CYSTITIS.

A Clinical Lecture Delivered at the Women's Hospital, Melbourne.

G. HORN E, I.A., M.D. , Ch.B., Melb.

Sometimes even the best operators find that dis-appointing complications and sequelae follow their most careful efforts.

One of the most distressing of these is cystitis. Ilan—Ian nature is weak, and the post hoc ergo

propter hoc argument is so alluring, that there is a tendency to blame catheterization for th e . untoward condition. Even there miay be a leaning towards making a scapegoat of the wielder of the catheter.

Let us enquire how far the shelving of responsi-bility is justified. This leads us to a consideration of the causes contributing to the production of the disease.

And at the outset let us recognise that although cystitis generally occurs in cases where the catheter has been used, still the conditions which rendered instrumentation necessary would in themselves pre-dispose to or even produce the inflammation.

The mucous membrane lining the bladder is a highly resistant organ, and its squamous-celled ,epithelium will, as a rule, defy the attacks of most bacteria. This can be demonstrated in most cases of gonorrhoea.

The infection is always found at the urinary mea-tus, but, although the whole canal is generally at some time or another affected, the bladder usually escapes.

Another instance of the bladder's resistance and recuperative powers is seen in a case at present in this hospital. She had been treated outside for tubercular cystitis ; lavage and argyrol instillations being used, but without improvement. The focus of infection was found to be in the right kidney. A nephrectomy was done, and I also removed the whole ureter by the combined v ab-dominal

inal and ab- ominal route. With the source of constant re-

infection remove(l, the bladder rapidly improved. Argyrol lavage is still being employed, but a spon taneous cure might probably have taken place.

You may rely, then, upon the bladder being not only strong to withstand attacks, but also upon it being able, under favourable circumstances, rapidly to recuperate if the source of infection be removed. In other words, although bacteria cause cystitis, their onset will be beaten off unless some other circumstances favour their attack.

Most commonly cystitis is initiated by the Bacillus coli communis; but the soil prepared thereby is often later subjected to a secondary in-fection of staphylococci which in their luxuriant growth 'mask the original bacteria.

After a gynaecological operation, causes-consti-tutional and local—exist predisposing to the de-velopment of ll. coli comimunis in the urinary tract. First, dealing with the 'constitutional, we find that

February 7, 191.:1. AUSTRALIAN MEDICAL JOURNAL. 1417

the mere administration of an anaesthetic tends to gravely alter the patient's condition. B. coli corn-munis are found in the urine as a result of constipa-tion, febrile conditions, and many other causes. The simple administration of an anaesthetic will in a large percentage of cases be followed by their invasion of the urine stream. I have seen one case of cystitis in a virgin after ether anaesthesia for a

dental operation. B. coli are frequently found in the urine of gynaecological cases before operation, -

but this is, I think, due to the presence of residual trine, which the relaxed conditions favour.

About three years ago, while studying the urine of patients in this hospital, I found that almost all of those whose urine was sterile before operation showed B. coli cominlunis ill catheter specimens within twenty-four hours after leaving the theatre.' -

These patients did not develop cystitis, but the in-fective agent was there ready to seize on any 'oppor-tunity. This opportunity may be given in the local causes introduced by the operation.

_ In all procedures which aim at correcting uterine misplacements the bladder is forced into an un-accustomed position. This position may more nearly resemble its normal locale, but time is re-quired to accomlmodate itself to new surroundings. This is particularly the case when, as in fixations and suspensions. whether by Gilliam's or Kelly's method, the uterus is dragged upwards. The base of the bladder is its least elastic part and that base is in intimate connection with the uterus. The dragging upwards therefore distorts the most vul-nerable part of the bladder.

Still more (langerons features are introduced when hysterectomies or anterior colporrhaphies are necessary. In these some part of the bladder wall has been separated from the subjacent tissues. If this separation be dexterously and gently carried out along layers of cleavage, but little injury may be clone. But the least deviation from, the correct plan, and any of that forcible rubbing away of the bladder, that is sometimes seen, will certainly inflict a trauma.

After the most expert work the bladder wall has often the bruised look that tells of impairment, and the mere fact of separation must interfere with blood supply and innervation.

In the early stages haemsatoinata and exudates are apt to form under its raw surfaces, and later these surfaces will attach themselves in new and abnormal positions that diminish both vitality and contractility.

In all the operations named catheterization will frequently be required: in uterine replacements to prevent a distended bladder from pulling on new

-formed supports, and in 'hysterectomies and col-porrhaphies to obviate the Movement of uniting surfaces.

,,, .11 y own cases were too few in number to generalise from, hut Dr. Ed. White, who has•made a study of a large •series, tells me that in about 80 per cent. of erases examined, after operation,that - either the bacilli coli were enormously increased in number orfound where before operation they could not be discovered.

14) 8 AUSTRALIAN MEDICAL JOURNAL. F'ebruary 7, 1914.

Now what I want to point out is that the catheter does not as a rule actually cause the cystitis, but that its unskillful use allows that inflammation to come on. It may carry inwards pathogenic or-ganisms from the urethra, and there are frequently such other than gonoccoci ; but its most usual fault is a failure to entirely empty the bladder. •

One assumes that aseptic methods have been em-ployed, that the distal opening of the catheter is occluded on entering and leaving the bladder, and that no roughness has been employed. But has the bladder been completely emptied?

Just before the stream ceases the fingers detect the flick of the bladder wall against the catheter's eyes. Withdraw it a little, or gently raise the out-side end so that its point dips down to the floor of the bladder, and quite a considerable amount is sometimes obtained. This is quite a common result in bladders whose elasticity is impaired.

A complete emptying of the viscus may be ac-complished by pressure above the pubes; consider, however, how often is this feasible after an opera-tion? •

Even with the greatest care the flabby bladder (and I have already given reasons why it is flabby) will not contract so as to express the last few drops.

There you have then another link in the chain of events that lead to cystitis.

The retained residual urine is not only a culture ground for organisms, but may become a direct irritant to the bladder. This trouble is so easily remedied that if a routine practice be carried out cystitis should practically never occur.

I direct my nurses when assembling instruments, etc., for catheterization to attach to the catheter about two feet of rubber tubing ending in a glass funnel, and also to prepare one ounce of a five per cent. argyrol or protargol solution. It is desirable for the nurses to work in pairs.

After the catheter is past, the urine runs into the lowered funnel which is emptied out. When the last has come, the funnel, still held lower than the. patient, has half the solution poured in. It is then raised so as to run the solution into the bladder by hydrostatic pressure. Do not raise it too high or •the sudden and increased pressure will give pain. Then the funnel is lowered, emptied, and receives the remaining half-ounce of solution: This is passed into and left in the bladder. The rubber tube is firmly gripped whilst the catheter is with-drawn. By this means the residual urine is washed away, and any pathogenic organisms that come either from kidney or urethra are neutralized.

The prophylactic treatment of cystitis should, however, be commenced before the operation. Whenever it is probable that the urine will have to be drawn off, it is wise to administer some urinary antiseptic before and after operating. Uro-tropin in fifteen grain doses is the drug that I gene-rally employ, but when administering it one must remember that it is not efficacious in alkaline urine. For this condition helmitol or salol must be substi-tuted.

There is another therapeutic agent which is of

great value, that is, the free exhibition of water or normal saline before, during and after operation. This serves nrauy beneficial purposes. It allays the thirst, that is often the patient's most urgent dis-tress. The symptom -s of shock are mitigated, and, what interests us -most in this connection, it pro-duces a free discharge of low specific gravity ur in e.

In this the growth of the B. soli is much less vigorous.

Cystitis is as a rule easily subdued if attacked in the early stages. When established, however, it is a most obstinate affection. The recognition of the first symptoms by the nurse is therefore most important.

Pain and a frequent desire to urinate will be early symptoms; but sometimes even before this is very marked a cloudiness of the urine denotes the possibility of pus. A frequent examination for this should be the routine as long- as the catheter is being used. In this early period a rapid cure may be effected, but delay will often leave the patient with a complaint worse perhaps than that for which the operation was originally undertaken.

SOME OBSERVATIONS ON OBSTETRIC TEACHING.

ARTHUR SHER\V'1N, (Late Resident Medical Officer to Oueen Charlotte's

Lying-in Hospital.)

This short paper is written not so much to com-pare the different methods of clinical teaching as adopted ill the great midwifery hospitals of Great Britain and Europe as to sketch lightly those out-standing features that struck me most forcibly dur-ing two years spent at the leading obstetric clinics of the present day.

That an "English woman's home is her castle" perhaps accounts for the fact that in Great Britain we find the midwifery work in the hands of an "army" of midwives and pupil nurses working -under the governance of the "Central Midwives Board" and apportioned out into districts for which some general or maternity hospital is directly re-sponsible. As a consequence midwifery hospitals are few and far between, and London, with its seven millions of inhabitants, boasts of only two hospitals devoted solely to obstetric purposes.

To anyone acquainted with the poorer parts of London, it must seem a matter of considerable surprise that the mortality is not considerable, for these women in the slums (often in the most abject poverty and living in a state of indescribable filth and overcrowding) will prefer to be delivered in their owls homes rather than leave them for the additional comfort and - cleanliness of hospital treatment, and it speaks volumes for the asepsis and skill of these midwives when we find a mor-tality rate -of often less than I per i,000 and very seldom more than double that number.

All through the great European capitals we find quite the reverse system. Here are found the magnificent buildings of the State -owned and con-ducted cliniques, each with several hundred beds

February 7, 1914. AUSTRALIAN MEDICAL JOURNAL, 1419

and in which many thousands of patients are treated annually. These large obstetric cliniques are very typical examples of their thoroughness as to detail, and nowhere so much as in their pathological and bacteriological departments, where the honorary pathologists and assistants are' hard at work section-cutting, blood sera experiments, and bacteriological examinations with an energy and enthusiasm that is in itself an explanation why we have to refer for information to Continental researches.

'l'he museums also attached to these hospitals are most instructive, and at some of them the collection of pathological specimens is extraordinarily good. In Paris especially was it interesting to inspect the museum of old instruments at the Baudelocque Hospital, for, remembering that France is the "'home" of obstetric art and the French the greatest mechanics of the age, it is not surprising to see the multiplicity of instruments invented and dis-carded as improvement followed improvement in their construction. Some of the instruments used by them in the early part of last century were weird and u nwieldly to an extreme degree-cephalotribes that took considerable strength to lift and worked by a small windlass and chain attachment like the gear-wheel of a 'bicycle; forceps mostly resembling two dessert spoons tied together with cord; and others so large that one could only guess at their use.

'l'he modern side of the museums was even more interesting than the "ancient" and contained nu-merous splendidly executed wax models specially designed for obstetric teaching, and great numbers of brilliantly-executed porte-folios, enlarged sketches and diagrams, all intended for the same purpose. The library belonging to Dr. l;unrm's klinik in Berlin is another feature of in-terest, and there books in all languages (including one written by Dr. Balls-Headley) may be found, intended for the benefit of students from whatever part of the world they may be drawn.

The instrument cases too at these hospitals give one cause for thought, especially in the matter of forceps, which seem to be numberless, not only all Continental makes. but British as well; though all these latter, after a short trial, have been dis-carded in favour of Tarnier's famous instru-ments, which seem to he universally used all over Europe and America, though we find the British, with that true conservatism for which they are so famous, still faithful to Simpson's and Milne Murray's, which latter admirably fulfil most re-quirements.

Prof. Schauta's omphalotribe seems at last to have solved the utterly unscientific and non-aseptic man-ner of dealing with the cord which has persisted for so many years, for in What other instance do we rely on the process of necrosis to effect its own cure'

Excision of the umbilicus, while it has excellent: results in hospital practice, is too delicate for ordi-nary midwifery practice and just at present seems inadvisable if only for aesthetic reasons.

Prof. Bar's umbilical clamp is also another step in the right direction, hut is not in favour outside France.

Turning for a moment to the routine treatment of patients in these ;treat Continental hospitals, one striking feature is the "incubator room," for pre-mature infants. where. by a clever contrivance and regardless of expense, the incubators are fed by a supply of air nixed with oxygen, thus converting what the folk on the other side of the Channel are pleased to term "death traps" into useful adjuncts for preserving infant life, and attached, as it were, to this room a dormitory where the wet nurses live, as artificial foods receive slight encouragement at these cliniques. The feeding of patients too differs materially from ours, and a large bowl of boui ll on containing 'substantial portions of meat, half a bottle of vin ordinaire and a small loaf of bread, such as one sees served out for lunch, might be considered rather terrifying if dealt out to one of our patients in the early days of the puerperuun, but the fact that they thrive on it is sufficient testimony as to its efficiency.

Married and single woncn are treated alike, ex-cept that in some of those institutions directly under religious authority they are put on different doors.

'Pile teaching staff of these great hospitals shows striking differences. l n Great Britain, with the exception of the Rotunda, and to a lesser extent the Glasgow Maternity and Simpson 'Memorial in Edinburgh. the staff consists. as it does in ,Aus-tralia, of visiting honorary physicians who - take turns of duty when the-v rank equally, but on the Continent we have one head or professor to the clinique, who has worked his way up from the Host junior position after years of arduous toil and perseverance ; for example, Professor Bar, at the head of the fanions 'l'arnier clinique, has under hint the following:—Seven non-resident house surgeons, one of whom is on duty for 24 hours each week, when he sleeps at the hospital, and on the other six days visits at 9 and works the wards till 12. 'Pile best of these is chosen for resident house surgeon, who lives in the hospital. His next step is that of chef de clinique, which would correspond to our registrar. From this he is promoted to "ancien chef (le clinique," and has charge of the "isolement" or septic wards. In all these positions they must attend the ihospital every day for some hours. The next step is that of "agrege professeur," who lectures to the students, does the rounds and operates in the professor's ab-sence, and, finally, after many years of constant clinical work, they attain the proud position of professor to the clinique. 'Phis is to my mind the outstanding feature of Continental hospitals, the teaching staff of which may be likened to some big commercial business directly under the control of one man, to whom all subordinates look for advice and instruction; whereas in Great Britain and our own hospitals here in Australia the teaching staff of in-patient honories rank equally, a state of affairs that certainly allows scope for the production of individuality, but must tend to minimise its benefits as a teaching school.

The result of this thoroughness and attention to detail in these cliniques is that students are

ij

1420 AUSTRALIAN MEDICAL JOURNAL. February 7, 1914.

attracted from all over the world to them, and in the special post-graduate course which I attended at Professor Bar's clinique amongst a class of some thirty :medicals were three Roumanians, 2 Greeks, a surgeon from Jerusalem, one from Beyrouth, one from Peru, several Spaniards, three Germans, and a number of pro-vincial French. These courses are held six times a year at this hospital, and the fees are divided up amongstlthe hospital staff.

The students' curriculum in' Great Britain has undergone considerable changes of late years. Pre-viously a course of lectures and attendance at 12

confinements in the district being all that was re-quired before presenting themselves for the final examination. But now that each clinical school has its own Obstetric. wards practical demonstra-tions and clinics are given, and the number of con-finements that must be attended has been raised to twenty.

On the Continent students have to attend daily lectures and clinics for four months at the obstetric hospitals and take it in turn in batches of usually four, for twelve hours about every week or ten days (depending on the number in the clinique), to be on duty in the labor ward till they have con-ducted twenty cases. These courses are inter-changeable, and we find students from, say, Vienna coming to Paris for midwifery and some other sub-jects, and going on to Berlin for more, and finally finishing up in Vienna, and vice-versa. The great difference on the two sides of the Channel then is that in one instance the instruction is gained largely from one's own observation on the district and in the other under skilled supervision in the large hospitals, as is the practice out here in Australia. The former state of affairs undoubtedly fits one to deal with cases under the same condi-tions and presenting the same difficulties as the general practitioner will have to cope with in the course of a midwifery practice, while the latter is a fit school for the scientists and research en-thusiasts, for which the Continent is so famous.

A REMARKABLE CASE OF FOREIGN BODY IN THE NOSE.

JAMES W. BARRETT, C.M.G., M.D., M.S., F.R.C.S., Eng.

(Lecturer on the Physiology of the Special Senses, in the University of Melbourne; Ophthalmologist to the Melbourne Hospital.)

A man aged 74 consulted me recently complain-ing of throat trouble. He had a few patches of membrane on the left tonsil, but he had a profuse purulent discharge from the left nostril. On ex-amining the nostril something hard was felt with a probe, was grasped with forceps, and ultimately removed. It proved to be a solid object 20 mm. in length. 7 mrn. across, and 8 mm. in its thickest part. Examined at the ' University, Dr. Bull pro-nounced it to be a piece ofbone. It was firmly embedded between the inferior terbinated and the septum in the posterior part of the nose. It was surrounded by granulation tissue which came away

with it. Alter its removal all symptoms subsided, and the patient made an excellent recovery.

The history is as follows :—He was a sailor on H.M.S. "Triton" during the bombardment of Sebas-topol in 1834—a shell burst and drove some timber on to his face, and other parts of his body. His face was shattered, his thigh was broken and his ribs were broken, and he was put in hospital at Balaclava. Since then he has always had discharge from the nose, and has at times had pains in his head. In 1879-25 years afterwards—a piece of wood was removed from the left side of the nose, a piece which he thinks was an inch long and about • as thick as a stout darning needle.

The question arises—what was the source of the hone now removed from the nostril? It is dense and hard. Is it a sequestrum ,which has lain in the nose for sixty years?

DEATH FOLLOWING EXTERNAL APPLI- CATION OF KEROSENE.

JOHN K. ADEY, M.B. (Junior Medical Officer, Sunbury Asylum.)

The patient, a senile dement aged 73 years, male, was an inmate of the Sunbury Asylum for three years. At 2 p.m. on the nth January one of the attendants noticed that he had some vermin in the axillae. The attendant then took some kerosene and swabbed it in the axillae, but did not rub it in. Some of the kerosene ran down the patient's sides into his groins.

The kerosene was not washed off, but he was clothed in a flannel, a shirt, and outside garments, and was sat in a chair in the sun. Some of the kerosene apparently ran behind his back towards the sacrum.

