per it might be wise to withhold it at first. Thus if a rectum, occurs in elderly people, and is soon associ- young man comes before us giving the history of a ated with penile pain and frequency of micturition. gradually increasing frequency of micturition by The bleeding is not profuse, but is fairly constant day and night, of the occasional passing of blood- once the ulceration which causes it is established. stained urine, we might reasonably suspect that he Pilharzia is not a common cause of haematuria had tuberculosis of the bladder, and, if we found a in Victoria, but a couple of years ago a well- nodule in one epididymis (he never having had nourished young man came to the out-patient de- gonorrhoea), or, perhaps, an irregular, tender pros- partment with slight and variable red water. The tate, our suspicion would be stronger, and even if only helpful point in his history was that he had we failed to find tubercle bacilli in his urine it been to South Africa in the Boer war. The cysto- would be unwise to put him to the risk of secondary scope disclosed very darkly pigmented areas in the infection by instrumentation, however carefully bladder-wall from old haemorrhage and a few raised performed. By this I do not mean that you are spots like yellowish sago grains. The ova were never to use the cystoscope in a case of urinary found in the urine. tuberculosis. 'l'here are instances in which it is im- 'there may be a symptomless haematuria of kid- portant to know how far the disease has advanced, ney origin, and here, as in the bladder, it is usually November 30, 1912. AUSTRALIAN MEDICAL JOURNAL. 797 clue to growth—papilloma or cancer. I l ut here again seen him constantly for the last ten years since the (as in the bladder) discomfort more or less marked occurrence, and he has remained perfeetly well. will at some time be noticed by the observant pa- Was this a case of so-called renal epistaxis? I sup- tient and raise more than a suspicion as to which pose a papillary vein may burst once in a while just side is bleeding. The cystoscope will aid in con- as a vein in the septum nasi does on occasion. firming this, as it will also where there is definite Although this lecture is a surgical one, it cannot renal enlargement or pain in more symptomatic be closed without a word or two of reference to the cases. We may here take as example the woman general diseases causing haemorrhage. In any who was in hospital at the sane time as the man case I do not think you will be wise in the taking with papilloma. She was sixty, and had lost weight of any case of haemorrhage to leave the blood un- during the last few months. She had discomfort in examined. So that, if they are present, you will the left loin and in the left hypochondriun and• discover leukaemia, or pernicious anaemia, or some flatulence. No enlargement could be felt at malaria. You will moreover in your investigations all but, she had had several attacks of copious search for signs of scurvy and purpura, or you may haemorrhage with free intervals. She had passed elicit a history of haemophilia. Then the question long worm-like clots. The cystoscope showed a as to whether the case is one of renal infarction will vigorously acting right kidney, but a catheter in the die-cct attention to endocardlitis, pneumonia, acute left ureter produced only a small quantity of urine rheumatism, osteomyelitis, and the like as causes in several hours, and this was deeply tinged with of the embolus. We all know how common blood. The operation disclosed a kidney high up, albuminuria is in the acute fevers, but let us not and thus impalpable. It was extensively diseased forget that they are occasionally a cause of haema- and was removed. Dr. L'renan reports to us that turia. Finally, certain drugs taken internally will it is cancerous. it will recur, 1 think, as we got it irritate the parenchyma up to a haemorrhagic de- rather too late. gree; amongst them may be mentioned turpentine, So that you see the cystoscope enables us to carbolic acid, urotropin, and cantharides. locate the haemorrhage in renal cases. it may dis- close periureteral tubercular deposit and thus fully diagnose the condition; or, on the other hand, a PERFORATING DUODENAL ULCER SIMU- small papilloma near one ureteral orifice will sug- LATING ACUTE APPENDICITIS: OPERA- gest that the large haemorrhage spurting from it is TION—RECOVERY. from a renal growth of the same nature. But the bladder finding in renal haemorrhage is often in- \GEN ;AK?1?P, 11.11., Ch.B. conclusive, and we must fall back on a consideration Won. Surgeon Gippsland Klospital, Sale.) of the history signs and symptoms to lead us to a correct diagnosis. Besides stone, tubercule, papill- On 28th September, 1012, 11.M., aged 37, a fine oma and cancer, already mentioned, we must keep healthy constable, after a heavy clay at court—being in mind renal mobility, hydronephrosis, polycystic in the witness-box most of the day—took suddenly disease, hydatid and inflammation as possible ill at 4 a.m. with acute abdominal pain, more severe causes. As an interesting case of the last, let me 011 the right side. As lie had been under treatment tell you of a young woman, who, when seen, had for two appendical attacks, and had been advised to been passing blood-stained urine on and o ff for have his appendix removed, he diagnosed his own months past. As a result she was quite blanched. case, and took the train at 7 a.m. from Stratford, Casts were also present in the urine. With a cer- intending to go to the police hospital in Melbourne tain amount of lumbar pain the possibility of stone for operation. was raised by her medical attendant. A radiograph 'l'he pain, however, became so intense that he had was negative, however. She was then examined by to be taken out at a railway siding and placed in a the cystoscope during a haemorrhage, and blood- shed. On my arrival at 9 a.m., in response to an stained urine was seen spurting vigorously from urgent telephone message, I found him in agony both ureters. The persistence of the haemorrhage and very much collapsed : he had vomited several was the unusual feature, but the final diagnosis was times, and, to use his own words, was "all out," and chronic nephritis. Later she became pregnant, and said it served him right, as he had been told at the had a very bad time with eclampsia, but recovered. police hospital this would happen to him. His pulse The more typical case for renal haemorrhage is the was I to, temperature subnormal, his abdomen as chronic nephritis with high blood-pressure, as hard as a board with extreme tenderness on - pres- Hurry Fenwick points out. sure over right iliac fossa. But with all care it is sometimes impossible to After a hypodermic of jq gr. morphia, he was arrive at anything more than a probable cause of brought 12 miles by motor into Sale to a private the haematuria, and the diagnosis will only become hospital. As soon as he had sufficiently recovered clear when the urgency of the case demands and from shock, at 2 p.m., 10 hours after the onset of the obtains operation. Even then occasionally the case abdominal pain, an incision was made over the ap- remains obscure. Or, if for one reason or another pendix. As soon as the peritoneum was opened no operation occurs, the solution may never be turbid yellow fluid like seno pus poured out, but it reached. I well remember a young and perfectly slid not have the faetor found with appendical cases. healthy man presenting himself with a marked The appendix, which was adherent, was removed, haematuria lasting for three days. After a careful and although not being the cause of his present con- study of the case, no cause could be found, I have dition, it showed ample evidence of previous attacks. 798 AUSTRALIAN MEDICAL JOURNAL. November 30, 1912.

An incision wras now made abóve the umbilicus : Menses always regular and natural ; last period 12th the same - turbid fluid flowed out ; the stomach and May. then the duodenum was examined, and a small per- On June 3oth she was suddenly seized with very foration with fluid exuding was found. Being severe pain in the lower part of abdomen, accom- situated deep down, it was a very difficult matter panied by faintness and vomiting; the faintness and indeed to close it, and, as a precaution, a piece of vomiting lasted only a few hours, but the pain was omentum was fixed to the site of the closure. more persistent, lasting about a week and gradually Owing to the patient's condition, gastroenterostomy diminishing. The clay after the attack came on she was out of question. A counter opening for drain- had a large amount of haemorrhage from the uterus, age was made over the pubes—the abdominal cav- lasting several days : it was much more profuse than ity not being swabbed or flushed otit—a drainage ordinary menstruation, but did not amount to tube was placed in each of the three wounds, the *"flooding." She was on this occasion attended by one over pubes extending down into the pelvis. a local medical man, who told her she was not preg- On his return to the ward, as soon as possible he nant. She felt well until July 15th, when she had was. placed in the Fowler position, with continuous another similar attack lasting about the same time; saline per rectum. the same medical man again attended her. About For twelve hours there was a great deal of drain- this time she noticed her breasts getting fall, and age, especially from the tube draining the pelvis. some time later thought she could feel a lump in On the fifth day the tubes were removed, the patient lower part of abdomen. She was a week before I making an uninterrupted recovery. saw her brought into town and again treated by the The above case is of interest in showing the diffi- same medical practitioner. culty there is sometimes in making a correct diag- On October 16th I was called in to see her. I nosis. Moynihan in a series of 49 cases of per- found her condition most obviously very serious ; forating duodenal ulcer, published in the "Lancet," face very pallid and drawn, anxious-looking, lips very says in 18 he made the first incision over the ap- pale, and pulse small and rapid, 136 to the minute. pendix after he had macle a diagnosis of acute ap- Temperature then 98°, rising several hours later to pendicitis. 'hhe reason of this being that the extrav- 101.4°. She had the appearance of a person suffer- asated contents gravitate down the outer side of the ing from internal haemorrhage, or perhaps septic ascending colon to the iliac fossa, giving rise to peritonitis. On examining the abdomen, I found symptoms suggestive of appendicitis. general distention ; palpation revealed great rigidity, Another feature is the absence of symptoms of especially over lower part; also intense tenderness; ulcer, which was evidently latent, the perforation but I could make out no defined tumour owing to being the first manifestation of its presence. rigidity. Percussion showed dullness all over lower Also, the turbid fluid found on making the first part of abdomen, tympanitic resonance and deficient incision so much resembled pus that the case might liver dullness above. Per vaginam, the cervix was easily have been mistaken for one of suppurating soft, with well-marked fullness and tenderness in appendicitis, and a tube left in the wound without Douglas's pouch and in left fornix; the uterus was doing anything further—the patient's Gloom in all very fixed, but owing to abdominal rigidity and probability being sealed. tenderness it was impossible to make out the size of In appendical cases this is, however, I am con- it. There was a dirty brown discharge from cervix, vinced,.the correct thing to do for the beginner or not offensive. There was colostrum in breasts. I the inexperienced. therefore diagnosed pregnancy, almost certainly in If, on opening the peritoneum, when pus is found, the abdominal cavity outside the uterus, with in- a drainage tube is substituted for the examining left ternal haemorrhage and acute peritonitis, and that index finger, nothing further clone, and no attempt she was in most urgent need of immediate whatever made to remove the appendix, a larger operation. She was, therefore, very carefully percentage of cases would recover than if a search removed by ambulance to private hospital, were made for the appendix. where she arrived in a very low condition. I have proved this over and over again when, 14 She was seen in consultation by Dr. Florance, of years ago, following the advice of Professor Mooroopna, that same evening, who agreed that Watson, of Adelaide, and partly for fear of doing operation was the only chance for her. She was so harm, although it was contrary to the teaching in low that evening, however, that we decided on post- those days, which was to remove the appendix at poning operation until next morning, and, in the all cost. I got out as quickly as I could, and was meantime, she had hypodermics of strychnine, and astonished to find how well the patients got on. was kept all night in a low Fowler's position, with NOTES ON A CASE OF EXTRA-UTERINE continuous saline per rectum. The next morning PREGNANCY. she had improved considerably, and, Dr. McKenna giving the anaesthetic, I first of all proceeded to ex- H. W. J. COOK, M.B., B.S. (Durh.), Shepparton. plore the uterus per vaginam. Sound passed up over 6 inches; I dilated rapidly with Hegar's dilators and The patient was a married woman aged 30, wife curetted, but it was empty except for a little deci- of a farmer, living some miles away in the country. dual membrane. Dr. Florance then opened the She had had one child, aged 2 years 7 months. abdominal cavity by an incision extended later to 5 No miscarriages. Never had any indication of inches in length. The whole of the lower part of uterine or other pelvic trouble until last few months. the abdomen and pelvis was found to be filled with November 3o, 1912. AUSTRALIAN MEDICAL JOURNAL. 799