Seven hours afterwards he was seen by Dr. Catarinich, and he was then in a collapsed condition and there were large raw surfaces on both sides, extending from the axillae to the groins, and a raw surface, about 4 inches by 6, in the lumbar region.

The condition was that of superficial burns, for which he was at once treated, but he gradually sank and diet- three days later.

The remarkable part of this case is that kerosene, which is frequently used as an external application ,

should have caused such rapid denudation of the skin. The superficial skin was peeled right off the affected areas, leaving large raw surfaces of true skin. This was probably caused by the clothes being put on over the kerosene and the free evapora-tion was consequently prevented, 'and, with the heat of the sun, the condition became like that of a poultice. There was no possibility of the kerosene being contaminated, as it was drawn directly from the tin as supplied by the dealers. A light could not have been set to it, as the clothes were not burnt.

The post-mortem showed that, considering his age, the patient was in a good state of physical health. There was no internal 'lesion.

Cases in which kerosene has caused reddening of the skin are not infrequent, but a case of death from external application is very rare, and I report this one as it may be of some medico legal interest.

711i FEBRUARY, zqz¢.

SCYLLA AND CHARYBDIS.

- The visit of an accredited representative of the parent organisation of the British Medical Associa-tion to Australia and New Zealand is an event of more than ordinary significance. The relation, at first hand, of the difficulties and danger through which the profession in Great Britain as a united body has been passing raises the question as to what are the future prospects of a wider union remain-ing a feasible proposition: Hitherto that wider union has rested mainly upon a common interest ill the progress of medical science, but with the new vistas that are opening up with respect to the rela-tion of the medical profession to the State, it is becoming apparent that some readjustment of the connecting ties \\i11 have to he taken into considera-tion.

The control of large overseas medical organisa-tions from a common centre is becoming a some-what unwieldy form of machinery, and it is almost certain that in the near future the different Empire groups of medical practitioners must be allowed to work out their own salvation in harmony with the political exigencies that may arise in their own sur-roundings. The National Insurance Act of Great Britain and Ireland may or may not be a beneficial piece of legislation, but its requirements are purely a matter of local concern. Assuming, as is pro-bable, that it will be copied in some degree by other constituent political units of the Empire, it cannot be supposed that the .attitude adopted in one place will be advisable, or even possible, in another. 'Mlle first point for consideration, therefore, will be as to what influences can he relied upon to main-tain the political union of the medical profession in the great Empire groups into which it must pre-sently he subdivided.

The one point that is all-important is that the medical profession should carefully and jealously safeguard itself from the taint of commercialism. It most reject the atmosphere of trades unionism and refuse to adhere to the trades union ideal. The • ideal of trades unionism is no longer a fair wage, it is merely a higher wage, and such an ideal must of necessity lead to a continuous unrest of working conditions. The medical profession is quite justi-fied in demanding that its remuneration shall be fair, but if the aim is to be merely higher fees, its status will be lowered from a learned profession altogether. The atmosphere of trades-unionism must again prove fatal to a, enlightened profession. It is an atmosphere of bitterness; of jealousy of new-comers; of dislike of new inventions; and of

I' ebruary 7, 1914. AUSTRALIAN MEDICAL JOURNAL. 1421

au5tratíau fRebícat Iouruat limitation of individual efforts. There is no room in medicine for increase of bitterness or jealousy; there is no place for the dislike of new methods, and if a member of the medical profession does not on any and every occasion 'give the best that is in him, then the spirit of the calling is for ever dead.

It is with some apprehension that a certain .ten-dency is observed, probably an unconscious ten-dency, to adopt the methods of trades unionism in recent medico-political disputations. The relation of the medical profession to the community is like that of no other profession, or calling. It is a peculiarly intimate and personal relation, more so even than that of religion, and it is essential that it should command respect. Organisation is ne-cessary, unanimity is desirable, but those who are entrusted with the conduct of negotiations must be carefully chosen and endowed with the needful breadth of outlook. There ought to be no sug-gestion of haggling and bargaining for what is a fair thing. The dignity of the medical profession is a phrase which is scoffed at in present .democratic days, but it will be a sad outcome for an organised profession if respect for the individual practitioner be destroyed.

The growing situation calls for all the medical statesmanship that can be summoned both for the adjustment of local and external conditions, and the presence of an influential member of the parent council affords an opportunity for discussing some, at least, of these conditions. There is danger alike in the Scylla of disorganisation and the Charybdis of truculent unionism, and it is now that the middle course should begin to be accurately charted.

gote5 anb Coruruerrtt. A correspondent in the London "Times"

Making Hay has drawn attention to the poor payment of junior officers in hospitals, and the matter has been rendered more apparent

by the dearth of applicants for such positions since the insurance Act .became law. Young men now decline to wait for hospital experience, but enter upon practice at once, and the lack of junior men is said to be felt in all directions. It cannot be doubted that this phenomenon strangely and swiftly bears out a prophecy made in these columns recently as to the effect of nationalising the pro-fession. When the Insurance Act was in working trim it was soon found that the ordinary general practitioner would earn much more money than under the old contract system. We predicted that when this was realised there would be an instant influx of men eager to go upon the panels, and this is precisely what has happened. It is easy to see that the next development will be the attrac-tion of the easiest means of becoming qualified, and a lowering of the general status of the profession by an eagFrness to begin .practice with an insufficient experi-ence. And the other result—an overcrowding of the arena—with consequent disastrous ending for all con-cerned—is only a question of time if the conditions re-main unaltered. We are in agreement that a number of hospital appointments are underpaid, and it will be ne-cessary to restore their attraction in some way. It is said that since the Act become law locum tenentes. have re-ceived from £9 7s. to £9 9s. per week, while the salaries of assistants have doubled.

Cancella- Rejected. D. at.hs. tions.

3579 10,129 .. 1326 1745 9703 .. 1307 2080 3211 .. 996

694 2403 .. 380 505 850 .. 108 310 1369 162

8913 .. 27,665 .. 4229

1422 AUSTRALIAN MEDICAL JOURNAL. February 7, 1914.

..11C tU fkl0tt$.

"Medical Diagnosis." J. H. Musser, M.D. 6th Ed. Revised by J. H. Musser, jun., M.D. Landon: H. Kimpton.

Glasgow: Alex. Stenhouse.

This is a popular American text-book which is probably known to a great many readers elsewhere. It is written with a special view to aiding diagnosis, and the first half of the work deals with general and special physical diag-nosis. The remainder summarises the leading features of regional diseases, and the whole work runs to about 800 pages. The feature of the book is a number of excellent illustrations diagrammatic and otherwise, and the teaching is sound and quite modern, a good account of cardio-graphic methods being included. The new edition should be popular with those who are in search of works of the kind.

COMMON I{' EALTH PENSIONS.

Since the Maternity Allowances Act came into operation, fifteen months ago, a sum of £810,415 has been paid away in £5 bonuses. A return furnished by the Federal Trea-sury on February 2nd gave the following details: —

Under con- State. Granted. Rejected. sideration.

New South Wales .. 61,212 479 536

Victoria .. .. .. .. 44,139 195 262

Queensland .. .. 23,707 .. 134 144

South Australia .. .. 14,930 .. 77 .. 99

West Australia .. .. 10,879 99 . 109

Tasmania .. .. .. .. 17,216 46 . 40

Total .. .. 162,083 1030 1190

The total number of claims that have been granted, re-jected, or are under consideration, is 164,303.

Invalid Pensions.

A total of 19,353 invalid pensions have been granted since the Act came into operation. There have been 3238 deaths, while 797 pensions have been cancelled, leaving 15,318 pensions at present in force. These involve a fortnightly payment of £ 15,000. Last June the total of invalid pensions payable was 13,739. The details of in-valid Pensions issued to date are as under: —

Cancella- Granted. Rejected. Deaths. tions.

7838 1578 .. 1289

425

5689 1333 .. 1107

168

2216 .. 658 .. 304

87

1369 .. 245 .. 225

54

177 .. 207 .. 74 24

1464 .. 226 .. 239 39

Total .. .. 19,353 .. 4247 3238 .. 707

There were 368 applications for pensions still under consideration when the return was made out.

Old Age Pensions.

Of old age pensioners, there were 86,546 receiving the benefits of the Act when the figures were made up to January 30, as compared with 82,943 last June. In all, 118,440 have been granted, but deaths numbering 27,665

and cancellations amounting to 4229, have reduced the total to that given. The details were as follow:—

State. Granted. New South Wales 43,577

Victoria .. .. .. 37,600

Queensland .. .. 15,726

South Australia .. 10,913 West Australia .. 4754 Tasmania .. ..

5870

Total .. 118,440 ..

Over 700 new applications for pensions are now under consideration.

CURRENT LITERATURE.

(gastric Ulcer and Gastric Cancer. Smithies (Journ Amer. 'Ted. Assoc., Nov. 15, 1913) dis-

cusses the relation between chronic gastric ulcer and gas-tric cancer by the aid of an analysis of 566 cases which were operatively and pathologically demonstrated as gas-tric cancer at the Mayo Clinic. The sex ratio in gastric cancer was found 'to be approximately that of chronic gastric ulcer-3.1 males to 1 female. More than three-fourths of the cases of gastric cancer occur in persons between the ages of 40 and 70 years; more than one-half of those of chronic gastric ulcer (134 cases) between the ages of 40 and 70 years. A family history, or one of blood relationship, of gastric cancer existed in 9.2 per cent., and of tuberculosis in 1.2 per cent of the cases. With regard to previous history, 41.8 per cent. of the patients who were proved to have gastric cancer had previously pre-sented the symptoms of chronic ulcer; 17.8 per cent. pre-sented the symptoms of "irregular" gastric ulcer, and 32.1 per cent. had the symptom-complex of gastric cancer with-out previous history of gastric trouble. Thus more than 60 Per cent. of the patients who had gastric cancer pre-sented a history of dyspepsia, and this history was gene-rally that of chronic gastric ulcer. The length of time of all symptoms of the "primary" cancerous group (182 cases) was 7.1 months. The average length of time of the precancerous dyspeptic period in 239 cases was 11.4 years. In this group the supervening period of evident malig-nancy averaged 6.1 months. In 81 per cent. of patients in whom prolonged dyspepsia had preceded cancer perio-dicity of the symptoms was noted in that stage, while in 99 per cent. of the Patients this periodicity disappeared when the process evidently became malignant. Vomiting was observed in more than 57 per cent. of the eases of gastric cancer, mo re than 40 per cent. exhibiting delayed vomiting. Of the entire group 15 per cent. gave a history of coffee-ground vomit. Delayed gastric emptying power was evident in nearly two-thirds of the cases in the primary cancer class and in nearly three-fourths of the non-primary division. In 55.4 per cent. of primary gastric cancer cases free hydrochloric acid was absent and in the non-primary class it was absent in 49 per cent. of the

• cases. More than 98 per cent, of the gastric cancers were .adeno-carcinomata, and sarcoma occurred but once in the 566 cases. Benign and malignant ulcers have been found associated in the same ,stomach. — (Med. Press and Circ.)

Pathogenisis of Cancer. D. E. Keating 'Hart ("Practitioner," Oct., 1913) con-

cludes thus: — I. The parasitic theory is given up, not as being im-

possible, but because, according to the present state of knowledge, it is unlikely and irrational; in microbial dis-eases, the injured cell leaves the virus intact, and one would, therefore, have to imagine a parasitism contrary to the histological laws of higher organisms.

State. New South Wales Victoria .. ..

Queensland .. South Australia West Australia Tasmania ..

Ii ebruary 7, 1914. AUSTRALIAN MEDICAL JOURNAL. 1 423

2. The ztbsolutc similarity is recognised of the condi-tions which govern the grafting of normal and cancerous cells, and determine failure or success.

3. It has been shown that ectopy, and the metastatic capability of cancerous cells are the consequences of their acquired properties, and of their cellular construction.

4. The purely hypothetical and inadequate interpreta-tions of the greater number o f authors are put aside.

5. The irritative theory is accepted as being the only one which embraces all the known facts in cancerous aetiology.

6. The biological conditions, created by irritation in the cells submitted to it, have been studied.

7. The reproductive power _ of cancerous cells has been proved, and their nutritive requirements demonstrated.

The correct inference from these is, I believe, that cancer is produced by cells overcultivated for a long time in the irritated zones of the organism; they are like hot-house plants, which, as a result of slow and prolonged increase of heat and food, acquire, after a variable period, the hereditary characters of over-production and over-feeding which distinguish them. Ectopy, the invasion of healthy peripheral tissues, Is accounted for by the same intensity of multiplication, which breaks down the normal barriers by mechanical pressure. Metastatic effects are due, at the same time, to the increased vitality of the cells easily carried.away in the lymph and blood streams, owing to the want of intercellular cohesion peculiar to cancerous formiation.

(lnlactogogues. In the British Med. Clin. Journ., Dr. J. Fortescue-Beicn-

dale says: — It is the very general opinion of experienced physicians

that little can be done to increase the secretion of milk in nursing mothers beyond such general measures as are in-cluded in the diet and hygiene of the puerperium. Of late years, however, three substances have been introduced which have been stated to act as galactogogues, and in view of the importance of breast-feeding, it is desirable that their possible value should be carefully considered, and a trial given to such of them as may, prima facie, seem likely to be of value.

The first of these is known under the • trade name of Galegol, and is obtained from the plant "Galega offici-nails," by extraction at a low temperature. The plant is one of the large family of leguminosm. and is used in Southern Europe for feeding milch cows. Galegol con-sists of a brown granular soluble substance, the taste of which is not unpleasant, and it is administered in doses of two teaspoonfuls to one tablespoonful per diem, mixed in milk or some other convenient vehicle, at a• tempera-ture not above 98.6 deg. F. It does not appear to be uni-formly successful, and in cases in which the quantity of milk increased, it is difficult to say how far this was due to other factors. At any rate, in some cases, in which the drug was suddenly discontinued, no decrease in the amount of milk was observed.

The next substance goes by the name of Lactagol, and is an extract of cotton seed (or hemp seed), the active principle of which is said to be the vegetable protein called 'Edestine. Cotton seed has for some time been used in feeding milch cows, but is unsuitable for medi-cation in the human subject, owing to the presence or various indigestible and irritating ingredients. In the pro-cess of manufacture the seeds are first finely powdered, and the oily and resinous portions removed by extraction with ether or benzine. An infusion cf the residue contains the active principle, which is thus freed from colouring matter and other impurities. The watery substance is evaporated in vacuo, and then ground into a fine brown powder, consisting almost entirely of protein, which swells up on boiling, but is not soluble in water. The dose is one teaspoonful stirred into a paste with cold milk. to which warm, but not hot, milk, or some other convenient vehicle can be added. It may be given three times daily. A good many favourable clinical reports have been made

on Lactagol, and it certainly seems worthy of au ex- tended trial, especially as it is apparently quite harmless.

The third substance is an extract of the posterior por-tion of the pituitary gland, which may be injected sub-cutaneously, or into the deeper tissues. Professor Scha-fer's earlier experiments on cats showed that a consider-able flow of milk followed the injection of pituitary ex-tract, but further investigations seem to show that its value is 'not so great as at first appeared. It is apparently true that a flow of milk can be excited by pituitary extract in women. Thus Mackenzie reported that in a woman who had only one breast available for lactation. an injection caused a flow of 100 c.c. of milk one hour after the breast had been pumped dry. But the very careful experiments of Gavin on cows led him to the conclusion that although doses of pituitary extract caused an increased collection of milk in the lower part of the udder, there was no in-crease in the total quantity secreted per diem, and no im-provement in the quality of the yield. A single case in the human subject reported by Sumpter seems to cor-roborate this result. The experiment was made on a young married woman, aged 28, who was nursing her sec-ond child. The milk, after five months' lactation, was beginning to fail. Four injections of 1 to 1.5 c.c. of pitu-itary extract, each c.c. of which represented 0.2 gram of fresh posterior lobe, was injected at intervals of two or three days. Shortly, the result was some immediate effect in increasing the flow, but longer intervals of rest between the feedings became necessary, and the gradual decrease in the total amount of the secretion continued. Until further evidence, therefore, is available, pituitary extract cannot be regarded as a practical galactogogue. Sumpter also experimented on the same subject with extract of the corpus luteum of the sheep, three injections of 2 c.c. (representing 0.1 gram of the dry substance in each c.c.) being given without any marked effect. The full reports of these experiments will be found in the "Quarterly Journal of Experimental Physiology" for the present year.

Transfusion. Ottenberg and Kaliski (Journ. A.M. Assoc., Dec. 13th)

conclude:- 1. Accidents in transfusion due to the occurrence of

hemolysis or agglutination of the donor's blood-cells by the patient's serum, or vice versa, can be absolutely ex-eluded by careful preliminary blood-tests. We have been able to prevent accidents of this kind in 125 transfusions.

2. The relation between test-tube 'hemolysis and intra-vascular hemolysis is close, and it seems likely that in all cases in which there is 'test-tube hemolysis, some intra-vascular hemolysis occurs. When this exceeds a certain limit hemoglobinuria results.

3. The occurrence of agglutination (between the blood of the donor and that of the patient) need not be regarded as an absolute contra-indication to the transfusion, but non-agglutinative donors should be chosen whenever pos-sible.

4. Phagocytosis of red blood-cells by leukocytes in the circulating blood of the patient transfused is undoubtedly connected with interagglutination of the two bloods; it occurred in our series in two cases in which the serum of the patients was agglutinative toward the cells of the donors (in one of the cases the serum was also hemo-lytic), and it did not occur in any of thirty-five non-agglu-tinative transfusions in which it was carefully looked for. These negative cases included two cases with extensive urticaria and one case with severe febrile reaction after transfusion. In the cases in which the serum of the donor was agglutinative toward the cells of the patient, no pha-gocytosis of red cells in the circul tion was seen.

5. In selecting donors with regard to agglutination, the agglutination of the donor's cells by the patient's serum is more important to avoid than the reverse.

6. Febrile reactions or urticaria and other skin erup-tions occur after about 10 per cent. of transfusions, irre-spective of hemolysis or agglutination, and are not due to fibrin ferment or to blood platelet destruction. These re actions, however, are never serious and the patients have done well in spite of them.