Clark soft 1)100(-clot ;' the intestines were every- cipally. In scarlet fever this was four_d to be not the liver but the lymph-nodes. The condition which an ap- where adherent, and extending upwards and to the propriate antigen must fulfil for use in the search for a left was a firm, apparently solid, tumour, dark in specific scarlatinal virus seemed to my associates and colour and about the size of a six months' pregnant myself to be the following:—(1) The organs must come uterus : the uterus itself could be felt below and to from an acute toxic case of scarlet fever in which the patient succumbed rapidly and without secondary reaction the right of it. The intestines, omentum, etc., were and complications; (2) the blood of the patient examined everywhere very firmly adherent to it, as also was in the last stage before death should contain no strep- the uterus. The patient was so low that it seemed tococci; (3) the blood-serum ought, further, on being test- inadvisable to waste time separating adhesions, so ed with an active scarlatinal streptococcal emulsion, to show no deviation of the complement and the activity of the tumour was cut into and a large amount of dark the streptococcus antigen used should be tested with the blood-clot having escaped from it, a foetus was ex- corresponding immune serum; (4) the extracts must show tracted about it inches in length and corresponding by culture experiments that they contain no streptococci; to quite five months of pregnancy. There was no (5) the watery Dorgan extract tested with antistreptococcus immune serum should show no deviation of complement. movement in the foetus, but it obviously had only From the specially mild character of scarlet fever in been a short time dead. There was a well-developed Chicago, it was not easy to find such foudroyant and toxic placenta, which was separated from the interior of cases as answered to these five conditions. My associates the sac with some difficulty, the separation being and I succeeded, after long preliminary tests, in finding followed by an alarming amount of bright haemor- three cases, the conditions in which corresponded to all the demands which we had placed on a suitable antigen. rhage. The patient quickly became pulseless, and We employed only inactivated serums, which were obtained we quite expected her to die on the table, so we on the day of the experiment. As amboceptor the serum rapidly and firmly plugged the sac with a large of rabbits immunised against sheep's blood was used. In order to know whether normal .aroboceptor for sheep's amount of gauze, stitched its edges to the abdominal blood was contained in the human serum, we tested this wall, and closed the abdominal wound as quickly as each time without the addition of antigen and amboceptor. possible with through and through silkworm gut If by this control test we obtained hemolysis, we removed sutures. the natural chief amboceptor by absorption and then re- _ peated the experiment. Besides the normal serums, serums After the operation the patient appeared to be of measles, diphtheria, erysipelas, malignant tumour, tuber- dying, she was so collapsed; but, by stimulation, culosis and nephritis were used as controls. None of these raising foot of bed, saline injections and other control serums prevented hemolysis with the extracts. In means, she rallied. Continuous saline per rectum 118 cases of scarlet fever the serums were tested in this was kept up with very little intermission for a way for antibodies against the extract described, eighty- one, or 68.6 per cent., showing a complete binding of couple of clays. by which time she had got up complement. It is interesting that of the serums from into Fowler's position again. Hypodermics of cases of scarlatinal nephritis examined, every one gave a pituitrin had a good effect. Twelve hours after positive reaction. In respect to the time of the first ap- operation the pulse was perceptible and 16o per pearance of these antibodies, it may be said that they do not seem to be present in the blood in demonstrable minute. quantities before the onset of the second week, the eighth The operation was performed on October 17th. day being the earliest in which positive reaction was ob- On October 18th the temperature was 99°, pulse im_ tained. So far as the duration of the action is concerned, proved, but still over 140; had calomel, and later the the serum was found to be active in the twelfth week, and in one case of scarlatinal nephritis even in the sixteenth bowels acted. week. The following conclusions were suggested by the On October 19th I removed the gauze plugging results obtained: from the sac. The abdominal wound looked well, 1. The serum of scarlet fever patients contains specific antibodies for an unknown virus. but the discharge from the cavity was offensive. 2. This unknown virus seems to be present especially in From this date the patient slowly and steadily the cervical lymph-nodes. improved. Offensive discharge from the sac kept These conclusions lead necessarily to the inference that up for a week or so; it was syringed out with the streptococcus is to be discarded as the etiologic factor hydrogen peroxide solution and also iodine lotion. of scarlet fever. The cavity has rapidly shrunk, and now, a month Salvarsan. after operation, is not much more than a discharg- Fordyce (Jour. Amer. Med. Assoc., October 5) con- ing sinus. She has had some bowel irritation, but cludes:— got out of bed after the third week, and is now quite The efficiency of salvarsan bears a direct relation to the convalescent. age of the infection. In the early stage three or four doses supplemented by 1 am indebted for assistance of Drs. hlorance and mercury will in many cases cure the disease in from six McKenna, and of Sister Iiurrowes. months to a year. The florid stage requires more intensive treatment; five Etiology of Scarlet Feier. or six doses followed by several mercurial courses are ne- cessary. Koessler (Journ. Amer. Med. Assoc., October 26), in an In some forms of syphilis of the nervous system the ef- article dealing with recent research, says:— fects of salvarsan are more satisfactory than mercury and It is obvious that it would be of value in our under- potassium iodid. standing of the pathogenesis of scarlet fever if it could be In malignant syphilis, when mercury has been given over demonstrated that other antibodies than those for strepto- a long period continuously without changing the clinical cocci are -present in the blood with some constancy. The manifestations or the blood reaction, not infrequently all attempt has been made unsuccessfully by several investi- of the manifestations disappear after one or two doses of gators with the complement-deviation method. The failure the drug. seems to have been due to the choice of an unsuitable anti- A reaction uninfluenced by a long course of mercury may gen from too close an adherence to the Wassermann me- be changed by one or two injections of salvarsan. In thod. In the search for antibodies in a disease the germ other words, a combination of salvarsan and mercury is of which is unknown or not capable of cultivation such more efficient in changing the blood reaction than either organs should necessarily be used as antigen which clini- alone. In the primary stage it is possible permanently to cally as well as anatomically appear to be involved prin- reverse the blood reaction with salvarsan. 800 AUSTRALIAN MEDICAL JOURNAL. November 30, 1912.

study of morbid anatomy of mentally separating Rugtrartau fliebtcaY journal the result of disease from the disease itself. Such difficulty is suggested in the following paragraph :- 3oth NOVEMBER, I972. " 1I uch work has been done of late upon the ir- regularities of the cardiac muscle. This work is MODERN PATHOLOGY. well known to you and is of the very best, and not by a breath would I belittle it, for it is no doubt In great teachers of medicine there are two gifts gradually emancipating a difficult subject of re- which are equally valuable, though perhaps seldom search from the mists of ignorance that envelop equally possessed. One is the power of observation, it and by true Harveian method. But I may per- the other a faculty for expression which is arresting haps be permitted to say as a caution, that it is pos- by its suggestion as much as by its assertion. Sir sible to attribute to disease of the muscle more im- Janes Goodhart may be taken as a living example portance than by right belongs to it, and I believe of a physician and pathologist to whom both gifts it will be accepted in the future, as the result of fur- have been vouchsafed, and his Harveian Oration is ther clinical observation, that many a case of ar- a fascinating combination of the dual qualities. It rhythmia where we now seem to be inclining to is also a striking instance of the courage of a single muscular disease is in truth an aberration of the mind in breaking away front tradition and boldly higher cardiac centres, and as such no true example declaring the position that has been gradually de- of pathological anatomy." veloping from the working of numberless other minds. The literary quality of Sir James Goodhart's writings is so graceful, and his illustrations, at times, almost so playful, that their scientific weight Poto anb Commeut5. is apt to be under-rated, but it can rarely happen that their suggestiveness is without result. The Melbourne "Herald" reprinted our The title of the recent address was "The Passing "Herald" article of last week entitled "The Heroics Anaesthetist and His Duty," which cannot of Morbid Anatomy," and the oration was a frank be taken otherwise than as complimen- declaration of what has been tacitly recognised of tary to its weight. At the same time our contemporary in- late years, that the concern of the pathologist is no dulged in some disjointed comments which were unfor- longer the demonstration of morbid anatomical tunately more marked by spleen than sincerity. Some goes sentences, savagely torn from their setting, were employed change, but the disturbance of function that in an endeavour to give them the distorted meaning that before. "Whereas," he said, "we used to display the medical profession was•afraid of public inquiry, where- disease in the gross, the results of disease, that is, as our article contained the statement, "It cannot be too we are now able to recognise finer changes and strongly laid down that in every case in which inquiry is desirable, it is equally desirable that the proceedings more minute evidences of bio-plasmic unrest that should be held in public." are behind those results, and these are the goal that In another special reference to the anaesthetic question, we make for now." The physician who has fól- under the fantastic title "Senseless Slumber," the "Herald" lowed disease into the domain of the pathologist quoted a number of sentences from an article by Mr. Cotes-Preedy in Hewitt's book. By some means the has been shown, for example, the thickened or "Herald" fortuitously left out one or two sentences which, actually atheromatous blood-vessel, or the gumma- for our readers' information, we have supplied. Mr. Cotes - totts viscera, or the altered nervous tissue, and Preedy writes: —"Coroners are doubtless acting in all sin- heard the declaration that this and this is syphilis, cerity in holding these public inquiries into deaths which may, unfortunately, be due to an anaesthetic, however well and he has gone back to the bedside comforted, administered. perhaps, as to what finding he may predict, but "But is it for the benefit of anyone that professional more than ever perplexed as to why the prediction men should be paraded in public owing to an accident that should be in one direction here and another there. may happen to the most skilful and careful? "Can it be suggested that the newspaper report of such The older physicians were not pursuing a mere an inquest, with the usual startling head -lines, is of any chimera when they laid stress on temperament, for real utility? The public are unnecessarily alarmed, and they were vaguely recognising temperament as no account is taken of the many thousand anaesthetics functional expression. It is an accepted paradox administered yearly under which beneficial operations are performed." that "a patient rarely dies of the disease from The "Herald" makes a pharasaical parade of its demand which he suffers," which is no more than a witty for more publicity. The "Herald" holdc the profession up recognition that, when function is sufficiently dis- to lofty scorn for daring to think of self-interest. It is, of turbed, a terminal infection ends the scene. course, not to the interest of any evening newspaper to use Sir James Goodhart puts the position pithily information over which it can erect scare headings. when he says that the pathology of the past sug- There have been many theories of sex gests to him "a struggle on the part of the patholo- A Theory determination, and many attempts to mo- gist to find out some morbid change for every dis- of Sex dify it both individual and collective, but ease, and it is indeed admitted that we have been Nature goes on in the old proportions ever more and more reducing function to terms of despite all attempts to teach her better methods. In the third volume of 22nd series of "International Clinics" structural change," and he summarises the path- (Lippincott: Melb., G. Robertson), there is still another ology of the present and future in the sentence, "It theory of sex determination by Professor Ciesielksi, who is now no longer so much the morbid change as the is apparently a botanist, although his professorate is not mentioned. The author mentions some of the theories that prejudicial function that is to be our quarry, or have gone before, such as the greater energy of one parent rather the passage of the one into the other." (Saury), or the existence of male spermatozoa and ova in There has always existed the difficulty in the the right side, and female in the left (Henke) ; or young November 30, 1912. AUSTRALIAN MEDICAL JOURNAL. 801 ova producing females and older ones males (Thury), and of 3.80 per 1,000 in comparisonison with the preceding so forth. In 1878 Ciesielski discovered a "settled law of year, and also a decrease of 1.59 per 1,000 compared with Nature," by which males or females are determined, but the average of the last twelve years. The ratio of cases of has hesitated to publish it for fear of lowering the public deaths to the number of men is the least since the year moral standard. The theory, in brief, is as follows:-"So 1868. This is chiefly attributable to the reduction of cases it comes about that I can now, without hestitation, assert of injuries, drowning, and suicide, though there is no re- that sex of the offspring depends in the conditions of fe- markable difference between the number of cases of disease cundation, and that this holds good in the same way, with- this year .and any other year. Of the total number of cases out distinction, in plants, animals and men. In plants of death, 140, or 3.12 per 1,000 of force died of disease; 10, fresh pollen produces male seeds, but the effect of stale or 0.22 per 1,000 of force, from injury; 11, or 0.25 per 1,000 pollen is to produce female seeds. In similar fashion in of force, by drowning; 18, or 0.40 per 1,000 of force by sui- animals and in men the sex of the offspring is determined cide; and 1, or 0.02 per 1,000 of force by homicide. by the spermatozoa only. For fresh spermatozoa (that is, The number of cases of men invalided from the service those derived from a discharge of semen within the space was 730, which shows an increase of 105, compared with of 24 hours after a previous coitus) produce male offspring, the last year. The ratio per 1,000 of cases is 23.78, being but stale spermatozoa (emitted after a longer period than an increase of 4.36 per 1,000 in comparison with the year be- one day from the preceding coitus) produce female off- fore, and also an increase of 6.87 per 1,000 as compared spring." At least there is tha merit of simplicity about this with the average of the last twelve years. The ratio per latest explanation! 1,000 of force was 16.28, an increase of 2.03 per 1,000 com- pared with the year before, and also an increase of 1.82 per 1,000 in comparison with the average of the last twelve HEAL'T'H OF THE JAPANESE NAVY. years. 