1424 AUSTRALIAN MEDICAL JOURNAL. February 7, 1914.

Strychnine in Heart Failure.

Parkinson and R. A. Rowlands (Quart. Jour. of Med., Oxford, Oct., 1913) have studied the effects of strychnine in 50 patients, 'adruitted to the London Hospital, suffering from heart failure. The pulse-rate, the blood-pressure, and the rate of respirations were examined, and the pa-tients were asked whether they felt any alteration in their symptoms after the injections of 'stryclhnine. The method employed was as follows: —The blood-pressure Was esti-mated by Leonard Hill's mercurial sphygmomanometer; the pulse-rate and rate of respirations by 'Mackenzie's ink-writing polygraph. Records were taken ten minutes, five minutes, and immediately before the injection. One-fif-teenth of a grain of strychnine sulphate was then injected. After 'the injection records were taken at the ends of each period of five minutes during one hour. At the end of each experiment questions were asked to 'determine whe-ther the patient felt any benefit from the injection. Con-trol experiments with pure water were undertaken in cer-tain of the cases.

Fifty per cent. of the cases had regular pulses, while 50 per cent. hadirregular pulses from .auricular fibrilla-tion. These two different classes of cases are considered separately, as it was thought that the cases with auricular fibrillation might react differently to the drug.

Of the twenty-five cases with regular rhythm, the ave-rage blood-pressure before the injection was 134.1 mm. Hg. ; after, 129.6 mm. Hg. The average pulse-rate before the injection was 107.3; after the injection, 104.0. The average rate of respirations before strychnine was 31.3; after, 30.6. In the cases controlled with pure water there was a similar slight fall in the average blood-pressure, Pulse-rate, and rate of respirations as in the cases treated with strychnine.

In the cases of auricular fibrillation a similar change was observed. The average pulse-rate before the injec-tion was 131.3; after, 127.9. The average 'respiratory-rate before the injection was 27.3; after, 25.3. Blood-pressure records could not be taken, as it was found that great variation in the strength of the heart-beats made the readings too unreliable to be of any value. In the control experiments with plain water a similar slight fall in the pulse-rate and respiratory-rate was recorded. Only a few of the patients admitted to feeling 'improvement in their symptoms during 'the experiment. A larger propor-tion of those treated with plain water than those treated with strychnine .admitted to improvement.

The authors consider that the slight fall in the blood-pressure, the pulse-rate, and the respiratory-rate was due to the fact that at the beginning of the experiment there was slight excitement and apprehension caused by the fitting of the apparatus, etc., and that as the experiment proceeded this wore off.

The main conclusion from these experiments is that strychnine 'has no effect which justifies its employment as a rapid cardiac stimulant in cases of heart failre. — (Glas. Med. Journ.)

Field-n ork in Tuberculosis.

In the "Journal of the American Medical Association" (Jan. 10th, 1914) Mary E. Lapham 'says:—

We guard our schoolchildren from infection in every way we can, but there are two sources of 'infection that do not sufnciently attract our attention. One source is in the unsuspected carriers of tubercle bacilli that during a lifetime cough a little, or have "winter colds" or "chronic bronchitis," but whose generalhealth and appearance do net suggest tuberculosis. One man complacently told me when he brought his wife that he had lost two wives from tuberculosis and probably he would lost this one, which he did. This man was the unsuspected carrier of tubercle bacilli. A few months ago the mother of one of my patients died at 68 and tuebrcle bacilli were found

iesi .hurtle 'before her death, but not until after two ei

lier children had died iron ► tuberculosis. We dis-

tinguish between the danger from cases with tubercle bacilli in the sputum and those without. In many cases the'prebacillary forms of Much's granules are present when the adult bacilli are not and their virulence is equally great, if not greater, so that the distinction between an open and a closed case must be changed to sputum con-taining no Much's granules and not capable of causing 'tuberculosis in a guinea-pig by inoculation.

Prophylaxis in the future must consist in preventing the 'development of a universal infection common to all mankind, which can in no way be avoided and only re-strained. The direct transmission front case to case is entirely inadequate to account for this universal infec-tion and we must seek some other explanation. We know that throughout the grasses and among trees and with the lower cold-blooded animals such as 'snakes, fish, tur-tles and lizards, and with the higher animals, such as birds, poultry, cats, dogs, sheep, pigs and cows, each class has its own peculiar kind of .acid-fast bacilli capable of producing tubercles and manifesting their genetic re-lationship to each other by tuberculin reactions. That these tubercle-producing acid-fast bacilli are universally present throughout Nature and that they all belong to the same family is unquestioned,- 'and that changes in type can be induced by changes in the host is indisputably proved.

Starting with these undoubted facts, it may be event-ually proved that the universal infection of the human race by acid-fast bacilli is comparable with its universal infection by colon bacilli and that the danger essentially consists in the assumption of pathogenic qualities. As as rule the human race has 'acquired the ability to restrain 'this assumption, but occasionally in a very small percentage of cases this ability cannot be estab-lished and tuberculosis results. The detection of this change at the earliest possible moment and its conversion into safety is the fundamental basis of our future efforts against the spread of tuberculosis. Periodic examinations of our schoolchildren would do much to reduce the tuber-culosis of adults.

T8rítt51j IfieòfcaY a5ocíatíon. VICTORIAN BRANCH.

BENDIGO DIVISIOI~N.

The annual meeting of the Bendigo Division was held at the Bendigo Hospital on Thursday evening, January 29th.

Those present were: —T:he President (Dr. T. E. Green), vice-president (Dr. Ffrost), and Drs. Catford, Cordner, De Ravin, Douglas, Eadie, Gaffney, Ker, Lyons, Penfold, and Williams. An apology was received from Dr. W. J. Long.

A number of interesting clinical cases were shown. Dr. Cordner showed a case which had been operated

on for intestinal stasis. The patient, a girl aged i 8, had had an acute attack of appendicitis twelve months before and had her appendix removed at the time. For three months subsequently the girl was well, but then began to exhibit signs of bowel ,stasis—anorexia, vomiting, abdominal pain, loss of weight and obstinate constipation, the bowels moving once a fortnight. As she did not improve on medical treatment, operation was decided on. Laparo-tomy was performed and the whole of the large bowel was found to be occupied by hard masses of faecal ma-terial. No apparent cause was found to account for the stasis. Ileo-sigmoidostomy was performed, followed by

February 7, 1914. AUSTRALIAN MEDICAL JOURNAL. 1425

regular n eovomcnts or we bowels, app+titc, loss of pain and increase of weight.

Dr. Green showed an infant who had projectile vomit-ing and visible gastric peristalsis. The child was four weeks old, and vomiting had started on the 16th day. The infant presented a picture of hypertrophic stenosis of the pylorus, except that the pyloric tumour was absent. On that account Dr. Green regarded the case as one of pyloric 'spasm, probably secondary .to hyperchlorhydria. Treatment by gastric lavage with plain warm water was causing the vomiting to rapidly cease.

Dr. Lyons presented the case of a child aged 1 year and 8 months, who had never been able to hold his head up properly, and could not use the left arm to any extent. It had been a diflilcult forceps delivery. There was tem-porary left-sided facial paralysis after birth, and on the second day the baby had convulsions for: the greater part of 24 hours. At present the facial expression is imbecilic and the head is constantly thrown back. The diagnosis was idiocy due to cerebral degeneration secondary to traumatic cerebral haemorrhage.

Dr. Catford showed a very interesting case of exostosis arising from the posterior aspect of the tuberosity of the right tibia in a boy aged 17 years. The lad's attention was first attracted to the tumour by getting cramp badly in the affected calf during a bicycle race 18 months ago. It caused him only slight inconvenience on prolonged exertion. The treatment was expectant. Dr. Catford then read notes of two cases of acute pulmonary oedema com plicating labour, one of which was fatal, the other re-sponded in half an hour to the injection of 1/Z gr. of morphia.

During the discussion following on these notes Dr. Hugh De Ravin recalled two cases, both of which had mitral stenosis. One recovered under the morphia treat-ment from several attacks, one attack finally proving fatal; the other case collapsed suddenly in the street and died before the arrival of medical attention. Another case he had seen in consultation was a miner, and the pre-disposing factor was apparently pulmonary fibrosis. This occurred at a military camp, and the patient recovered with the aid of morphia.

Dr. Lyons had seen two cases. One was a male with a double mitral bruit, who suffered from numerous attacks. The other was a woman whom he found dead after an attack during labor.

Dr. Ffrost had attended a case who developed acute oedema just after labor, and who recovered with the usual treatment.

Dr. Penfold read a similar case from the "Lancet."

Dr. Green raised the question as to whether the oedema was due to increased vascular tension. If so, the rapid recovery after morphia could be explained.

After the exhibition of cases Dr. Green delivered the Presidential address. He alluded to the dispute between the Association and the lodges, and appealed for a united expression of opinion from the profession. He deprecated the growing habit of relying too much on laboratory tests at the expense of the "tactus eruditus" and careful clinical bedside examinations. He also drew attention to the fact thatmost of the much vaunted modern remedies were overestimated in value, and counselled their conservative use.

The election of office-hearers resulted in President, Dr. Ffrost; vice-president, Dr. Catford; hon. secretary and treasurer, Dr. Williams; committee: Dr. Green, Dr. Ker, Dr. Penfold, and Dr. Douglas.

Dr. Ffrost wished Dr. Cordner bon voyage and welcomed Dr. Douglas.

A vote of thanks was accorded to Dr. Green --the re- tiring president—and Dr. Ker—the retiring hon. secre-tary and treasurer.

This concluded the business of the evening, and then the retiring president, Dr. Green, entertained the members at a banqut.

GENERAL.

The Australasian MedicalCongress will be opened on Monday. Nearly three hundred delegates will attend from all parts of Australasia. At the formal opening speeches will be given by the Governor (Lard Liverpool) and the Prime \ 'linister (Mr. 'Massey).

A special clinic was arranged recently by Dr. William Seaman Bainbridge, professor of surgery at the New York Polyclinic Hospital and Medical School, when Sir W. Arbuthnot Lane, Mr. Herbert Paterson, and Dr. Bainbridge himself operated. Sir Arbuthnot Lane performed three operations. One was on an infant ten days old for the cure of cleft palate and hare lip; one was a short-cir-cuiting operation on a patient suffering from intestinal stasis; and the third was a "plating" for fracture. Mr. Paterson did an exploratory laparotomy and Dr. Bain-bridge a short-circuiting operation for intestinal 'stasis. In addition several persons who had been operated upon or treated by Sir Arbuthnot Lane and Dr. Bainbridge for intestinal stasis of varying degrees of severity were shown. Some of these had been operated on as long as five years ago, but all were in excellent health. The theatre in which the clinic was held was filled to over-flowing, there being present surgeons from all parts of the United States.

The total deaths in France in 1911 were 775,088, equal to a death-rate of 19.59 per 1,000, a total increase of 70,318 over the preceding year. The increase was mainly among children under one year and people over 60, the excess in the former group being 30,172, in the latter 26,410. Enteritis was the predbmiiniant factor in the first group, carrying off 46,769, or nearly half of the total number (118,300) of deaths in children under one year, an increase of 28,631 over the preceding year. Typhoid fever showed an excess of 1324 deaths in 1911 over the mean of the preceding years, probably due to the excessive heat, which diminished the supply of pure drinking water and also led to the consumption of impure ice. Epidemic dis-eases showed a general decrease. Influenza, the most fatal, caused 9600 death's. The total deaths from epidemic diseases were much the same as for deaths from violence and suicide—viz., 29,470, as against 29,163.

The Empire Hospital for paying patients, Vincent-square, Westminster, the building of which has just been completed, will fulfil a function in the treatment of the sick which has hitherto been, to a large extent, neglected in London. It is 'intended primarily to provide the most efficient and thoroughly-equipped nursing accommodation for paying patients, who hitherto have had only the al-ternative of resorting to a private nursing home, where the fees charged are beyond their means, or to another where the nursing is inefficient or the building quite un-suited for the application of Modern hygienic treatment. The 'Empire Hospital has been started with private capital and will be conducted on business lines, but the promoters of the scheme only look for a reasonable return on the money invested. The charges wjll be from three guineas a week upwards, according to the accommodation re-quired, and each patient will be attended by the medical man of his or her own choice, the hospital management providing the nursing staff. There is also an honorary advisory medical committee, comprising some of the best known members of the profession in London, with Sir

Francis Laking at their head. The building is of five storeys, and the situation, on the sunny side of the quiet and spacious Vincent-square, an ideal one for a 'hospital. At present there is accommodation for forty-four patients,

but there is provision made for expansion when needed.

1426 AUSTRALIAN MEDICAL JOURNAL. February 7, 1914.

As to the construction of the building, it is almost un-necessary to say that it has been carried out on the most modern 'hygienic principles. The hospital is of fireproof material throughout, all corners are rounded to provide against accumulation of dust, and every room is well lighted from outside. The kitchens are furnished with the most efficient apparatus for cooking by electricity. There are two operating theatres, and a separate room for administering anaesthetics, a sterilising room, an X-ray room, and ;â series of bathrooms, including a Nauheim bath, Dowsing radiant heat, electric light, and .hydro-electric needle baths.

At Enfield Petty Sessions David Hole, farmer, and Percy Manning, farrier, both of 'Enfield Highway, were

summoned at the instance of the Royal Society for the Prevention of Cruelty to Animals for permitting the burn-ing and burning respectively a horse's mouth. A solicitor said that on 'November 26 Hale noticed that a horse which was his property had swollen gums and could not eat its food. He took it to Manning, who 'treated the animal for "lamp:as," which, said the solicitor, was a purely imag-inary 'disease. Manning burnt the horse's mouth, a prac-tice which had died out for twenty or thirty years, as it was found that the disease did not actually exist. Man-ning admitted that 'he had burnt the animal, and 'said: "I have fired thousands, and I hope to fire many more." A veterinary surgeon said that if the mouth was burnt the functions of the palate were interfered with and very serious results might ensue. Burning 'had never been a practice amongst qualified veterinary surgeons but only among farriers. The chairman said the bench were of opinion that the defendants had sinned more through ignorance than anything else. They would be fined 10s., including costs, and veterinary fees of one guinea each.

A report has been presented 'to the London Insurance Committee with reference to the work of the medical referees lately appointed. About 30 approved societies had made use of the scheme, and over 700 applications had been dealt with. The following analysis was given in re-spect of 471 applications received to the end of October: —Of cases dealt with, 33 men were declared by the referees fit, and 54 unfit, for duty; 175 women were declared fit. and 167 unfit. In the 76 cases withdrawn by approved societies examinations were arranged, but the insured per-sons failed to attend. In the majority of such cases they "declared off" from ,benefit. Of the 208 persons reported as "capable" of work 30 per cent. were originally fur-nished with certificates for debility, anaemia, weakness, etc., and 15 per cent. with certificates for rheumatism and dyspepsia. The reports did not show that any high per-centage of these cases were malingerers, but that low vitality, lack of nourishment, and mental inertia were predisposing causes of "invalidism." The few cases of e'wi3us malingering had generally been in respect of per-sons in receipt of low wages. The interpretation of "incapable of work" had presented some 'difficulties, and in some cases the referees had reported that though in capable of 'his usual work an insured person was capable of light work. The question whether pregnancy in itself should be regarded as incapacityalso arose.—("Lancet.")

LISTER INTERNATIONAL MEMORIAL. The treasurer in Victoria (Mr. R. Hamilton Russell)

desires to acknowledge the following 'further contributions

to the ,fund:- Goulburn Valley Branch, B.M.A. (per Dr.

Florence) .. .. .. .. • .. .. .. .. £2 2 0

Dr. Frank Legge .. .. .. .. .. .. .. .. 1 1 0 Mr. Russell desires to intimate that during his absence from Victoria any contributions to the above fund will be received and acknowledged by Dr. A. E. Rowden White, 85 Spring-street. He desires also to state that a bank draft for £ 91 9s. 6d., being the amount subscribed 'to the fund in Victoria up to the end of December last, has been transmitted to the general secretary, Sir John Rose Brad-ford.

Tßrf tt^ j filleòtcal afizoctatton. VICTORIAN BRANCH.

Dr. Stewart Ferguson, 34 Collins-street, Melbourne, Hon.

Secretary.

NOTICES.

MELBOURNE PEDIATRIC SOCIETY. The monthly meeting will be held as usual on the 2nd

Wednesday (February 11th, 1914) at the Children's Hos-pital.

II. DOUGLAS STEPHENS, Hon. See.

Warning Notices. New South Wales.

Medical men proposing to apply for the position of me-dical officer to friendly society lodges in any part of New

South Wales are requested to communicate with the Hon.

Secretary, B.M.A., 30-34 Elizabeth-street, Sydney, or with

Dr. S. W. Ferguson, Hon. Secretary, Victorian Branch B.M.A.

Warwick Friendly Societies, Queensland. Before applying for any position in connection with the

above, medical men are advised to obtain information from the Hon. Secretary, Queensland Branch B.M.A., Brisbane.

Medical men, before applying for the position of medical officer to lodges at Longreach, Central Queensland, are in-vited, before doing so, to apply for information to the Hon. Secretary, Queensland Branch, B.M.A.

Medical practitioners are asked, before applying for any

appointment advertised by the United Friendly Societies of Invercargill, N.Z., to communicate in the first place

with the Secretary, British Medical Association, 26 Yarrow-street, Invercargill; or H. E. Gibbs, Secretary B.M.A., Box

156, Wellington; or the Secretary, B.M.A., Sydney, N.S.W.; or the Secretary, B.M.A., Melbourne, Vic.; or the Secre-

Court Sherwood and A. O. Foresters Launceston. Wellington Mills. Medical men are advised to communicate with Dr. S. W.

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

N.S.W. Branch.—Last Friday In month. Queensland Branch.—Last Friday in month. S. Aust. Branch.—Last Thursday in month. W.A. Branch.—Third Wednesday in month.

Telephone 1434 Central.

EDITORIAL NOTICES.

It is particularly requested that all literary matter. books for review, etc., be addressed to the Editor, Dr. Alex.

ewers, 65 Collins-street, Melbourne. Single copies may be obtained from the Manager, at the

Medical Society Hall. All business communications and advértisement applica-

tions should be addressed the Manager, "A.M. Journal," Medical Hall, Brunswick -street, East Melbourne.