01' the total number of cases of invalidings 659, or 14.70 per 1,000 of force, were for disease, and 71, or 1.58 We have received the Annual Report of the Japanese per 1,000 of force, in consequence of injury. Naval Medical Authorities, which, though dated 1912, only The patients remaining over from the preceding year covers the figures for 1909, which may be regarded as a were 1,465, a decrease of 66, compared with the year before; somewhat belated compilation. We make the following and the ratio per 1,000 of cases was 47.72, which exhibits an increase of 0.15 per 1,000 as compared with the previous extracts:- The number of patients suffering from disease or injury, year, but a decrease of 4.83 per 1,000 compared with the average of the last twelve years. The ratio per 1,000 of as well as the number of days' sickness during the year, shows some decrease as compared with the preceding year, force was 32.68, being a decrease of 2.23 per 1,000 as com- and the average of the last twelve years (i.e. from the year pared with the preceding year, and also a decrease of 12.24 1897, when the Revised Regulations for the Service of Sur- Per 1,000 compared with the average of the last twelve years. geons brought an increase in the number of slight cases The actual number of patients admitted to hospital was registered, down to last year; and the same holds good for 7,210; but the number of cases 7,606, which shows a de- all the following paragraphs). The decrease in the number crease of 363 persons as compared with the last year. The of cases of disease or injury this year appears to be in in- ratio per 1,000 of force was 160.83, which exhibits a de- verse ratio to the increase in the number of force, a phe- crease of 11.84 per 1,000 as compared with the preceding nomenon very rare, having occurred before only in the year year, but an increase of 9.041 per 1,000 in comparison with 1899. The proportion of days' sickness to the number of the average of the last twelve years. force also decreased, the ratio of deaths especially showing The total number of days' sickness in hospital was a remarkable decrease compared with the previous years. 380,898 days, which shows a decrease of 2,690 compared The number of days' sickness per patient, as well as the with the last year, being an average of 50.08 days per number invalided, however, exhibited some increase. patient, and shows a decrease of 0.57 per 1,000 compared To proceed to particulars, the mean daily force in the with the preceding year, but an increase of 0.14 per 1,000 service for the year 1909 was 44,830 persons, an increase of in comparison with the average of the last twelve years. 973 as compared with the mean daily force, 43,857, of the Venereal Diseases. previous year. The total number of old and new cases of disease and in- The number of cases under this group attained 6,265, jury entered on the sick-list was 30,703 (the actual number which show a ratio of 139.75 per 1,000 of force, being a de- of patients 30,307), which shows a decrease of 1,478 as crease of 27.53 per 1,000 as compared with the preceding compared with the 32,181 cases of the previous year. The year. There was one death, the ratio being 0.02 per 1,000 ratio per 1,000 of force is 684.88, which exhibits a decrease of force, which exhibits a decrease of 0.03 per 1,000 com- of 48.89 per 1,000 as compared with the year before, and pared with the previous year. The number of cases in- also a decrease of 169.99 per 1,000 compared with the valided was 10, the ratio being 0.22 per 1,000 of force, which average of the last twelve years. shows a decrease of 0.10 per 1,000 compared with the last The total number of days' sickness was 872,606 days, year. This heading every year furnishes the largest num- showing a decrease of 33,794 days, compared with 906,400 ber of cases, though it shows this year more or less de- days of the preceding year. The ratio per 1,000 of force crease, but the ratio to cases in general is still 20.41 per sick daily is 53.33, which shows a decrease of 3.14 per 1.000 cent., showing decreases of 2.39 per cent. and 4.14 per cent. compared with the last year, and also a decrease of 5.11 as compared with 22.80 per cent. of the preceding year and per 1,000 in comparison with the previous twelve years. the average of the last three years respectively. Arranged The number of cases recovered was 26,434, which exhibits according to the actual number of cases the diseases reck- a ratio of 860.96 per 1,000 of cases, being an increase of oned under this heading are as follows:-viz., gonorrhoea 2.91 per 1,000 when compared with the previous year, but a and its sequels, 2352; soft chancre, 1446; secondary and decrease of 21.93 per 1,000 compared with the average of tertiary syphilis, 1203; bubo, 903; and hard chancre, 361. the last twelve years. The number of cases of discontinued treatment was 1,894, being a ratio of 61.69 per 1,000 of cases, which shows a de- CURRENT LITERATURE. crease of 2.60 per 1,000 in comparison with the last year, and also a decrease of 20.61 per 1,000 in comparison with the average of the previous twelve years. Senility. The total number of cases of death was 180, which, in McCorkle (Long Island Med. Journ., June, 1912) says comparison with the previous year, shows a decrease of 163, that many old people sleep far more than they think they the unusual number of deaths in the preceding year being do. On the other hand, many old people sleep far less than due to the inclusion of cases from the Matsushima disaster. 'we think they do, and the want of sleep in the decadent is a The ratio per 1,000 of cases was 5.86, which shows a de- constant menace to comfort, well-being, and life. A sleep- crease of 4.80 compared with the year before, and also a de- less night propogates its unpleasant influence into and casts gloom over the following day. Pure circulating air, with- crease of 2.54 per 1,000 in omparison with the a average of the last twelve years. The ratio out draft, is a wonderful tonic to the aged, but the bed per 1,000 of force was 4.02, showing a decrease should be warm. Cold sheets drive the blood out of the AUSTRALIAN MEDICAL JOURNAL. November 3o, 1912. cutaneous internal organs, especially the brain, 54.1 per cent. of that form of Bright's disease against 67.4 he sleep point. It has been said per cent. of Hindus in the total subjects. The double rate old age." A little hot toddy at bed time is a wonderful hypnotic for the old. At first it of parenchymatous nephritis among the Europeans is also not explainable on any other ground, such as their age stimulates the cerebral circulation, giving pleasant thoughts and a sense of well-being and comfort. Soon the tide chan- incidence, for it will be seen from the figures in Table IV. that parenchymatous nephritis is most frequent in the ges, and then the warm blood from the internal organs is carried to the surface, giving a sense of warmth to the body. early decades of life, in which there are a smaller pro- portion of Europeans than of other races The circulation in the brain comes down to the sleep point, In the records, so it might have been expected that there would have been and sleep speedily supervenes. But this sleep is often of a correspondingly low incidence of large white kidney short duration, and must be supplemented by other rem- among them rather than a great excess. On the other edies. Chloralamide, although not much used in general hand, in the case of granular kidney, it appears from practice, is of signal service in treatment of the old. It is Table IV. that one-half of this type occur over the age of soluble in whisky, and may be taken with the hot toddy at forty, and as there are nearly twice or more Europeans bedtime. By the time the alcohol has reached its limit of over that age, the exceptional prevalence of granular con- usefulness the chloralamide will take up the good work, and tracted kidney among Europeans is largely accounted for in the majority of cases a good night's sleep is the result. by this fact alone. The slightly lower rate among Hindus Even though the patient be disturbed by a distended blad- is also explained by the low age incidence of that race der he soon drops to sleep again. in the records. We may, therefore, conclude that an ex- The senile heart is the organ that calls for the most cess of proteid diet only predisposes to the parenchyma- watchful care; having grown weary, it is often sorely in tous form of Bright's disease, while a largely vegetarian need of help. Dr. Richardson made the statement years one protects to some extent against that disease. ago that almost every heart after sixty, without any mani- The sex incidence shows a considerable and surprising fest disease, becomes at times irregular, and that not in- excess among females, which is equally marked in the two frequently there may be established a regular irregularity great classes of Bright's disease. This is at variance with