MELBOURNE HOSPITAL CLINICAL SOCIE'T'Y. 4th Fri-day in the Month.

Clinical Meeting 3rd Wednesday In month.

PEDIATRIC SOCIE'T'Y.—Second Wednesday in month. EYE & EAT{ SECTION.-4th Tuesday in Month. VICTORIAN BRANCH. —Ordinary Meeting, 1st Wednesday

in month.

February 14, 1914. AUSTRALIAN MEDICAL JOURNAL. 1427

ADDRESS IN MEDICINE.

S I .\ CLAI R GILLIES, 1f.D. , Lond. (President of the Section.)

(Delivered at Australasian Medical Congress, N.Z.)

After acknowledging the honour of his position and referring to the vast field of modern science, Dr. Gillies said:—

During the latter part of the last and the be-ginning of this century advance in every branch of medicine has been enormous. New and un-expected fields have opened before our astonished gaze and rich prizes have rewarded the labors of our pioneers. In no department has development been greater or more rapid than in that of bac-teriology and preventive medicine, and from no other has humanity reaped a greater or more last-ingharvest. The stimulus given by Pasteur, Koch, and Lister has produced a response in the large and enthusiastic army of workers devoting their lives to this subject to-day. And not alone now are they occupied with the bacterial plants which held the stage so prominently in the earlier days: the limelight to-day is on the protozoa, their animal cousins. Perhaps the most conspicuous of recent developments in this field is the discovery of what have been termed the ultra-microscopic or filterable viruses, those microbes so infinitely minute as to be beyond vision with even the high-est powered microscopic lenses, but whose existence is proved by the infectivity of fluids which have been passed through the so-called "germ-proof" filters—filters witidh surely retain microbes of ordi-nary size. It is to be noted that these filter-passers are by no means few in number, some 38 varieties have been detected already. Nor are they con-cerned merely with rare or curious conditions:

vaccinia (presumably variola), rabies and yellow fever in man, pleuropneumonia, foot and mouth disease and swine fever in animals are among those set down to their account. The labours of Lands-ter, Levaditi, F lexner, and Lewis have taught us that to this group belong also the cause of acute infantile paralysis—a malady previously of rather mysterious causation. The causative organism has been recovered not only from the spinal cord and cerebro-spinal fluid, but also from the basal secre-tion of patients and contacts, placing this crippling disorder of childhood among the infective and in fectious diseases. Fortunately the tendency to infection is only slight, otherwise in the days of our ignorance wider spread would have occurred.

Of ordinary bacteria, the two of most interest to us in this part of the world are the Bacillus of Eberth and that of Koch, responsible respectively for enteric fever and tuberculosis. Enteric fever is fast disappearing from our midst, thanks to the recognition of its bacterial nature and mode of conveyance. Knowledge that in country districts the fly is an important factor in its spread has done

much to minimise its incidence in places where water carriage of excreta is lacking. So great has been the decreased incidence due to improved ,sani-tation that sonic doubt the value of protective in noculation to those exposed to infection. In all titedical,problent's so many varying factors are con-cerned that proof it often difficult, but, in spite of the general decrease of enteric throughout the civil-ised world, figures now available seem to show conclusively that protective vaccination against this disease is of great and lasting value, and should be practised in all districts and institutions where risk of infection exists.

Tuberculosis, the "great white plague" of Oliver \\ endell Holmes. still bulks large as a curse of civilised roan, accounting in Great Britain for one death in every three between the ages of twenty and forty-five, the must active and productive pc- riods of life, while in _Ansttalia some 3700 per

-sons die from it very year. Little wonder that at last the race is thoroughly aroused to its import-ance and the -need to use every effort, individual and collective. for its extermination. 'Though far from victory, much has already- been accomplished. in I l ìgiand, the death -rate from tuberculosis has been reduced to almost half in 31 years, while in the United States it has fallen from 4.9 to 1.9 per i000, considerably less than half. It must be remembered, however, that during. the same time the general mortality from all causes has fallen greatly though not quite to such an extent. In America, between the years 1881 and 1912, the death-rate from causes other than tuberculosis has fallen from 26.1 to 12.1, a decrease approximating to, but not quite so great as, that from tuberculosis, leaving a margin of 7.6 per cent. as the lessened tuberculosis compared with the general death-rate.

Dr. Gillies reviewed the modern attitude towards. tuberculosis, and believed the tuberculin diagnostic test was reliable and specific. He also referred to the awakening in regard to syphilis. He proceeded as follows:—

The study of the internal secretions and the duct-less glands has attracted many workers, and our. knowledge on this subject has been considerably extended, though we are still only on threshold. \\ e nócy recognise that a gland may have both an external 'and internal secretion, that is, may produce not only a secretion which escapes tltrougit its duct, but also one which passes directly into the blood circulating through the gland. This is readily demonstrated by ligature of the vas de-ferens in young animals, when, though the animal remains sterile, normal growth occurs. If, instead of the vas, the whole cord is ligatured, the changes seen in castrated animals are reproduced.

To these internal secretions Starling has given the name hormones, and it is probable that the in-ternal secretions of most glands consist of not one, but several, hormones, which, carried by the blood stream, exert specific excitatory, and inhibitory effects on varying organs and tissues. The main-tainance of normal bodily health depends on the presence in the blood of a proper proportion be-tween the numerous hormones circulating in it.

1428 AUSTRALIAN MEDICAL JOURNAL. February 1 4, 1 9 1 4.

No longer can the blood be represented as con-sisiting simply of corpuscles and plasma, the latter having a fixed content of albumen and salts. Hid-den in it are numerous hormones, on whose inter-actions and fractional alterations depends the nutri-tion of our bodies, while every infection, however slight, leaves its mark temporarily or permanently in the form of specific antibodies.

The most important of the ductless glands are the thyroid, para-thyroid, pituitary and suprarenal, while internal secretions have been shown to he present in the pancreas and genital organs.

With arrest of thyroid secretion and the produc-tion of myxoedema we are all familiar, and also with the results of over-secretion—exophthalmic goitre --though whether this is an over-secretion of nor-mal or pathological hormones, and of the cause of such over-secretion, we still are ignorant. That the hormones are secreted in varying proportions is ren-dered .probable by the varying severity of the crises and symptoms occurring in this disease.

In our ignorance of the cause of such hyper-secretion, our means of controlling and regulating it 'are unsatisfactory. Slight cases frequently re-spond to rest and adrenalin, while regular . expos-ore to Xrays over a considerable period has given promising results, the chief objection to this latter method being that it renders more difficult subse-quent removal of a portion of the gland, which, in capable hands, is admittedly the most successful treatment, however humiliating it may be to con-fess that we cannot decrease the activity of an or-gan without mechanically reducing its bulk.

The researches of Schaeffer, Cushing, Herring, and other workers have thrown much light on the structure and function of the the pituitary body. and have established the fact that the secretion of the anterior lobe activates skeletal growth and sexual development and controls the deposition of fat and the nutrition of the skin and nails ; while that of the posterior lobe and pars intermedia regu-lates the tone and contractility of plain muscular fibre and . of the heart, besides supplying hormones that stimulate the activity of the mammary gland and kidneys. The pituitary has a remarkable in-fluence on metabolism, and is largely the cause of the rapid growth which takes place at puberty. The effect of deficient secretion in youth is seen in dystrophia adiposogenitalis—Frolich's syndrome —characterised by high carbohydrate tolerance, in-creased deposition of fat, dry skin, impaired nu-trition of hair and nails and arrest of sexual de-velopment. Hyper-secretion produces the well-known picture of acromegaly with decreased carbo-hydrate tolerance or actual glycosuria. Where it supervenes in youth it causes gigantism. Should subsequent deficiency of secretion occur, we aee

rsity. somnolence and increased sugar tolerance superimposed on the picture of acromegaly. As vet the treatment of these conditions by 'extract of the gland has been disappointing. In acr..,rne-o'il_- where there is already hypersecretion it can -

not be expected that any good will result from giving. the extract. Here the surgeon has stepped

ill and records some brilliant results from partial removal. 'I'h e operation is a formidable one, and in the absence of eye symptoms and intolerable headaches, should not be lightly undertaken.

The close inter -relationship and inter-dependence hew cell the secretion of the various ductless glands is suggested by the increase in the size of the pituit-ary in myxoedema or after removal of the thyroid, by the simultaneous enlargement of the two glands, and by the enlargement of the pituitary after cas-tration.

'l'he close relationship, both thyroid and pituitary, to the pancreas is shown by thedecreased carbo-hydrate toleration, or even diabetes occurring in connection with exophthalnic goitre and acrome-galy. Experimental evidence seems to establish the fact that the thyroid secretion tends to check the activity of the islands of Langerhans, whose hor-inones govern carbohydate metabolism.

As regards the suprarenals, it is now firmly es-tablished that the medulla produces a secretion of extreme activity which stimulates contraction of non-striped muscle through its action on the myo-neural junction. As adrenalin, hemisine or epine-phrin. it is extensively used clinically. The cortex Of the gland provides a secretion which regulates the deposition and destruction of pigment and prob-ably also profoundly affects the development of the sexual organs and chacteristics. Destruction of the suprarenal induces the clinical picture of Addison's disease, but treatment_ by glandular extract has proved of little value.

Enough has been said to indicate the advance of knowledge in this direction to show how compli-cated is the inter-relationship of these secretions and to confess how little we yet know of their slighter functional disturbances and the method of their control.

Considerable change has taken place in our con-ception of cardio-vascular disease. The importance of raised blood pressure has been emphasised of late years. and few practitioners are now without some instrument for its record. The tendency still persists with many to consider high pressure a disease in itself to be attacked and reduced in every case, instead of attempting to unravel the cause and so determine which cases should be treated, which left alone. Instruments for its record are not infrequently employed without recognition of the possible fallacies attending their use..

Turning to the heart itself, we no longer con-centrate attention on murmurs and slight degrees of valvular incompetence, recognising that the con-dition of the cardiac muscle and the likelihood or not of future degeneration are all important. The epoch-making work of Mackenzie with the polygraph, of Lewis with the electrocardiograph. and the pathological studies of Tawara, Keith and others have revolutionised our knowledge of the physiology of heart muscle. Most of us are now conversant with that collection of less differentiated muscular tissue the sino-auricular node, "the pace-maker of the heart." whence normally originate the impulses governing the cardiac rhythm; with the

February 14, 1914. AUSTRALIAN MEDICAL JOURNAL. J 429

auriculo-ventricular node, the auriculo-ventricular - bundle and its distribution to the ventricles. Many of you are also familiar with the work that ha.s unravelled the various .arrhythmias and has es-tablished the mode of production and significance of such conditions as pulus alternans, auricular flut-ter, auricular fibrillation, and heart-block. Thanks to the electrocardiograph we can detect slight grades of hypertrophy of the right or left side of the heart, blocking in various parts of the auriculo-ventricular bundle, the seat of origin of irregular systoles, the presence of flutter or fibrillation.

The study, of cardiac disease by the polygraphtad electrocardiograph is a striking instance of the close inter-relationship between medicine and physiology. In this case the clinician has been able to repay some of his debt to the physiologist by opening up fresh fields of knowledge. Though much has been done there is yet much to learn from these instruments, and no well-equipped hos-pital should be without them. We must beware, however, lest our enthusiasm over details blinds us to the fact that the pumping station is only one, if the most important, part- of the irrigation system, and lest we transfer our attention from one detail to another instead of acquiring a more comprehensive grasp of the circulatory system as a whole. Among other advances secured by these instruments is a completely altered view of the mode of action of cardiac tonics. No longer does digitalis and its congeners figure as a muscle tonic, but as a poison blocking the conduction of im-pulses from auricle to ventricle and so allowing the latter to rest and recover its. power.

The importance of syphilis as a cause of cardio-vascular disease is becoming more clearly recog-nised, routine application of the Wasserman test showing that nontrauanatic aneurysm and aortic re- gurgitation arising apart from rheumatic fever, are as frequently due to this cause as are locomotor ataxy and paralytic dementia ; while many cases of unexplained muscle failure react positively to the same test.

In the realm of neurology greater exactness of diagnosis has followed more accurate knowledge of the functions of the various tracts and centres in the brain and cord, and the co-operation of the neurologist and surgeon has rendered possible operative interference •undreamed of a few years ago.

Though deprecating cerebral operations in any but Most skilled hands, we should all learn and apply the lesson that early decompression in cere-bral tumour not only preserves sight and lengthens life, but also relieves' the pain in one of the most terrible and fatal diseases to which man is heir.

:1s the result of wider knowledge, so-called func-tional diseases are decreasing in number, and it is no longer permsisible to salve our conscience with the diagnosis neurasthenia, without further effort o determine the underlying cause, be it toxic or due

to overstrain. For our increased knowledge of the causes of

the symptoms of digestive disorders we owe much

to the surgeon, much have they done to disentangle for us the symptoms produced by gastric or duo- denal ulcer, cholecystitis, and chronic disease of the appendix. Fot "the inestimable gift of the path- ology of the living," to quote the words of that brilliant surgeon and orator Moynihan, we are deeply grateful, as we are for the further restric- tion of the bounds of that unsatisfactory domain "functional dyspepsia." But are not some of our surgical friends just a little like the intelligent globe-trotter, who, coming to a new land, sees quickly aspects of life and civilisation which have not struck those living . in their midst, and who forthwith, concluding- that he knows all, advises remedies for evils of which he but partly grasps the cause. If the physician has in the past been prone to unduly postpone operative interference, are not certain of our surgical 'brethren a little over-sure of their surgical cures. If every case of gall stones and cholecystitis, however mild, is to be submitted to the knife, we must 'have assurance that the cause that produced the first attack will not recur. Before we accept the diagnosis of duo-denal ulcer from the anainnesis alone we must have proof of the care and impartiality with which the history was elicited and even then know from experi-ence that the best taken history often leads astray. 'l'he diagnosis made, we still recognise that the majority recover without operation. If, while fully alive to the distressing dyspeptic symptoms that may accompany chronic appendiceal trouble, we await further proof that the commonest site of a gastric ulcer is "in the right iliac fossa," might we remind the eager operator that reflex diges-tive disturbances may have ' their origin elsewhere than in the appendix or gall-bladder—nay, even above the diaphragm, and that the urgency of symp-toms is sometimes dependent on undue irritability of the nervous centre rather than on the magni-tude and importance of the stimulus. If we still suspend judgement on the theory that all gastric ulcer is -due to obstructive appendicitis, what are we to say of the views of a distinguished surgen who lias recently invaded the realms of medicine, who holds that gastric ulcer, gall stones, rheuma-toid arthritis, tuberculous disease of bones and joints, diseases of the breast, cystic and malignant, of the thyroid, and iiMany other troubles are due to septic absorption from the intestine, and that their salvation is found in joining the ileum to the sig-n1oid, or in removing' the whole colon.

The limitations of the X-ray picture of the Ilis-muth.meal in the diagnosis of gastro-intestinal af-fections have yet to be fixed, and as in every new method, conflicting results abound. Already, however. the bismuth meal has afforded useful evidence in both gastric and intestinal disorders, and with the adoption of a standard meal, both as regards quantity and quality, as recommended at the last annual meeting of the British Medical As-sociation, more uniform and useful results will be obtained.

\n outstanding feature of modern medicine is greater precision in diagnosis. This has been gained partly: by the use of instruments of greater delicacy,

1430 AUSTRALIAN MEDICAL JOURNAL. February 14, I914.

partly by the elaboration of biochemical and bac-teriological tests. The use of these instruments and the application of such tests demands both time and special training with the consequent evolution of the specialist. It would be hard to overestimate the gain to diagnostic medicine of the isolation of the organisms in a suspected case of, say diph-theria; tubercle or enteric, of the Widal or VVrasser-man tests, of gastranal'ysis, the fluorescent screen, and fray picture the polygraph, electrocardiograph and sphygmomanometer.

Verily, we are blessed compared with our fore-fathers in the multiplicity and delicacy of our diag-nostic methods. But is their use always altogether free from danger to our patient? So rapidly do new methods appear that we scarcely master one and recognise its limitations before we throw it aside, lured by the brilliance of a newer and more at-tractive method. Old, well-tried tools are some-times cast away for others of which we know little, and which must be wielded by specialists, in whose ability and accuracy we must blindly trust. While welcoming and appreciating every new method of diagnosis, let us not forget that it has its limita-tions, and that the more complicated its mode of application and the greater the number of vari-ables in its technique, the greater the chance of error in the result obtained. Positive results in capable hands are of the greatest value, but do we always recognise the -value of the negative? "Fail-ure to find" is too often unjustifiably construed "absence," and cases could be multiplied showing the danger of relying blindly on laboratory find-ings.

These newer methods are the happy possession of the dweller in large,towns and of those who have access to large hospitals. For the rank and file, for the man in the small town and country a sound knowledge of older clinical methods is as essen-tial as ever it was.

With the present trend of medical training do we not run some risk of producing in the future medical scientists in the place of efficiently equipped general practitioners. Let me illustrate my mean-ing.

Cushing, in his admirable address on Surgery at the International Congress, told us, in speaking of syphilis:—"To-day the clinical acumen of the prac-titioner has given way to clinical test by the labora-tory expert, and only when the disease is thus proved to exist is a diagnosis accepted. The dis-covery of the spirochete and the study of its bio-logical habits have taught us that in certain parts of the body, especially in the central nervous sys-tem, the organism is not accessible to former methods of treatment, or indeed, if reached, it may have acquired immunity and resistance to the very drugs supposed to destroy it.

Let us suppose the malady has taken the form of a cerebral gumma. The patient has headache, and there is a suspicious clinical history. What is required? A lumbar puncture, a cytological ex-amination of the fluid and a Wasserman reaction re-quiring one specialist, an ophthalmogical and peri-

metric requiring another; a neurologist, certainly, for a careful study is necessary to determine, if possible, the situation of the lesion ; probably, too, a rontgenologist, and perhaps in the end another to administer salvarsan; or in the case of a non-absorbable fibrosyphiloma, as likely as not an opera-tion will be needed; and this for what yesterday was a simple problem easily faced by the practi-tioner single-handed!"

That gives you one general practitioner and five specialists, not counting "the ,proibable surgeon," to deal with a condition which is, not was, being successfully diagnosed and treated daily by well-equipped general practitioners. Certainly all these procedures may be needed in exceptional cases, but to make them the rule and require them on every occasion is not only unnecessary, but savours of scientific pedantry. Our duty to our patient is to reach a correct diagnosis by the simplest method and that least disturbing to his peace of mind, body and pocket. If we can do so as the result of bed-side examination backed by clinical experience, why oust clinical acumen in favour of these numer-ous special methods, provided always we do not fail to avail ourselves of them in cases of doubt, and bear in mind that a positive laboratory re-sult obtained by efficient workers must weigh heavily in the scale against mere clinical experi-ence.

To the specialist our debt is great and ever-growing. Equipped by a sound medical education and a sufficiently wide experience of general medi-cine, the concentration of his powers on certain regions or phases of disease has added, and is daily -aiding, untold wealth to our store of knowledge. Every day we are in greater need of his special skill. But is there not some danger of over-zeal ill this direction, and are we not inclined to force unduly this attractive growth? Are not men tend-ing to specialise too early, before they have ac-quired a sufficiently wide grasp of general medi-cine and surgery, and are they not apt, in conse-quence, to take sometimes an exaggerated and dis-torted view of the import of symptoms through to close attention to one narrow field, failing to recog-nise that symptonms arising in their special area are not infrequently but part of a general disorder, and that no local disease should be studied without reference to its general connections. Do all join the ranks of specialism from a keen desire to push forward the hounds of knowledge in that particu-lar branch; or may it sometimes be the smaller field and larger fee that lures us?

Let me cite a few examples that have recently come under my notice of mistakes due to unbal-anced specialism.

A man of middle age, having for years some slight nasal obstruction, develops violent headaches. A rhinologist discovers and removes an enlarged middle turbitial, "the obvious cause"; but, the pain remaining unrelieved, a general overhaul is sug-gested, with the discovery of Advanced chronic ne-phritis.

A woman, with commencing cough, de.:\ides that

February 14. 1914. AUSTRALIAN MRDIEAL JOURNAL. 1431

she has catarrh, and seeks a throat specialist, who, finding a small nasal polypus and some granula-tions and enlargement of the tonsils, treats her for 'six months, ere she seeks the general physician, to be told that she has advanced tuberculosis.

:\ clergyman with gouty ancestry develops head-aches, and hies him to a gout specialist, who for years treats him unsuccessfully for gouty head-aches, which yield at once to correction of asti-gmatism by appropriate glasses.

A young married woman, with a strong tubercu-lar history. develops cough and slight fever with debility. She is long regarded as a case of tuber-culosis, till examination of her nose reveals sup-purating sinuses, whose treatment results in cur,..

Is there not need to pause at times midst our vaunted cures to better study the natural history of untreated disease? We, as a profession, and more particularly, perhaps, our surgical brethren, are inclined to-day to unduly belittle the vis medi-catrix naturae. Nature mày be a poor surgeon, and may not be as conversant as ourselves with up-to-date medical theory, but she still effects many cures in spite of us.

\ doctor's child, with non-suppurating tubercu-lar glands in the neck. is taken to two eminent surgeons, who say operation is absolutely neces-sary. Fearing the knife, the parents take him to an expert in vaccines. who assures a cure by small closes óf tuberculin, guided by study of the opso-nic index. To he quite certain they consult another vaccinator, who also promises cuure, but the dose must be large. Bewildered by such conflicting ad-vice, they delay, and the child gets well ere they can decided on the right treatment.

Doubtless each of these specialists was right in promising cure, hut each and all neglected the fact that under suitable hygienic conditions the majority of such cases are able to effect their own recovery.

Do not misunderstand me in this matter. Spec-ialism has clone, and is doing, magnificent work for the public and profession alike. To it we owe much of our advance in knowledge of disease. But there is a real and growing danger of it restrict-ing itself to a too narrow field, and, by ultra-con-centration, failing to compass the true solution of the problems set before it.

This difficulty of preserving a broader view be-sets us .all—general practitioner and specialist alike. Insensibly we drift into certain channels and float contentedly on,. raising our heads at -lengthening intervals to view the fields around, satisfied that the glimpses we get between the tangle of custom on the banks is all there is to know, or giving un-duly credulous ear to the tales of those who have ventured to penetrate at certain spots the over-hanging brushwood. Hence comes our readiness to adopt every new mode of treatment and blindly follow every fashion of.he day. True, we have abandoned our faith in polypharmcy and in all hut a few well-tried drugs. In their places the bac-teriologist dangles before us serums and vaccines,

which, in and out of seasons, we inject into a gap-ing- -public "aviclus rerum novarum.'

In the matter of vaccines it is difficult to at-tain a .satisfactory view-point; impossible to arrive at a final general conclusion. In a limited class of case their efficacy seems to be definitely es-tablished, and prospectively their usefulness may be extended by further study. Nothing is easier to a bacteriologist than the isolation of some mi-crobe from a specimen and the preparation of a so-called vaccine therefrom; but the applicability of the vaccine is not merely a matter of the aseptic injection of a sterilised culture; its proper use de-mands more consideration for the recipient as a patient than is commonly bestowed in such cases. I do not suggest that there are not consientious men endeavouring to understand this question, and to - do what is right, and wish with all my heart that they may succeed in reaping the fulfilment of the theoretical promise of vaccines. But prac-tically we have no great body of data about them, so in the meantime it is meet to call a halt in the in-discriminate injection of vaccines made from organ-isms whose connection with the lesion treated is often more than problematical, and to remember that the enthusiasm of the imlmuniser is not in- frequently in proportion to his ignorance of the natural course and trend of the malady he treats.

'l'o quote the words of Theobald Smith, "Let the medical profession see to it that vaccine therapy does not degenerate into inconsiderate and reck-less experiments on human beings; that it does not create false hopes in hosts of patient; and that it does not originate and end in commercialism and the desire to exploit the weak and unfortunate." These are plain words, but, in my judgement, none too strong. It is greatly to be feared that oppor-tunity, combined with professional ignorance, are like to prove too much for human virtue.

In this exploitation of the public, the public press bears no mean share. Ever in search of novel and sensational news, it gives ready ear to the un-scrupulous self-advertiser; or, more dangerous still, the blind but honest enthusiast. Without waiting to verify its facts, and reckless of the harm it may do, it heralds some new discovery or cure. Forth-with an eager public rush to the specialist who employs the particular cure, or demand it from their regular attendant. Under such circumstances it takes a strong will and a high sense of duty to tread the narrow path when the press and pUl) is acclaim our weaker brother as he glides comfort- ably along the broad and gilded way to affluence.

'".'lie mass of modern medical literature and facility for publication, while of value, have their draw-backs. We tend to rely on what we read, rather than on our own observation; we swallow some-one's brilliant results without knowing the per-sonal factor of the writer, of his capacity for care-ful, critical observation; of his knowledge of the course Of disease; of his freedom from self-hypnot-ism. Innumerable workers, many inadequately trained, with little clinical or pathological experi-ence, befog us who have not the time to follow

1432 AUSTRALIAN MEDICAL JOURNAL. February 14. 1914.

sufficiently closely the growth of the particular branch with which they deal to enable us to dis-tinguish the base from the true metal.

It is by Congresses such as this that we clear our mental horizon, appraise the personal factor, and from comparision of varied experience obtain a more correct perspective in• our work.

With the rapid growth of medicine, it is increas-ingly difficult to find time in the curriculum of the student to combine adequate scientific studies and efficient practical training in general and special subjects. The tendency seems to be to cut away some of the groundwork to leave more room for the ornamental superstructure, but at no time than the present has there been more need for sound scientific training and culture of the faculty of critical observation combined with adequate general clinical experience on the part of our students, if we are to save the practitioner of the future from becoming the credulous tool of the unbalanced en-thusiast or of the specious vendor of pseudo scien-tific proprietary nostrums.

-Wherein lies the remedy to these dangers which beset the efficiency of our profession?

In a body of soundly equipped general practi-tioners, who, though not themselves specialists, are yet able to weigh the advice of the latter and to view it from a broader standpoint.

In a wider arid more thorough knowledge of the natural history and trend of untreated dis-ease.

In insisting on our specialists being in the first place sound all-round practitioners.

In a closer correlation between general practi-tioner and specialist.

in insisting that every patient- shall reach the specialist only through the medium of and after careful examination by a competent and consien-tious general practitioner.

In the recognition by the general practitioner of his limitations, and in his readiness to avail him-self of the aid and co-operation of the specialist.

In frequent opportunities of exchanging ideas and correcting impressions. such as are gained by at-tendance at medical discussions and congresses.

In one and all, ever keeping before our eyes the fact that the welfare of our patient is, and must always be, the supreme and only object of our endeavours, remembrance and practice of which precept has set medicine apart as the most noble among the professions, neglect of which debases it to the level of a sorry trade battening on the mis-fortunes of our fellows.

And now, ladies and gentlemen, I have taxed your patience long enough. If I have lapsed from a tale of heroes into a too close scrutiny of the weak spots in our armour, believe me it is in no carping spirit, but from an earnest desire for the

- welfare and efficiency of our profession and that we may more truly merit the eulogium of Elisha Ilartlett, who says of us, "In the_ circle of human dutie, I do not know - of ally, short. of heroic and

perilous daring, or religious martyrdom and self-sacrifice, higher and nobler than those of the physi-cian. His daily round of labour is crowded with beneficence, and his nightly sleep is broken, that others may have better rest. His whole life is a blessed ministry of consolation and hope."

Sciatica. Grace ("Lancet," Jan. 10) writes:—

The method adopted is as follows:—First it is neces-sary to find the definite tender point or points in the line of the sciatic nerve. These can be found (1) by direc-tion of the patient, (2) by pressure, (3) by the use of the vibrator, and last and best by the use of the static spark; but this latter, if attempted at the first consulta-tion, may unfavourably impress a timid patient.

Having found the tender point, the parts around it are exposed for 20 minutes to the rays of the 500-candle-power light; this is applied as close to the bare skin as the patient can stand the heat, and by turning away the light for a moment, or by passing the hand lightly over the skin a consideral3le degree of tolerance can be established. The obvious effect is hyperaemia. After 20 minutes' exposure to the light the patient is seated on a chair on the insulated platform. An electrode of some easily-moulded metal -- I use pewter—is applied over the tender spot, usually about half-way between the great trochanter and the tuberosity of the ischium, or over the sacro-sciatic notch. The size of the electrode I generally use is 3 1/2 by 4 1/2 inches, but if the part is very tender, a larger electrode will be better borne.

An adequate static machine should be capable of giv-ing a 12-inch spark in all weathers between the ter-mirralhalls of the prime conductors when the patient is connected to themachine, and this spark should be capable of regulation down to 1/2 inch, or less' for par-ticularly tender points. With the electrode applied to the patient's skin and connected by a wire to the positive side of the static machine, the negative side being grounded and the spark gap closed, the motor is now started and the spark gap gradually opened, keeping the number of sparks passing at the gap at not more than 300 a minute at the outside, while 200 a minute is even better.

The operator will not have opened the spark gap very far, in all probability, before the iratient will complain of pain. When this point is reached the spark gap is closed again until the patient says he feels just a little tenderness, and at this point it is kept for five minutes or so, when the spark.gap can again be widened, this time with probably less discomfort to the patient. The treatment by the static wave current is kept up for 20 minutes, or less if the patient shows signs of fatigue. 1 then go on, if I deem it advisable, to give a few static sparks to the muscles of the buttocks and thigh, to any tender points in the course of the nerve, and to a tender 'patch probably due to fibrositis, wliich I often find in the gluteal or lumbar region in these cases.

These sparks are given with the patient standing on the insulated platform, which is connected to the nega-tive side of the machine, the positive side being grounded. A ball electrode held in the hand of the operator and also grounded is approached to within 4 or 5 inches of the Spot, to which the spark is to be applied. The patient feels a smart blow or cut as with a light whip, and is not apt to annreciate the treatment at first, but after experiencing the relief these sparks bring will often ask to have them repeated and point out the spot where they should be applied.

This ends the treatment, which should be applied daily at first until marked improvement is obtained, when a treatment can be given twice weekly, hi-weekly, and finally stopped. This treatment is equally successful in neuritis of the arm, or in uncompliacted neuritis any-where when a. definite tender point can be found.

reb ruarv l4, Igl.l. AUSTRALIAN MEDICAL JOURNAL.

Ru5trartan fliebtcat journal

luth FEBRUARY, 1911.

SMALL-PDX AND VACCINATION.

The recrudescence of small-pox in Sydney is a disquieting piece of intelligence, and it is to be earnestly hoped that it does not presage a widely-spread reappearance of the recent epidemic. One useful purpose it may serve—to convince the people of New South \Vales that there is one, and only one, way to deal with small-pox, and that is hv vaccinating the whole community.

It is difficult to realise the reasons for the re-luctance of politcians in the sister State to become sponsors for any comprehensive scheme of com-pulsory vaccination. It is a reluctance not confined to any shade of political opinion, although the Labour Ministry were obviously half-hearted in their particular proposal in this direction. There appears to be something relaxing in the climate of Sydney, leading to a spirit of fatalism in matters of public hygiene, not unlike that which is en-countered in similar climates in the south of Eu-rope.

It is not likely that any new presentation of the case for vaccination will receive much attention at the hands of those engaged in law-making for the people of New South Wales, so that it is futile to make the attempt. There appears to be a fixed distaste for introducing any measure with regard to vaccination which savours in any degree of the hated word "compulsion." In that position it seems the matter of compulsory vaccination must be left. But it might be suggested to the politicians that it would be possible to obtain with goodwill a great measure of vaccination which would never be accomplished by force. Recent events have shown that the populace as a whole has no great or inherent objection to be vaccinated, although they \v.ill have none of it merely on the score of compulsion. But why make vaccination compul-sory at all' There is another way which we have before suggested, and which we believe would work

very effectually. Let the Government abolish pub-lic vaccination altogether as at present understood, and make every medical practitioner a public vac-cinator. In other words, supply every medical man with pure lymph, and pay him a small fee for every successful vaccination performed by him. The or-dinary medical attendant in every family would then be the effective propagandist for the opera-tion. He would advise it, perform it, and he paid for it. The scheme might work out at a greater cost than the older plan, but it would be a small price to pay' for a population that would not only be vaccinated, but voluntarily vaccinated.

li canwh;le it is incumbent upon Victoria to keep her own house in order, and in this regard it is comforting to note that the Victorian board of Public Health is at last awaking to the fact that in the

event of a widespread outbreak in -Melbourne, the

old quarantine ground at t'ortsea would he quite unsuitable, even were it available. This fact was

pointed out at the outset of the Sydney epidemic, and it is beginning to be realised by the authorities. As soon as it is decided to create another quaran-tine station, there will be no lack of vehement objections. But the Board must allow itself to be guided by its medical officials, and refuse to Iisten to popular clamour, for the matter is one that can

-not much longer he delayed.

TOrttíg1) Aebícat a5^ocíatíon. VICTORIAN BRANCH.

GEELONG DIVISION.

The Annual Meeting was held in the Ha ll on Decem-ber 16.

Present: The retiring President (Dr. A. W. Marwood) in

the chair, and twelve members. The report and balance-sheet for year 1913 were received and adopted. Dr. Ken-nedy reported the proceedings of the Conference in Mel-bourne between the ,B.31.A. representatives and delegates

from the Friendly Societies. Vote of thanks passed to Drs: Kennedy and Darby for

attending the Conference. Election of office-hearers for 1914:— President: Dr. T. J. M. Kennedy. Vice-president: Dr. Gavin McCallum. Hon. Secretary and Hon. Treasurer: Dr. G. R. Darby.

Comimthttee: Drs. H. F. Divins, R. G. McPhee, A. W. Mar-wood, F. J. Newman.

Dr Moreton suggested that an endeavour be made to

arrange for as many members as could get away to be given the opportunity of being shown round the wards of

metropolitan hospitals, preferably on the date of a society

meeting, so that Geelong members could also attend the

meeting

Dr. Marwood, the retiring president, welcomed the new

members and explained to them exactly how matters stood

as regards the profession in Geelong.

After the meeting, Dr. Maywood entertained the members.

MELBOURNE PEDI:ITRIC SOCIETY.

The usual monthy meeting of the Society was held on

10th December, 1913, at the Children's Hospital, at 8.30

o'clock. The following is an epitome of the cases shown and dis-

cussed. 1. By Dr. F..H. Cole: Child three weeks old. Meningo-

cele and ,prolapse of the uterus. 2. By Dr. F. H. Code: Girl aged five years. Well till

two months ago, when gait became gradually unsteady,

until she can only walk now with assistance. Voluntary tremor and incoordination of left arm , tinnitus, optic neuritis; some vomiting and Rombergism. Past history of otorrhma 31/2 years ago.

3. By F. H. Cole: Boy aged 8 years. Symmetrical swel-ling of knees and ankles, tenderness, and some fever, 9 months' duration.

4. By Dr. Alan MacKay: Child who had Edebohls de-capsulation of kidneys performed some six years ago.

Kidney condition now quite well. 5. By Dr. Hewlett: Two cases of congenital pyloric steno-

sis, with bismuth meal demonstration. 6 By Dr. H. D. Stephens: Boy aged 16 years; normal height

but weighs over 25 stone. Was normal in size at birth,

hut took fits from 10 mos. of age; walked and talked late.

Mental condition is subnormal. Has six toes on each

1464 AUSTRALIAN MEDICAL JOURNAL. 'February 14. 1914.

foot, and extra finger on left hand. Is shortsighted, but apparently no hemianopia. Gets attacks of headaches and vomiting, and squints at times. Penis is retracted and looks undeveloped. R. Testis is not palpable. Oase of hypopituitarism.

7. By Dr. Ferguson: Boy aged 12 years; has suffered from attacks of abdominal pain for three years; vomits during attacks sometimes with blood. Now has large spleen, also ascites, which has developed in hospital. Since admission has had a severe haematemesis. No blood changes except those due to the hæmatemesis. Was-sermann negative.