of the heart. Many remedies are at hand, but when we get European experience, and I am unable to offer any rea-

into trouble digitalis is the remedy par excellence. The sonable explanation of it. question arises at once, what about the blood pressure? Table IV. Not all sclerosed arteries have high blood-pressure. In Age Incidence of Parenchymatous and Granular Kidney many cases there is hypotension, and here digitalis becomes Compared with that in London. invaluable, and even with high tension its untoward action

can be counterbalanced by vasodilators, such as potassium PARENCHYMATOUS GRANULAR. ALL DISEASES. iodide and erythrol tetranitrate. The senile heart as a rule does not need large doses of the remedy, nor oft - repeated doses. The text-book dose is too large and re- Calcutta. London. Calcutta. London. i Calcutta

peated too often. Digitalis is a chronic remedy and lasting

in its effects. Its action, once established, will last two or No. Z No. No. No. three days after the administration of it has been discon-

0-10 12 6.4 27.3 2.5 tinued. In senility a sustaining dose is indicated-a single 11-20 23 ' 9 4 16 4.7 1 0.4 13.4

21-30 ^ dose once a day may be all that will be required. Any prep- 27.6 10 22 7 1i 19.1 17 7.0 35.3

31-40 9 29 8 21 4 26.2 38 15.7 aration of digitalis may serve the purpose, but the fat-free 27.8 41-50 12.8 4 9.1 17 202 i 73 30 2 13.3 tincture is perhaps better borne by the stomach. Another 51-60 2 4.5 27 27 4 55 22.7 5.8 +60 2 preparation, known as Nativelle's digitalin is a most reli- 2.4 58 24.0 1.9

able one. The dose is small-one granule once a day or Total ... ^ I 47 84 -;4 ... 1 242 every second day may be all-sufficient.-(Ther. Gazette.") In Table 1V. are shown Granular Kidney. the data regarding the age in- cidence of parenchymatous nephritis and granular kidney Prof. Leonard Rogers (Indian Med. Gaz., Oct., 1912) respectively, together with the figures of Dickenson in

makes some generalisations from a study of post-mortem London, as recorded in his article in Clifford Allbutt's Sys- records in Calcutta:- tem of Medicine, for comparison. The Calcutta data re-

From the point of view of diet the race incidence of veal a very marked difference in the age incidence of the

Bright's disease in Calcutta is of considerable interest, for two forms of Bright's disease. Thus, in the first two de- the poorer classes of Hindus eat little meat, Mahomedans cades of life no less than 29.8 per cent. of the parenchyma- eat more than the Hindus, and Europeans considerably tous form occur against only 4.7 per cent. of the granular

greater quantities than either of the Indian races. The variety, while over the age of forty years only 12.8 per

data are shown in Table III, together with the sex figures, cent. of parenchymatous fall against no less than 50 per and for comparison those of all the subjects in 4,280 post- cent of granular disease. Dickenson's London figures

mortems of which the data are available. show a similar but even more marked variation between the two forms of disease. The first decade shows the Table III. maximum prevalence of the parenchymatous form, which Race and Sex Incidence of Bright's Disease. is strikingly different from the Calcutta experience, and is doubtless due to the great proportion of scarlatina cases Parenchy- Granular matous Total All in the London series, which Dickenson notes mostly oc- Kidney. Kidney.y diseases. curred in the first decade, while this disease is very rarely if ever met with in Calcutta. (See Fevers in the Tropics.)

Further, in London the high incidence of granular kidney continues over the age of 60, which is not the case in Cal- Hindus •,• 67.4 Mahomedans ... cutta, but this is simply due to the fact that only 1.9 per Ejuropeans 20.5 cent. of the Calcutta post-mortem subjects were over that ethers 8.2 3.9 age, while in London the proportion must be far higher. Total Males Female „. 78.1 I have also worked out the age incidence of the cases in 21.9 which only early granular changes were present and find that the maximum prevalence of the disease both begins

The above figures are of considerable interest. In the and • 1 ends a decade earlier than that of advanced cirrhosis first place, they show that the incidence of Bright's dis- of the kidney, which points to the disease being one of ease is twice as great in proportion to their numbers very slow development, usually taking years to produce

among the meat-consuming Europeans, while it is below marked contraction of the organ. the normal proportion among the largely vegetarian Hin-