8. By Dr. White: Male aged 10 years; four years ago a swelling occurred on the upper lip the size of a pea, soft and painless. It was excised, but recurred three months later. It is said to be extending more rapidly along the buccal mucous membrane during the past 12 months. No enlarged cervical glands.

9. By Dr. Silberberg: Achondroplasic infant girl, aged 9 months; mother well developed. Obstetric history; first weakly at birth, now healthy; then two miscarriages. Next died of marasmus; next child the patient.

CURRENT LITERATURE.

Radium and Cancer.

At the American Congress of Surgeons, Kronig read a paper. He said that they had treated 254 cases of can-cer with Roentgen rays and radium, 150 of them on purely therapeutic lines and without operation. Of these 150, 140 were treated with Roentgen rays and mesothorium; in 10 the Roentgen ray alone was used. Of 64 cases of carcinoma 43 cases had been treated for the prevention of secondary growth almost exclusively with unfiltered Roentgen rays; while 21 cases were treated partly with filtered and partly with unfiltered rays. The difference was striking. While 32 out of the 43 cases died of carci-noma, they had been able to follow the subsequent his-tory of 20 out of the 21 cases, and found that 60 per cent. of the recurrences occurred the first year after operation. Recurrent cancer had been treated with radio-active substances. The 140 cases treated with Roentgen rays and mesothorium should be differentiated into two groups: 1. Those in which carcinoma had not spread beyond the primary focus into the neighbouring tissue, and in cancer of the cervix where the carcinomatous growth had spread into the parametrium and glands, so that operation was out of the question. 2. Those carci-nomas in which additional metastases were already pres-ent. While it had been found possible to produce re-markable retrogressions and checking of the carcinoma-tous metastases by intense radiation of Roentgen rays and radium, in all cases the carcinoma had spread later on. They could not say they had saved a single patient. In the second group the majority of cases were at the present time impossible of cure.

Gastric Ulcer.

D. J. Kidd ("Med. Chron.") summarises a paper of Verbrycke (Jour. A.M.A., Nov., 1913) thus:—

The statistics of three thousand hospital cases show that only 36 per cent. of cases of gastric ulcer a re diag-nosed correctly. The writer thinks that at least 90 per cent. are diagnosable by modern methods. In addition to the acute and chronic ulcers, he recognises the chronic non-indurated ulcer, possibly a forerunner of the in-durated: this third form may last for years unrecog-nised. He reminds us that gall-stones and gastric ulcer often exist: we must beware of regarding gastric ulcer as of necessity the sole morbid lesion present in a given case.,

(a) History is unreliable: pain may be absent; is not characteristics of ulcer; the front to back pain is rare. Pain appears at a fixed time after meals, variable, but constant, for the individual: it Is relieved by more food, alkalies, or vomiting. Heart-burn, pyrosis and regurgita-tion are common but not pathognomonic. Hmmastemesis

occurs in probably less than 10 per cent. of cases. Nau-sea and vomiting are absent in 50 per cent.: even when present their value is nil unless the vomiting stops the pain. Alternating periods of euphoria and misery are common. The greater the pain, the niore severe are the other symptoms, and vice versa.

(b) Physical examination is 'slightly more reliable than history and synrptomatology: usually there is a tender point in the epigastrium, or at 8 D. vertebra behind, or in both places; tenderness is slight, occasinoally absent: to be of diagnostic value, it should be always in the sanie place, and there should be but one spot; muscle spasm and rigidity, when ,present, are but further evidence of tenderness.

(c) Special tests and laboratory aids are the most ex-act diagnostic means. Verbrycke "attaches more import-ance to the test for occult blood than to any of the others." Such bleeding occurs in the large majority, 'regardless of duration or variety: it is characteristically intermltten, therefore several examinations under varying conditions are needed. The benzidine is the best and most delicate test: test-tubes must be absolutely clean. If the first test be positive, put patient on a meat-free diet for several days, and re-test. If still positive, exclude all bleeding points (gums, piles, etc.). Hyperacidity is com-mon, but of far less value than hyper-secretion (though this it not pathognomonic). Meunier's gastric rinsing with 1 per cent. acetic acid and testing of the rinse-water for blood has helped Verbrycke several times. X-rays are valuable, but need interpretation by an expert gastric radiographer. Einhorn's thread - impregnation test is "well-nigh perfect as a test for localisation of ulcer, but is still more or less sub judice: certain posi-tive threads are almost infallible, but a stained thread does not always denote ulcer even in the 'absence of cirr-hosis and cancer."

Technique: A silk thread, swallowed at night by patient and retained all night, rubs the ulcer and causes oozing of !blood: the resulting stain is plainly visible when thread is pulled out next morning. Verbrycke has "found that those threads with a plain mark or two marks de-noting the rim of an ulcer, with an unstained portion between, are never misleading." A. stain on two or more threads at exactly the sanie spot is "a sure indication of ulcer." But Verbrycke "cannot believe that the many instances of diffuse stained thread are all caused 'bv ulceration." A stained thread, however, always denotes a morbid mucous membrane, either ulcerated or soft and spongy.

(d)(d) Therapeutic test. Cases defying .diaanosis will have to be treated as ulcer, and results of treatment noted. In some doubtful cases Verbrycke has been thus rewarded by success.

Conclusions: Several combinations practically assure a diagnosis: (1) Tender point with occult blood; (2) hy-per-secretion with tender point; (3) ditto with occult blood; (4) tender point with repeated positive thread tests: (5) ditto with hmatemesis; (6) hæmatemesis with hyper-secretion; (7) hypersecretion with positive thread tests.

Repair of Defects of the Ureter.

Eisendrath (Jour. A.M.A., Nov. 8, 1913), says: —

Often a normal functionating kidney might be say , d if the diseased portion of a ureter could be removed and resulting defect corrected by anastomosis of ends, or sub-stituting another structure for the removed segment. Methods of anastomosis of severed ends are (1) end to end, (2) end to side (Van Hook), and (3) invagination methods (D. Antona).

"Experiments on dogs and results in human beings show that the Van Hook method of invaginating the proximal end into a slit on the lateral wall of the distal end, gives the most satisfactory results of any method of anasto-mosis." Implantation into bowel is impracticable be-cause of persistent diarrhea from urine irritation and fre-quent occurrence of ascending infection. Many have thought that by transplanting some structure whose vi-tality could he maintained until union had occurred, the ureter could be resected and kidneys saved. Among the

February rq,, 1914. AUSTRALIAN MEDICAL JOURNAL. 1435

structures employed as grafts are segments of arteries and veins; loops of intestine, excluded from the remainder of the bowel, but still attached to their mesentery; the appendix, attached to its mesentery, hut separated from the rest of the bowel; the long born of the dog's uterus; flap of bladder in the form of a tube, the upper end of which was sutured to the ureter. Those experiments were uniformly unsuccessful because of (1) necrosis of flap or graft, (2) adherence of proximal end of ureter to abdominal wall and formation of urinary fistula, or (3) gradual con-version of transplant into connective tissue.

Eisendrath "thought that if we could secure as a free transplant a portion of the bladder, coni!pletely separated from the rest of the bladder, and insert this graft be-tween the two ends of the divided ureter, we would thus secure a structure of which the lining membrane was accustomed to the presence of urine, and thus less apt to undergo cicatrical changes." Twelve experiments were made using as a transplant a portion of the fundus of the bladder about 1 inch wide and 2 inches long, the bladder then being closed by two rows of chromic gut sutures. A segment about 1 inch long was then removed from the ureter and the ends of the ureter, both proximal and distal were split (for a short distance) and the ureter fastened to the interior of the wall of the transplanted bladder segment by several chromic gut sutures passing through the entire thickness of the wall of the trans-plant and. tide on its outer aspect. A tube was then formed by suturing the edges of the transplanted bladder segment with one row of chromic gut through and through, and a second ,sero-serous row of fine arterial silk. In order to prevent the retraction of the ureter from the interior of the transplant, several chromic gut sutures were inserted through the walls of the ureter and trans-plant above and below the entrance and emergence of the ureter."

Eisendrath's results in these twelve experiments cor-responded exactly to those of men using other methods as noted above, namely, necrosis of graft, urinary fistula at site of abdominal wound or conversion of graft into a fibrous cord; so he arrives at the following conclu-sions:—

"1. One can transplant portions of the bladder to take the place of segments of the dog's ureter.

"2. These transplanted segments will preserve their vitality, even though they have no vascular connection with the bladder.

'3. It is immaterial whether the divided ends of the ureter are brought into exact end-to-end appromiation with the transplant, or are sutured to its inner surface in the manner described.

"4. Even though the bladder mucous membrane is ac-customed to the presence of urine, it will undergo cicatri-cial changes in the same manner as other structures,, as artery, vein, appendix, bowel, horn or uterus, which are lined with endothelium or mucous membrane, not accus-tomed to presence of urine.

"5. Even though union of the transplant occurs, it soon becomes transformed into connective tissue drawing the two ends of the ureters together with resultant stenosis of the ureter and hydronephrosis and hydroureter."-("Post. Graduate.")

(The Editor of the "Post Graduate" queries statement 2.)

Duodenal Ulcer. •

Hey (Med. Chronic.) su:m:marises a paper in Edin. Med. Journ., Nov. 1913, thus: —

In the first seven years, only twelve cases were recorded, whilst in the last five, 145 were operated upon. The con-dition was found to be eight and a half times commoner in men than in women. Eleven patient were under 20 years of age and 70 per cent. were between the ages of 20 and 50. The youngest treated was a boy of 14, and a striking feature with regard to age incidence was that

in patients under 30 there was a marked absence of a history of severe indigestionbefore perforation. Such history was absent in 45 per cent. of all cases noted. In the majority of patients suffering previously from dys-pePsia, the symptoms had beenpresent for a year or more before perforation occurred.

There was no record of anything which could be re-garded as a premonitory sign of perforation, and similarly it was found impossible to conclude that there were any noteworthy factors such as physical exertion determin-ing the occurrence of perforation. It would therefore seem justifiable to conclude that manual workers suffer-ing from duodenal ulcer are not specially liable to per-foration and that perforation occurring in a manual worker cannot be fairly ascribed to the nature of his occupation.

There was a well-marked tendency for perforation to take place about two hours after a meal, i.e., at the time

,when the pain of duodenal ulcer is most acute. Pain was the most characteristic symptom, and at the onset was felt most severely above the umbilicus: in eight cases, however, it was most severe in the right iliac fossa, and in six it was worst in the lower abdomen generally. "A patient with a duodenal perforation is felled at once by agonising pain, while the pain of appendicitis begins more moderately and gradually increases to a maximum reached some time after its onset." In severe cases it shot through to the right shoulder or scapula thus re-sembling the pain of gall-bladder affections. .Severe and frequent vomiting was a grave symptom, and so also was the rare occurrence of hmmatemesis. Food material recognisable as such was rarely present in the peri-toneal cavity. A subnormal temperature with a pulse-rate over 110 was a most ominous sign. Variations of muscular resistance on palpation were of little value. The liver dulness was absent in rather less than one-third of the cases.

The ultimate results were better when operation hav-ing decided on, morphia was given; in a few cases the symptoms were masked by the drug so that operation was dangerously delayed. The "Reaction Period," described by Miles,_ in which abatement of pain and shock with general improvement comes on a few hours after per -

foration, was present in no less than 20 per cent. of all cases. In many the feeling of comparative well-being was so marked as to make the patient very un-willing to submit to operation.

In only six cases was food matter Mound in the abdo-men, and more than half the patients in whom the fluid contained definite bile died.

In almost every case the perforation was situated in the first part of the duodenum and within 1% inches of the pylorus. On four occasions it was the posterior surface which gave way and once there were two per-forations. Three times the opening could not be closed, and the patients died. ,Gastroenterostomy was obliga-tory by reason of an almost complete duodenal obstruc-tion in 39 cases, and 22 of these were fatal ; in 49 pa-tients it was done with the general condition compara-tively good, and here there were only three fatalities. The material given is not sufficient to enable a dog-matic statement to be given about the necessity for a primary gastro-enterostomy, but we personally would judge front the statistics that such procedure should be omitted except in the rare cases of almost absolute ob-struction of the duodenum with the patient in very good condition. Even when all things were taken into con-• sideration, it appears definite that swabbing gave far bet-ter results than douching. A pelvic drain was generally employed, but latterly .drainage through the upper wound was almost entirelyabandoned.

,Sub-phrenic abscess developed in five cases, and the first symptoms usually appeared in the second week.

There were 60 per cent. of recoveries, but during the last five years these were increased to 65 per cent. Of those operated upon within nine hours of perforation, four out of every five recovered; after twenty-four hours, twice as many died as lived.

1436 AUSTRALIAN MEDICAL JOURNAL. February 14. 1 9 1 4.

GENERAL.

According to a "Lancet" correspondent, Dr. Somen ad-vances a theory of the mechanism of the phenomena at-tending the "knock-out" blow on the lower jaw in box-ing. These phenomena have been variously attributed to a sudden displacement of the brain or the cerebro-spinal fluid, or to re flex inhibition. Dr. Somen's theory is that the shock of the blow on the chin is transmitted through the temporo-maxillary articulation to the internal ear where the disturbance of the semi-circular canals give rise to vertigo, loss of equilibrium and of conscious-ness. The interference with equilibration is even more pronounced when the blow is received on one side, which accounts for the more severe effect of such a blow over one received in the middle of the chin. Physiological experts, like Dr. Babinski, and medical experts in sports, such at Dr. Heckel, who have themselves experienced the effect of this blow. have approved of Dr. ,Somen's. theory. The dangerous points for the boxer are those whence reflexes take their origin—the epigastrium, from its relation to the solar plexus, and the lower jaw from its relation to the semi-circular canals of the internal ear. The anterior surface of-the larynx should also be mentioned a blow on which may induce a fatal reflex, but this blow is ruled out in boxing sand is practised only by the apaches, who appear to have imported it from the African Kabyles.

The eighth annual meeting of the Melbourne Pediatric Society was held at the Grand Hotel on 22nd January, 1914. The report showed a 'highly satisfactory state of affairs. Ten meetings had been held during the year, at which 68 cases of interest were shown, besides speci-mens. The attendance at the meeting were uniformly better than in previous years. This evidence of the popularity of the society is undoubtedly due to the fact than clinical cases take precedence over everything else. Owing to increased accommodation being provided at the hospital, the committee of the Society are able to enrol a limited number of new members. The office-bearers for 1914 were elected, and the usual votes of thanks tendered to the retiring office-bearers, committee of the Children's Hospital and others, At the conclusion of business, an adjournment was made to the dining-room, where some 30 members entertained Dr. R. R. Stawell at dinner. The President, Dr. Officer, in proposing the guest of the evening, expressed the regret of all present at Dr. Stawell's resignation from. the Children's Hospital. This statement was elaborated by Dr. P. Webster. Dr. Stawell, who was enthusiasticlly received, regretted leav-ing the institution where his associations had always been of the happiest.

PERSONAL.

The friends of Dr. Al. Lang will be pleased to know that he has made very satisfactory recovery from his recent operation. Upon the counsel of his advisers, he has resolved to have 'prolonged rest from practice, and on Saturday last, with Mrs. Lang, left for London in the "Ar-gyllshire."

We regret to record the death of Dr. Ronald Mac-dougall, which was recently reported by cable as having occurred in Palermo, Sicily. The late Dr. Macdougall was well known in Victoria, having practised for many years at Queenscliff, where he held the rank of Surgeon-Captain in the Victorian forces. He was a native of Dublin, and in his younger days was known as one of the -best amateur lawn tennis players in Ireland. He was very popular in Queenscliff, not alone for his pro-fessional skill, but for his genial interest in the wel-fare of the community in which he lived. He sold his practice in that town about ten years ago, owing to fail-ing health, and since that time travelled widely, only practising intermittently, as his health allowed. He visited

jßrítífifj 0ebtca1 Ztotoctatton. VICTORIAN BRANCH.

Dr. Stewart Ferguson, 34 Collins-street, Melbourne, Hon. Secretary.

NOTICES.

Warning Notices. New South Wales.

Medical men proposing to apply for the position of me-dical officer to friendly society lodges in any part of New South Wales are requested to communicate with the Hon. Secretary, B.M.A., 30-34 Elizabeth-street, Sydney, or with Dr. S. W. Ferguson, Hon. Secretary, Victorian Branch B.M.A.

Warwick Friendly Societies, Queensland.

.Before applying for any position in connection with the above, medical men are advised to obtain information from the Hon. Secretary, Queensland Branch B.M.A., Brisbane,

Medical men, before applying for the position of medical officer to lodges at Longreach, Central Queensland, are in-vited, before doing so, to apply for information to the Hon. Secretary, Queensland Branch, B.M.A.

Medical practitioners are asked, before applying for any appointment advertised by the United Friendly Societies of Invercargill, N.Z., to communicate in the first place with the Secretary, British Medical Association, 26 Yarrow-street, Invercargill; or H. E. Gibbs, Secretary ß.31.A., Box 166, Wellington; or the Secretary, B.M.A., Sydney, N.S.W.; or the Secretary, B.M.A., Melbourne, Vic ; or the Secre-

Court Sherwood and A. O. Foresters Launceston. Wellington Mills. Medical men are advised to communica.re with Dr. S. W.

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

MELBOURNE HOSI'I'l'.U. CLINICAL SOCIETY.-4th Fri-day in the Month.

Clinical Meeting 3rd Wednesday In month.

PEDIATRIC SOCIETY.—Second Wednesday in month. EYE & EAR SEC'l'ION.4th Tuesday in Month. VICTORIA N BRA NCH—Ordinary Meeting, Ist Wednesday

in month.

Melbourne about two years ago and was then more or less a confirmed invalid, but still full of mental vigour and energy. He had many hobbies, and was an exception-ally accomplished amateur photographer. Dr.Macdou-gall, while practising at Queenscliff, married the second daughter of Mr. T. Lewers, of Melbourne, who survives him

Dr. C. S. Ryan recently resigned his position on the honorary staff of the Children's Hospital, Melbourne. Thl committee of the institution, in acecpting the resignation, expressed its appreciation of Dr. Ryan's services, extend-ing over thirty-five years, and placed his name on the list of honorary consultants to the hospital.

I)r. R. O. Douglas, lately medical superintendent at St. Vincent's Hospital, Melbourne. has taken up the duties of medical sperintendent of the Bendigo Hospital during the absence on leave or Dr. Cordner.

'Dr. W. F. Brownell has succeeded to the practice of the late Dr. T. S. Hutchings, of Euroa. Dr. Brownell was for some time resident at the Alfred Hospital and re-cently became entitled to the degree of M.D.- in the Mel-bourne University, though this will not be conferred till April.

Dr. C. E. C. Wilson has removed from Wallaroo to Ka.dina, S.A.

February 21, 1911. AUSTRALIAN MEDICAL JOURNAL. 1437

LISTER, THE LABORATORY AND THE

BEDSIDE.

- (Presidential Address in the Section of Surgery, Australasian Medical Congress, Auckland, N.Z., February, 1914.)

R. 11:AMILTON RUSSELL, r.R.C.S ., Eng., Senior Surgeon to the Alfred Hospital, Melbourne.

\I y gratitude for the very high honour that has come upon me throng-It your invitation to fill the Presidential chair in this important Section of Con-gress isboth deep and sincere. 'l'he interval that has elapsed since ve last niet in session has wit-nessed the turning of a page of unexampled pro-

and fruitfulness in the history of surgery. Idle maker of modern surgery has passed from among us, having bequeathed to us a splendid heri- tage for us to employ as best we may. Much has been written and spoken during the months that have passed about the work and personality of Lord Lister by men who have enjoyed the privilege of intimate association with him, and it would seem that there is good reason why I should make more than a passing allusion to him, for am 1 not war-ranted in thinking (if 1 may be permitted without sacrifice of decorum to obtrude an observation of a nature purely personal to myself) that one inci-dental but direct result of the teaching- of Lister may be discovered in the honour you have done m-e in setting me in this place. I myself am conscious that it is so. and I rejoice in the knowledge that whatever you have found of worthiness in nre, I may ascribe it to his influence, his teaching, and his example, and offer it as the only tribute it is in my power to offer to his beloved and honoured memory.

My thoughts revert to the time, now some 35 years ago, when I first entered the wards of Kings College Hospital as a student under Lister, and began to learn that the making and the dressing of wounds was to be studied as one of the fine arts. It is customary nowadays to contrast what is called the antiseptic methods of Lister with the aseptic methods of the present day, with the more or less tacit implication that there is not merely a dif-ference in method, but in the principle involved. There seems to be a prevalent idea that the dif-ference is to be found in the fact that whereas Lister was in the habit of applying strong chemical antiseptics to his operation wounds, we have made a great advance in protecting wounds from the in-jurions contact of antiseptics. So we have; but I must point out that this is an improvement in our methods only, and it !became possible when it was proved that air-borne micro-organisms are not to be feared as the cause of wound infection. Prior to this critical discovery, it was clearly impossible to prevent whatever antiseptic agent v vas being - used to purify the air from - coming in contact also with the wound, but this was quite recognized by Lister

as an evil, from which, however, in the state of his knowledge as it then existed, there could in the nature of things be no escape. Nevertheless, his desire constantly expressed. to protect the wound as far as possible from the contact of antiseptic substances, was noteworthy ; the spray was kept at as great a distance from the wound as possible consistently with what appeared to be efficiency, and an impermeable layer of varnished oiled silk was placed immediately on the wound to protect it from the irritation of the dressing, and when in the early eighties Lister had convinced himself that the carbolic spray was un-necessary, he was prompt to abandon its use gladly: and from the abandonment by Lister himself of the spray we may date the birth of modern aseptic methods. It is, I imagine. needless for me to ob-serve that my sole object ill making these observa-tions is to be found in the interests of historical accuracy. No one would even conceive the thought, when we speak of the great advances that we have made in building up our modern aseptic methods upon the antiseptic methods of Lister, that any derogation from .our vast indebtedness to him is conveyed or suggested thereby. What always does occur to me, however, and must be vividly be-fore the view of anybody who knew intimately the working of Lister's mind, is that the contributions

that " \V'e" ( with a capital \l') have made indepen-dently of him towards the establishment of present day surgical methods, do not after all amount to quite so much as we are prone to think. The mat-ter may not appear to be of so much importance as I seem to attach to it, but a mildly cold douche ad-ministered to our self-sufficiency is never unwhole-some, and 1 am tempted to venture on another. The transition from the antiseptic methods, as practised by Lister, to the aseptic present-day methods, has not been altogether unattended by loss. It does not present a picture of unqualified progress all along the line, in my humble opinion. There is no doubt that the belief that prevailed in the days of my studentship that the air was a prime source of clanger to wounds, and that the access of a puff of air unpurified by the carbolic spray was a source of grave risk to the patient's safety, faulty as we now know it tb have been, nevertheless made for the most extraordinary precision and skill in the appli- cation of surgical dressings. It is a common observa- tion of twine to my students that the fine art of sur- gical dressing has died out without simpler modern methods: not that I deplore the loss of a ritual which we now know to have been bacteriologically unnecessary, but that splendidly unnecessary ritual carried with it much that was incidentally of real advantage to the patient. For one thing, the dres- sing- had to be so applied that it would remain in place without shifting a hair's breadth for a week if necessary, and the close study of methods of pre- cision designed to accomplish this purpose led quite naturally to the incidental attainment of means to further the comfort of the patient, so that the fires= sing of a wound by Lister became a very- beautiful and complete work of art. I well remember a dis-

1438 AUSTRALIAN MRDICAL JOURNAL. February 21, I914.

tinguished visitor, after watching Lister do a dres-sing, remarking, "The great physician, Graves, de-sired that on his tombstone should be inscribed the legend, `He fed fevers'; I would suggest for your epitaph, `He dressed wounds.' " With all our vaunted advances and improvements, wounds are not dressed nowadays so beautifully as he was wont to dress them; it is quite true that in the vast majority of cases the need for such precision does not exist, for most of our wounds that are not al-ready infected, we are able to close without drain-age, and in neither case is the antiseptic or aseptic dressing of such supreme importance. Neverthe-less it not rarely happens that the exigencies of a special case make urgent demands for accuracy and confidence in our methods of antiseptic dressing of the kind that Lister practised and taught ; and lo! they are forgotten. While I am on this subject, I cannot forbear to tell a story that used to be told to successive generations of students always with bated breath and in the strictest confidence. I am not aware that the confidence has ever been broken, but I venture to break it now, for I judge that the passage of the years has rendered it permissible for me to do so. The antiseptic dressings, as some of us remember, used to be fixed in position by means of elastic webbing, applied in a prescribed manner, fastened by certain safety pins, of which each had its prescribed place and function. It fell to the lot of Mr. Lister, as he then was, to assume the re-sponsible duty of subjecting to surgical treatment a lady of supremely exalted rank. During the pro-gress of the case, he was one day driving away from the Royal castle, after dressing the patient, when a dreadful doubt gripped him. There was a brief, a very brief mental struggle, and then the carriage was promptly turned round, and confession was duly made to the occupant of the loftiest throne 011 earth that he had forgotten one of the safety pins!

Lister stands probably alone among surgeons in that he combined the qualities that make a great experimental investigator with those that are essen-tial to a great clinical observer and student, and his capacity for adjusting the values attaching respec-tively to the love of laboratory and the facts of the bedside always seemed to me unerring and per-fect, and to constitute one of the chief secrets, silent and intangible, of his power of sustained achievement. As narrated by Sir Rickman Godlee in a recent address, his ingenuity and accuracy in devising and carrying out bacteriological experi-ments called forth expressions of astonishment and admiration from Pasteur, while Sir Michael Foster once referred to him as "one whose career as a practical surgeon we as physiologists selfishly de-plore, for we see in him a puissant captain." There are few more significant principles contributing to form the substratum of good and successful work at the bedside than a just .estimate of the correct re-lationship between clinical and experimental work, and lack of the requisite clearness of mental vision in this matter is, I believe, one of the most potent

causes of unexplained disappointment and failure. We sometimes observe a man of high intellectual power, honest, painstaking, and industrious, who seems to unaccountably fail ; and by that I do not mean in respect of worldly advancement and pub= lic estimhtion, but he fails in the actual practice of his profession at the bedside. If I were asked to state in general terns what in my opinion is the most frequent defect that underlies this regrettable phenomenon, I should reply without hesitation, "Inability to distinguish clearly between the facts of the laboratory and those of the bedside." Let it not be thought for a moment that I tinder-estimate the extreme value of experimental research; quite the reverse is the case. It has sometimes happened to me to be asked by a young aspirant to become a hospital surgeon and practitioner of surgery, how he is to begin. His practice is all in the future. He has not as yet, perhaps, a hospital appointment. What can he do that will help him to both? What work shall he work at that will, as he expresses it. "lead to something"? My answer is always the same :—"Go to the laboratory at the University, and work at something; it matters little what, so long as you work. Try to find out all about some-thing, and you will soon find that you know more about your subject than other people do. No frag-ment of knowledge but has its value, and that value will be enhanced to you an hundredfold if it hap-pens to be your own peculiar possession. Its ac-quisition will surely lead the way to further impor-tant attainments, until presently the widening sphere of your knowledge will begin to touch at various points the province of the work at the bedside." Some thoughts such as these must conic to us when we glance at the earlier scientific works of Lister, and note the nature of his inquiries. In respect of science, and particularly those depart ments of scientific research that are dependent on the microscope for their elucidation. Lister may be said to have been "born in the purple." for his father was a distinguished scientist who made weighty contributions toward the perfecting of the compound microscope. It is not surprising, there-fore, that the earliest scientific researches of the famous son should have been guided and influence(' .

by this circumstance, so that we find him at 2a years of age bringing forward noteworthy paper upon such subjects as "The Cutaneous Pigmentary System of the Frog," "The Contractile Tissue of the Iris," "The Muscular Tissue of the Skin," and "The Structure of Involuntary Muscle Fibre." all notable equally for minuteness and accuracy of ob-servation and reasoning, as for independence of thought and faithfulness and simplicity of descrip-tion. Very soon we find the subjects that engage his attention are beginning to assume a character of more direct clinical significance, and with re-searches on "The Early Stages of Inflammation," and the )Croonian lectures on "The Coagulation of the Blood," we become conscious of the first steps on the path of scientific study which will even-tually lead him to the great achievement of his life.

February 21, 1914. AUSTRALIAN MEDICAL JOURNAL. 1439

I have made a somewhat long digression prepara-tory to emphasizing what always seemed to me the almost inspired faculty possessed by Lister of sifting out from the store of his scientific know-ledge that which was available for employment in actual practice at the bedside, and putting aside what was too incomplete and theoretical to be reckoned upon. Perhaps no better illustration of this could be advanced than his attitude on the sub-ject of anaesthetics, a matter to which he devoted special interest. Chloroform was the agent exclu-sively used, and it was always in his hospital prac-tice given by a student. This does not mean that the administrator was ignorant and untaught; on the contrary, he was most thoroughly drilled in the principles that were to guide him in the adminis-tration, and those principles were of the simplest. Briefly the administrator's attention had to be con centrated on keeping the air-way free and unim-peded, and by means of certain signs to read the individual patient's condition like a book; but he was not permitted to examine the heart or to feel the pulse. This last feature of his method has given rise to much wonderment and adverse criticism. :Ind I would like to endeavour, if I ,may, in a few sentences, to set forth what I believe to be th . hind of reasoning u pon which it rested. Expert ni;ent is able to show that if a dangerous overdose of chloroform be given slowly and in proper dilu-tion, cessation of respiration will invariably occur before cessation of the heart's action. It is also well recognised that rapid overdosage by too con-centrated vapour of chloroform will cause sudden death. I;oth of these sources of danger can' be quite étl ectuall v guarded against, but the finger on the pulse will be of no value in either. But again it is admitted that apart from either of the above causes, a patient will very rarely suddenly die under chlo rof•orrn ; will the finger on the pulse not prove a serviceable aid in such a case? There is not the slightest reason to suppose that it would; ill fact, it is dead certain that it would not. It is true that administrators have stated that they believe they have received valuable warning of danger from the 'behaviour c:f the pulse, but how can they possibly tell? Such statements are the merest guess work. Moreover, there is no reason for supposing that the patient

dies because the heart stops beating, because it is just as obviously true to say the heart stops beating because the patient dies. The fact is we concen-trate our attention upon the heart simply because it is the first and most tangible object for us to literally put our finger upon, but surely if we are to probe the mystery of sudden death at all, we must go further back than the heart, to the nervous sys-tem that controls it. There has of late years been a small army of skilled workers who have devoted immense efforts towards the elucidation of the mys-tery that surrounds many examples of death under anaesthetics, and we of Melbourne regard with jus-' tifiable pride the fact that we have in our midst a worker in Dr. Embley, who by patient and inde-fatigable labour has made contributions of lasting

value to our store of physiological knowledge. bearing on the innervation of the heart and vascular system, a subject peculiarly concerned as it would seem with the phenomena of death under anaesthe- tics.

Nevertheless, valuable as such researches are, it cannot be too clearly stated that any endeavour to carry their teachings from the experimental labora-tory to the operation room is likely in the present state of our knowledge to render confusion worse confounded, and to bring about the very disasters they are designed to prevent. Our knowledge of the physiology of the nervous system consists in any case of a small sprinkling of isolated facts that together constitute only a fraction of a vast terri-tory as yet unexplored. To convert our knowledge of the nervous system into active treatment is only here and there advantageously possible, but the in-timate relation between the nervous system and the fact of sudden death is at present entirely outside our field of practical endeavour, and it is well for us to recognise it. What we are wont to call "The Mystery of Life" awaits solution, and whatever the solution maybe, it would seem certain that it vv;ll he at least intimately concerned with the physi- legi of the nervous system ; and when the mys-

tery of life is solved, as it doubtless will be by those who come after us, then will the mystery of life's sudden cessation, that we call death, be like-wise revealed. It was, I conceive, upon some such lines of reasoning as that I . have laboured, withal Imperfe..ily to sketch, that the toaster mind of pro found thought on minute physiological detail Oe-termined that in a matter involving such tremen-dous issues as the administration of chloroform, the safer course is to let the heart severely alone, and trust to the guidance of other and simpler things. It would hardly be possible to instance a more striking example of the capacity for distin-guishing and excluding from practical application theoretical matter that he believed to be indeter-minate and incomplete, and consequently unsafe for our guidance. Some few years ago there ap-peared the report of an address delivered by one of the foremost of our English surgeons, Sir Berkeley Moynihan, under the title of "The Pathology of the Living." The theme of this discourse, as original in its substance as in its title, was designed to point out that the pathologist can by no means be re- • garded as the sole repository of pathological know-ledge, but that on the contrary the sphere of his labours is subject to very distinct and notable limi-tations in many directions ; and that these barriers thàt oppose themselves to the pathologist can in many cases be readily passed by the observant practical surgeon, and by him alone. So numerous are these instances, that it has cone about that the

pathological discoveries of the clinical observer con-stitute a distinct field of pathological knowledge that never could have 'been opened up and worked

by the student of the pathological laboratory and

the deadhouse. It would appear at first sight dif-ficult to instance a more striking example of the in-ter-relation between 'laboratory research and clini-

^

1440 AUSTRALIAN MEDICAL JOURNAL. Pebruary 21, 1914.

cal findings than this; nevertheless, it would appear even more remarkable that there should be also an anatomy and embryology of the living, that is to say a certain field in those subjects in which the anatomist and embryologist must look to the clinician for suggestion and guidance. I think it probable that but for the information provided by clinical experience, the embryologist unaided would have known but little even

embryologist of such an ob-

vious arrest of development as hare-lip and cleft palate, while I am pretty sure that such a condition as imperforate rectum would have remained undis-covered altogether, or perhaps have been recorded as a curiosity and enshrined as a museum specimen. I mist ask your indulgence in alluding to a matter in which I have had some personal concern, but I would point out that for generations the fact that roughly 23 per cent. of individuals have peritoneal sacs occupying one or other of the commoner seats of hernia bad escaped the eye of anatomical research, until reasoning, based upon clinical ob-servation, seemed to render it certain that they must be there; and then they were looked for by \ir. Murray, of Liverpool and promptly found. :Again, the explanation of the remarkable tendency of femoral hernia to pass upward over Poupart's ligament was unknown, until the mystery was solved by clinical observation and reasoning, al-though the causation of the occurrence is entirely a developmental one. The fact, too, that an obtura -

tor sac is present in individuals with a frequency that vastly exceeds the frequency of occurrence of the rare obturator hernia, is a piece of anatomical knowledge that is, I believe, peculiarly the property of the Melbourne University Anatomy School. It is significant that the one redoubtable opponent of the saccular theory of hernia is to be found in one of the most distinguished anatomists of our, tiny-c. Professor Arthur Keith, who occasionally shivers a lance against it, but whose brilliant and useful career has adorned a field into which clinical experi-ence has not entered.

1 ant anxious to pass from this subject to others that have less of a personal colouring, but I cannot forbear to draw attention for a moment to Lister's attitude on the question of what is commonly spoken of as the radical cure of hernia. He was, I believe, the first surgeon ofmodern times to per-form an open operation for non-strangulated 'hernia, but he frankly disbelieved in the possibility of curing hernia by operation, and with the know-ledge in his possession as to the etiology of hernia, that view was surely well-founded and inevitable. Ile considered that the proper purpose of opera-tion could only be to render a hernia that was not controllable by a truss, amenable to truss treat-ment; to reduce the irreducible hernia, and to re-move adherent omentum from the canal. It was to him inconceivable that by any method of suturing, or by - any other artificial device, the weak, incom-petent abdominal wall could be rendered perma-nently strong and efficient. This view was of course based on the belief current in his day that hernia was the result of weakness of the muscula-

ture of the abdominal wall, and is an interesting example of acute and correct reasoning betrayed into error by an unsuspected Haw in the scientific knowledge underlying it. On the other hand, we are now in a position to state conversely that the saccular theory of hernia is essential to the rational conception of any possible operation for perma-nently curing hernia; or to put the matter in a somewhat different way, if the saccular theory were not true, no operation for the cure of hernia would be possible.