dus, the Mahomedans occupying an intermediate position Moling Picture and Eye. in both respects. The especially low incidence among Bahn (New Orleans Med. and Surg. Journ., October) has Hindus is seen to be almost entirely due to the small pro- noted, after a more or less protracted moving picture portion of parenchymatous kidney among them, namely, seance, in normal eyes, in order of frequency: 1. Injection November 3o, 1912. AUSTRALIAN MEDICAL JOURNAL. 80 .3 of the lid margins and conjunctiva, increased in those pre- Corpus Luteum Therapy, disposed, and produced in the normal. 2. Lachrymation, usu- Krusen (Amer. Journ. Obstet., October, 1912) says:— ally associated with the above, but not always. 3. Retinal After a careful study of the literature and the observation fatigue or a sense of tiring deep in the eyes, as may be believe that the following conclu- or less pro- of our own patients, I produced by looking at any point for a more sions formulated by Morley are justifiable: tracted time. 4. Pain in and around the ciliary region, 1. The ovary possesses an internal secretion. noted especially in the astigmatic, and in those with mus- 2. This internal secretion is produced by the corpus cular anomalies. 5. Headache, either frontal or occipital, luteum. usually the former, on both sides. 6. Muscae volitantes. 3. In so-called ovarian insufficiency, relief may be ob- 7. Dizziness. Bahn believes that moving pictures, if fav- tained with an extract of the corpus luteum. ourably presented, are a more or less severe test of distant 4. No untoward symptoms result from its use in condi- vision and endurance on the normal eye, depending, of tions where it is indicated, even if no relief is obtained. course, on the length of time the pictures are viewed. The 5. The extract should be given a fair trial before it is vast majority of persons with normal eyes can endure four discontinued. sittings of thirty minutes each per week, with but little The extract used should be one that has been care- or no temporary unpleasant symptoms and no permanent 6. fully prepared. ill effects. 7. All glands that possess an internal secretion are more The large proportion of those who complain of unplea- or less intimately connected. sant symptoms under this time from moving pictures under 8. Further experimental work will no doubt add new the most favourable conditions have some error or refrac- light to many of the questions that are still in a nebulous tion not properly corrected, improper muscle balance or stage. defect of sight, or constitutional condition lowering eye endurance. The symptoms produced are essentially those of asthenopia and their sequelae. Moving pictures, how- ever, under unfavourable circumstances, poorly developed, CORRESPONDENCE. scratched or defective films, inferior cameras, objectionable screens, irregular and poorly-focused projection, too great or too slight illumination, etc., even in moderation, will Climatic Physiology. produce asthenopic symptoms in any pair of eyes, normal (To the Editor of "The Australian Medical Journal.") or abnormal. In those who suffer premature or severe Sir,—I am sending you a copy of my paper on the asthenopic symptoms from moving pictures under the "Analysis of Some Experiments in Climatological Physi- most favourable circumstances and in moderation, relief ology." The conclusions may be indicated as follows:— lies in the correction of any refraction error, and the bene- fits that medical science can afford, on the one hand, and It is found that for experiments in air sensibly still the less or no moving pictures on the other. loss by evaporation from the skin and from the lungs, and the loss of carbon dioxide or of carbon from the lungs May be sensibly represented by— Prognosis of Diphtheria. Loss = A tBTD. A. Harris ("Practitioner," 1912, lxxxviii, 878) gives the Where A and B are constants, T denotes the air tempera- ture, and D dryness; that is, the saturation deficit important points as follows:— or capacity of the 'air at the temperature T to take up fur- 1. Heart sound. 2. Position of the cardiac impulse. 3. ther moisture. Pulse. 4. Area of cardiac dulness. 5. Extent of surface and The question of the proportion of loss to the weight of affected by the membrane. 6. Amount of albumin, the body demands further investigation. The loss is pro- amount of urine passed in the 24 hours. 7. Smell of the bably proportional to linear dimensions for still air and breath; marked fetor is an unfavourable sign. 8. Colour to surface dimensions for rapidly moving air. of the membrane; a dark membrane being of evil import. 9. Occurrence of hemorrhages from any mucous membrane The form of the function by means of which the results or under the skin; small petechiae are of very grave im- can be represented is fully discussed. It is not simple be- port. 10. Marked enlargement of the cervical glands. 11. cause in still air the evaporation must diffuse and is slow The occurrence of certain other symptoms, such as vomit- in consequence: in moving air it is rapid. Probably some ing, abdominal pain, restlessness, etc., which are very seri- such function as— ous signs. Vomiting occurring to any extent within the L = f1, (T) f2, (D) (1 k (V .-- a (1—e--bV) Wn first twelve days often betokens a fatal issue, and it is will be necessary, in which 2L 'denotes loss of weight, V almost invariably associated with altered heart sounds. denotes wind velocity, and W the weight of the person, K, The following alterations in the heart sounds may be met A, B, and C being constants to be 'ascertained, and N de- with in diphtheria, marked in the order of their gravity:— pends on wind velocity.—Yours, etc., . (a) Marked irregularity of the sounds associated with re- G. H. KNIBBS, duplication of the second sound (best heard at the apex). Commonwealth Statistician. The rhythm and the general nature of the sounds corres- pond very accurately to the noise heard when a horse gal- [Mr. Knibibs' paper forwarded to Library.—Ed. "A.M.S."i lops. These sounds are often heard in the so-called vomit- ing cases, but they have been heard, in several instances, in which no other symptoms presented themselves. The Maternity Bonus. prognosis is very grave. There is always dilatation and (To the Editor of the "Australian Medical Journal.") displacement of the apex beat. (b) Both sounds of equal Sir,--In reference to the signing of certificates for the duration, neither of the sounds being accentuated. The maternity bonus without a special fee, I don't think we sounds are generally shorter than normal, more especially the first sound. They nearly approach the sound made by have much to complain about. a watch ticking. The apex beat is generally displaced, but I think we will get fees now where previously we would not to the same extent as in (a) and the prognosis is not have never been paid, and we will lose nothing by granting so grave. (c) Softening (sometimes almost inaudibility) those certificates free. of the first sound and accentuation of the second sound. So far my own experience has been most favourable, This condition is often associated with paralysis of the pal- for as the "fivers" have come to hand my fees have been ate. Patients generally recover from this condition, al- paid with a promptitude which is most gratifying, and in though the convalescence is slow. (d) The occurrence of no case have I asked a fee for signing the certificate. various murmurs of which mitral systolic is the common- The 'maternity bonus of this "vicarously generous La- est. That this condition is not that of endocarditis is bour Government"—+whatever that may mean—is not, in shown by the gradual disappearance of the murmur. It is my opinion, going to 'do us any harm.—Yours, etc., really of minor importance, not allow these cases to get up until the 28th day of the disease. The murmur often takes A. G. McGOWAN. eight to ten weeks to disappear. Ballarat. 804 AUSTRALIAN MEDICAL JOURNAL. N0vcnlber 30, 101.2. GENERAL. j6rití5fj StiebícaC Zkiiloctatíon. In connection with the A.N.A. National Fete, a general VICTORIAN BRANCH. meeting of all sub-committees connected with the forth- coming Exhibition of Hygiene will he held at the Hard- ware Club rooms, 350 Little Collins-street (near Eliza- Dr. A. E. R. White, 85 Spring-street, Melbourne, Hon. Sec. beth-street), on Thursday evening, 5th December, at S o'clock. Progress reports will be submitted by each sec- tion, and the proposed exhibits outlined. After the reports NOTICES. have been given, an open discussion is invited, when sug- gestions and criticisms will, it is hoped, be received for the consideration of the various committees. The next monthly meeting will be the Annual Meeting, December 4th, at 8.30 p.m. The U.S.A. correspondent ("Lancet") says:—In the New The first business will be the e'ection of office-bearers for 1913; then the retiring President's (Dr. York "Spectator" of October 5th Mr. F. L. Hoffman points [. F. Wilkin- son) address. Preceding it will be a out that whereas in the ten years ending in 1891 the homi- Special Meeting of the Branch at 8.15. cide rate in the great American cities was 5.0 per 100,000 persons, by the end of 1910 it was 7.2. Memphis, Penn., Dr. Alollison will move alteration of Rule 32 of Medical shows the highest homicide rate during the decade ending Society of Victoria:—After "Every ordinary member" de- 1911—namely, 47.1 per 100,000. Then come Charleston, lete the words "residing not more than twenty miles from S.C., 27.7; Savannah, Ga., 25.6; New Orleans, La., 22.2 The the G.P.O., Melbourne," and delete the words "or if resi- rates were also high for St. Louis, 12.6, and San Francisco. dentmore than twenty miles from the said place," and in- 11.2. During 1911 the homicide rate in most cities was sert "pro' ided that members not more than two years' above the average for the decade ending 1910. Mr. Hoff- qualified need only pay." And in Rule 31, instead of man shows by tables the homicide record for the past 30 "October" read "December." years, the comparative rates in 30 American cities from Dr. Henry Laurie will move the following alteration of 1901 to 1911, and the comparative mortality from homicide rules of B.M.A. and Medical Society of Victoria:—In Rule by geographical distribution in the United States. The 4 (B.M.A.) the word "eight" be deleted and the word average homicide rate for the decade ending 1910 was 6.9 "fourteen" be inserted in lieu thereof. In Rule 28 (B.:11.A.) per 100,000 population of all cities; 14.7 for southern cities, and 35 (Med. Society) the words " fi ve" (5) be deleted and 9.7 for western cities, 7.8 for central cities, and 4.3 for the words "seven" (7) be inserted in lieu thereof. eastern cities. During 1911 there was an increase in each For the year 1913 the Council of the Association and division except the western, which showed a slight decline. Committee of the Society be empowered to elect six mem- Comparing the rate for all cities for the decade ending bers to fill the extra positions created as above. 1910 with that for 1911, there was an increase of 20.2 per cent. In another table Mr. Hoffman compares the homi- In Rule 5 (B.M.A. and Med. Society) delete the words cide rate of the United States with that of England and "No member shall be nominated as an office-bearer unless he shall have been consulted, and signified his willingness, Wales, greatly to the advantage of the latter, and lays to be so nominated." stress on the extremely high homicide rate now prevailing in the United States. For both sexes the rate in the Uni- ted States is 4.8 per 100,000 people, as against 0.9 for Eng- Warning Notices. land and Wales. The comparison, says Mr. Hoffman, brings Court out in startling contrast the present disregard of human Sherwood and A. O. Foresters, Launceston. life in the United States. Medical men are advised to communicate with Dr. A. E. R. White before applying for positions advertised by An effort is to be made at the next meeting of the Bullfinch Medical Fund, W.A. Council of the University of Melbourne to secure the re- admittance of University students at the ceremony of the Telephone 1434 Central. annual commencement. The exclusion of students from this annual ceremony has created a curious anomaly, but VICTORIAN BRANCH.—Ordinary Meeting, 1st Wednesday that drastic course was adopted by the authorities owing to the unseemly behaviour of some of the students. The in month. motion which Dr. Bride will move at the next meeting of Clinical Meeting 3rd Wednesday the Council reads:—That the students be admitted to the in month. next annual commencement, and that the professorial board be asked to make arrangements accordingly. PEDI . ITRIC SOCIETY.—Second Wednesday in month. EYE & EAR SECTION.-4th Tuesday in Month. PERSONAL. MELBOURNE HOSPITAL CLINICAL SOCIETY.-4th Fri- day in the Month. Dr. J. P. Ryan has received the medal recently struck in Paris to commemorate the Franco-German war of 1870. N.S.W. Branch.—Last Dr. Ryan already wears several decorations of that cam- Friday in month. paign, including the Cross of the Legion of Honour. Queensland Branch.—Last Friday in month. S. Aust. Branch.—Last Thursday in month. Dr. D. Lemon has resigned his position at the Ballarat W.A. Branch.—Third Wednesday in month. Hospital and will enter upon private practice.

The Medical Board of New South Wales has registered Dr. J. C. Croom, of Melbourne, who is house surgeon at the following:—J. C. Booth, M.B., B.S., Edin., 1912; R. T. Leeds General Hospital, sends a paper, which will appear Orford, M.R.C.S., Eng., L.R.C.P., Lond., 1890; T. W. Hine, in the "Journal" shortly. M.D., Dub., 1868; R. A. A. Macqueen, M.B., Syd., 1912; E. B. Thomas, M.B.B.S., Adel., 1911; T. Wilson, M.B.B.S., Dr. W. :Moore has returned to Melbourne and resumed Durh., 1902; J. T. Tennent. M.D., C.iM., Glas., 1882; J. Aird, practice at Hilton House. M.B., B.S., Edin., 1899; and additional, H. Flecker, F.RlC:S., Edin., 1912. Sir Normand MacLaurin presided at the annual meeting of the shareholders of the Bank of New South Wales. Sir Dr. J. Kennedy, who has been doing work in Liverpool and Scotland, also made Charles Mackellar, who is president of the Board, but is a professional trip to Belgium. still away in England, was granted further leave of ab- He is now at St. Bartholomew's Hospital, and intends to sence. It is certainly unusual to find two medical men as return to Melbourne at the end of the year, guiding hands in such a large financial enterprise.

Library Digitised Collections

Title: Australian Medical Journal 1912

Date: 1912

Persistent Link: http://hdl.handle.net/11343/23178

File Description: Australian Medical Journal, November 1912

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