Among the numerous enduring impressions that I received when as a mere lad I had the great privi-lege and delight of sitting at the feet of Lister was a possibly exaggerated distrust of the value of sta-tistics, and of what I may terni the statistical method when introduced into the study of sur g ical ques-tions, 1 am speaking of a time when the value Of antiseptic methods in surgery was regarded as a "question," and the claims advanced by Lister as "not proven." It sounds very absurd now to sug-gest an ,appeal to statistics to prove that aseptic woun d - are more desirable than infected ()ties. but that is of course an instance of wisdom con-ing -after the event. In any case, statistics were al•ray, being demanded, and what is more to the ;point, wlien they were forthcoming, they seemed ludic-rously incapable of demonstrating anything. I t was vain for Lister to aver, as he did time and main, that the matter was not one for statistics at all; that sounded like an evasion. Nevertheless. the veriest tyro who saw and was taught to under-stand his principles and methods would see quite clearly that statistics were not wanted. . famous continental surgeon, when shown for the first time the phenomenon of the organisation of blood clot occurring in a gaping osteotony wound, ex-claimed in astonishment, "Statistics have nothing to do with this." I learnt a great lesson from that incident, and one that has frequently been brought to -my nemory. That great surgeon did not scruple to draw immense and far-reaching conclusions from the thoughtful observation of a single case. Since that day, I have very frequently heard a warning tittered as to the danger of generalising from a single instance, and of the necessity of having a number of cases tinder review. before any safe con elusion can be arrived at. I always think this is rather a pity, and 1 mast confess to a firmly-rooted belief in the supreme value of single instances accu-rately studied. \\- hatever happens in any case hap-pens in obedience to pathological law, and the laws of pathology are just as immutable as any of the other laws of nature. Any apparent violation of pathological law can only mean that there is some underlying factor that has escaped our detection, and should compel' us to a closer and more search-ing scrutiny to lay it bare; whereas on the other hand, it is very easy to foster an attitude of philo-sophic agnosticism in the presence of any deviation from the traditional normal, which is a distinct en-couragement to put it aside as s(uiiething dangerous and m'isleading. .A series of hundreds of operations, tabulated and arranged and nicely rounded off in

February 21, 1914. AUSTRALIAN MEDICAL JOURNAL.

1441

terms of percentages. always seems to tine to pos- sess but very limited value, so limited indeed that

it is strictly confined to one person, the surgeon

who performed the operations: and even he can

learn nothing from the contemplation of his tables

when he has compiled them. The rich experience

he will have gained cannot .even be expressed in that tray, much less can it be imparted to others. for it will consist actually in the soin of a multitude of observations of individual cases, all of them

slightly varying one from ,_mother, but all of them obeying pathological laws which are fixed, and which never van-. after all it is not the fact of performing a large number of operations that in itself constitutes real experience, unless in addition the surgeon who performs them possesses the quali- ties that are essential for a good clinical observer. And what are those qualities? Can they be in any way defined or indicated? Or better still, can the practical steps by which a surgeon should seek to make himself a good clinical observer he set forth

for our help? In order to cío this, 1 cannot do

better than refer to two of the notable features of

Lister's hospital work. First, he visited his warts

every clay in the week. Secondly. he in variably dressed his operation cases himself for the first.

few clays. We might be tempted at the first blush

to write this down as philanthropy, the mor e readily that the character of .Lister displayed in a

measure to which my experience can furnish no

parallel, the true philanthropic instinct. I Iut it was not philanthropy alone that impelled him;

there was a practical aim to be achieved. Put shortly and in simple terms, lie was profoundly con- scious that the daily observation of individual cases

is the only sure way to be continuously accumu- lating knowledge. The mere performanc e of an operation, or of an— number of operations, can im- part knowledge of only a very circumscribed and

imperfect character. The close following of a single case from clay to day, the close scrutiny of the behaviour of a wound. of the sutures, of the

discharges, and of the general phenomena disl>iaA-ed

by the patient will yield a richer harvest of valuable

equipment to the surgeon than any amount of

operative experience, in which the after treatment

is committed mainly to the charge of others_ Of all

the practical lessons that I carried away from m y studentship under Lister, I am disposed to rank the

instilment of this principle in the highest place.

And now I ant conscious that the period during

which it is fitting for me to claim your attention is

nearing its tern, and I am apprehensive lest there

may be some among you that will have experienced

disappointment at my choice of a subject which is not closely connected with the burning surgical

questions that for the moment are exercising our minds. There is no lack of such material ;

^ it is indeed so abundant that the difficulty of making

selection would have been formidable. The dread-ful mystery of malignant disease is being hard

pressed -by the organised onslaught of a scientific

army, but the secret has not yet been dragged forth.

The whole world, both medical and lay, is holding

its breath at the therapeutic possibilities that may

cyolye from our better actluaintatre'c wit raditinr, and iic wise are also withholding their judgment but in no carping spirit. The operation of - gastro. entero stoney has found itself ; its sphere and it,•

limitations have become defined, its value error

in) ousl y enhanced thereby, and what was quite re-cently a kind of surgical con fl agration lias settled

down into a steady luminous fl ame. The conflagra- tion has. however, only passed on a little. and the

air is now heavy with accouwi of bismuth meals. enteroptoses, and kinks. The dominant fact, never-theless, is that since these matters are engaging the

earnest attention of level-headed and honest

workers, we may rest assured that the ultimate re-sult will be a substantial increase in our knots

-

ledge. I might allude to numerous other matters that are either co .mparatiyely new or as yet imper-

fectly understood, such as the pathology and stir

gory of the hv-lrop]lysis and Of the thyroid and para-thyroids; or, turning our thoughts rather towards

therapeutic agencies, the have an inviting field in the use of serum -therapeutics and vaccines. llut

upon none of these subjects am I able to Speak with the authority conferred by exceptional knowledge and experience. There has, however. been one subs

ject that has been prominently in the surgical field

that has possessed for me more than ordinary in

terest, and about tvltich, if on will like to hear tire,

I should like to make a few observations.

The question of the treatment of simple frac-tures, which occupied the attention of the members

of this section at our last meeting in Congress, itas

since then been prominently before the profession,

and an organised attempt has been made by means

of a committee appointed by the IIritish \1edical

Association to investigate the respective merits of

what are knower as the operative and the non-

operative methods, and to settle the vexed question

as to whether it is necessary and right to cut clown

on recent fractures, and fasten the ends of the hones

together with plates 'and screws; or whether we

may not rather look to improved methods of non-

operative treatment for the amendment of our

faulty results. .after an exhaustive investigation, a

very minutely detailed report was published, which

was surprisingly inconclusive. It is true that the re-sults of the operative method showedd a slight ad-vantage over those treated without operation, but

surely unless this had been a foregone conclusion,

there could never have been any question about the

matter to he answered. The case of the advocates

of frequent operation was destroyed, moreover, by

one strenuous proviso in the report of the commit-tee, substantially to the effect that the resort to

open operation should be the sole prerogative of skilled operating surgeons in hospital, while the

ordinary practitioner must confine himself to non-operative methods; but seeing that the ordinary

practitioner has to learn to treat fractures from

skilled surgeons, in hospitals, during his student- ship, his chance of learning to treat such injuries

properly would obviously become less than ever in

proportion to the readiness displayed by his

1442 AUSTRALIAN MEDICAL JOURNAL. February 21, I9i4.

teachers to substitute operative for the more diffi-cult and trotiblesonie non-operative plan. A most remarkable feature of the whole of the discussion appears to me to be presented by the fact that for some years past there has been a third method of treatment before the profession, advocated with energy and ability by the highest authority. and foi which it is claimed that better results can be ob-tained than by either the old routine method or by the operative mtethod of Sir Arbuthnot Lane. I refer to the method entitled by its author, Just Lucas'-Charnpionniere, "Treatment by Mobilisation and Massage." Mention of this method gives me the opportunity of making reference to the great loss the profession of surgery has recently sustained through the death of the distinguished French sur-geon. An excellent account of the method has been recently published by an English disciple of Lucas-Championniere. Mr. Mennell. Anybody reacting for the first time the detailed accounts of the re sults obtained is likely tò find them almost incredi-ble, especially with respect to the rapidity with which union takes place, and the slight amount of shortening, notably in fractures of the femur. Why, then. has this method of treatment not made more rapid headway? To my mind, the reason is perfectly clear. in spite of the fact that I am pre-pared to substantiate with complete confidence the accuracy of the published accounts. • The truth is, a most unfortunate tactical blunder was made at the outset in the choice of a title, and the profession has been frightened, and very justly frightened, by the terms `mobilisation and massage." It might not unnaturally be supposed that mobilisation meant some kind of deliberate "Moving about," and that "massage" meant "massage," but it is scarcely possible to over-estimate the gulf that separates the real truth of the mat-ter from what would appear at first sight to be the meaning of the terms used to express it. If, in-stead of "mobilisation and massage," the method had been designated "Simplicity and common sense" it would have been quite as correctly en-titled, and long ere this it would have gained uni- versal acknowledgment, and driven all competitors from the field.

I have no time to devote to a detailed account of the methods we have been adopting in the treat-ment of fractures, but in a few brief sentences I should like to set out some of the more important conclusions at which we have arrived.

(T) The difficulties met with in the treatment of fractures are undoubtedly largely, I do not say en-tirely, of our own making.

(2) The long Liston splint in the case of the thigh; all appliances with foot pieces in the case of the leg and ankle; almost all splints for frac-tures of the humerus, and most splints for the fore-arm, are ingenious devices only for the creation of difficulties.

(3) There is usually, if not always, a position of the limb in which the fragments will fall naturally into place provided they are free to do so.

(4) When there are a number of long and power-fulmuscles acting upon the fragments. as in the case of the thigh, a light extension is necessary to combat the tonic contraction of the muscles.

(5) Any apparatus which would be uncom-fortable and annoying if applied to an uninjured limb, will, "a fortiori," be more uncomfortable and more disturbing if applied to an injured one; a sim-ple little camknion-sense principle that is often strangely overlooked.

(6) It is an absolute rule that no recent fracture shall be put up in splints and left for several clays; the splints must be taken off frequently, at least every second day, or 'better, every clay, the patient encouraged to -move the joints, fingers, toes, as the case may he, and generally to carry out the essen-tials of "mobilisation" as laid down by Lucas-C'hampionniere, and take an intelligent interest in his fracture and not he afraid of it.

here is an illustrative example of the kind of method I have been employing for some time past which may possess some interest.

Some months ago a body of students from the other two large leading hospitals of Melbourne came by invitation to see the Alfred Hospital, and among other things, T took them' to the bedside of a muscular young footballer, who had been ad-mitted a few days before, and made in substance the following remarks to them :—"This is a fracture of the shaft of the femur, about the middle, in a very-muscular man, and this is the way we treat such an injury. No long splint its used, simply extension in a comfortable, slightly flexed position, by means of an arrangement of small pulleys, thin cord, and zinc oxide plaster. The limb is supported com-fortably on pillows and abducted. The measuring tape shows there is no shortening whatever. The patient can raise himself up, be propped up at tinges, and generally move about and make himself comfortable, so that the irksomeness of his confine-ment to bed is reduced to the minimum. We find that by this method not only are the final results infinitely better than those we formerly were able to obtain, but the period of treatment is shortened by nearly one half. Firm union is usually obtained ill four weeks. I expect it in this case, and shall be disappointed if it does not occur. One of the pieces of knowledge that has come to me since I have been treating fractures in this way is with regard to the extreme rapidity, almost one might say suddenness, with which a bone will unite; it all seems to happen in the course of about the fourth week."

The foregoing are in substance the remarks I made to the students. That which acutally han pened in that case was as follows :—At the end of three weeks, there appeared to be no union; three clays later, the hones vwere obviously united with semi-firm union, while at the end of four weeks the fracture was absolutely firm. I then discovered that the alignment of the bones was not quite cor-rect, but that .there was- a. slight convexity forwards, causing an exaggeration of the normal anterior.

February 2I, 1914• AUSTRALIAN MEDICAL JOURNAL. 1443

curve of the bone. It was not a serious matter, but in order to correct it, I suspended the leg at the knee, and passed a jack-towel, to which was at- tached a 20-pound weight, over the middle of the thigh and hung it over the opposite of the bed. T failed, however, to make any impression on the firm union, and after trying for three days in this way I gave it up. It was a matter of only trifling importance. At the same time there was in the ward a case of Pott's fracture in a young'man. At the end of a fortnight, he was able to take the splints off during the day, and re-apply them at night. At the end of three weeks he left the hos- pital. These are precisely the type of results ob- tained, so far as I can discover, by the late Dr. Lucas-Championniere and \Ir. Mennell. The me- thod employed, so far from being elaborate and alarming, is at least as simple as the older methods, and quite as easy for the busy general practitioner to master and employ. Moreover, it appears, un- less I am greatly mistaken, that the methods that for the last two or three years I have been employ- ing in the treatment of fractures, of which the two cases briefly narrated will serve to roughly indicate the general plan, differs in no essential feature from the methods of Lucas -Chamrpionniere. lout with this bare allusion, I must perforce leave the sub- ject, for which I. hope shortly to find some other opportunity for a more detailed statement. This address has by intention and design been about my old master, Lister, and it is not altogether without fitness, that it should be brought to a conclusion with the subject of simple and compound fractures, for we all remember that it was in the treatment of compound fractures that modern surgery had its birth. In any case, I believe that I gauge the feel- ing of you all aright if I submit that nothing of an intimate nature that pertains to the personality of Lister can at this juncture fail in interest for mem-bers of our profession. It has been truly said of the great English statesman, Gladstone, that by his example he introduced a new ami exalted standard of honour into international politics. If it cannot be said of Lister that he introduced into surgery a standard of ethics that was in any way new. that is simply because our profession has always abounded in men of lofty ideals and singleness of purpose. We of the medical profession believe (and I do not hesitate to risk a charge or arrogance in voicing the belief) that the greatest mien of our profession are the greatest men that the race of mankind has to show. Sir Berkeley Moynihan the other day, in speaking of Lister, referred to him simply as "the greatest man our profession has pro-duced," and those who knew Lister intimately, who became conscious of his humble-mindedness and modesty, his purity in thought, word, and deed, his deep and child-like religious faith, and his abound-ing love of his fellow-man, recognise that they have witnessed the culmination of the highest qualities that civilisation has as yet brought forth. We cannot hope to emulate his great achievement, but we are here to make serious endeavour to contribute, each of us something, towards the furtherance of the healing art that he pioneered for us, and our

Causes of Insanity. The Paris correspondent of "Ilancret" says:—

Dr. Auguste Marie, Medical Director of the Insane Asylum of Villejuif, has published some interesting sta-tistics of insanity in Paris with specialreference to occu-

yea snago has long heldQs made

Accordinghtolit the liberal professions always tarnished the greatest number of in- sane; then in decreasing order came soldiers, sailors, do- mestic workers, ,people of 'private 'income, land owners, in- dustrial workers, agriculturists, merchants and trades- people. ,Social evolution, by modifying the conditions of various occupations, has brought about important changes In this order, which, however, are not always the same in all countries. Among professional men the intoxications play a 'daily increasing role, while general paralysis conse- quent on syphilis claims more and more numerous victims among the middle classes and the ■rich, whatever their oc- cupation. Dr. 'Marie's statistics deal with the cases of mental alienation observed recently in the population of Paris, and confirm this evolution; and the interesting point is the recorded percentage borne in each occupation in comparison with that of the total population. In stone- working trades, which furnish a considerable and alto- gether unexpected 'percentage, 492 insane are found out of 24,012 workers, or 2.04 per cent. In occupationsdealing with the animal kingdom (drivers and stock-raisers) are found 671 insane :out of 57,891, or 1.17 per cent. In chemi- cal industries, or from lead intoxication, 649 cases of in- sanity in 63,220 persons, or 1.02 per cent. Among commis- voyageurs there are 1072 insane out of 37,398 persons who make their living thereby, or 2.85 per cent. The liberal professions and ,sedentary commercial occupations, which formerly headed the

-list, now give only 1.02 per cent. The occupations least affected by insanity are industries connacted n ith the timber trade, with thansport, and with alimentation, whose percentages vary from 0.48 to 0.85. 011 the whole, the class of workers is much more affected with dementia than used to be supposed before statistics were collected on this :principle. Dr.

-Marie, it is true, includes in insanity very diverse mental ailments which were not formerly comprised therein when only dementia pure and simple was recorded. For instance, he includes in ibis sta-tistics mental debility, mania, melancholia, enfeeblement of intellect, alcoholic insanity, and parasyphilis• The role played by alcoholism in the genesis of dementia in France is considerable, and is continually increasing in all the asylums in the country. Dr. Marie records a very curious new observation, viz., the increase of cases of madness im the various industrial omu:pations, due to the excitement of social conflicts and the iSyndicalist struggle. The de-generates, who are to be found in - all classes of society, accentuate the tendency to violence.Some of this class were found among the pout-office employees at the time of the strike of 1908-09. These were really feeble-minded .per-sons, victims of moral shock due to the perturbations and diverse mental preoccupations occasioned by the strike. Dr. Marie thinks that these troubles may convert such sub

-

jects into leaders or inspirers of violence, such as is general enough in strikes, especially when accompanied by alcoholic excitement. He does not assert that all the leaders are of this class, though a certain number of them are.. With native gallantry he forbears to make any allusion to women in this connection.

strivings can but be aided and fortified by turning our mental gaze upwards "unto the hills"; and I would venture in conclusion to quote from the words of yet another of the world's great teachers, words which seem to me peculiarly appropriate to the purpose of this address :"Whatsoever things are true, whatsoever things are honest, whatsoever things are just, whatsoever things are pure—if there be any virtue, and if there be any praise, think on these things."

144.4 AUSTRALIAN MEDICAL JOURNAL. February 21, 1914.

austrattan fifiebicat journal 21S1 FEBRUARY, 191¢.

PELTING THE PANEL.

As evidence accumulates there appears to be little doubt that the medical panel system of the National Insurance Act in Great Britain is a failure. Even the • reports of the increased emoluments of the medical practitioners seem to he largely mythical, or else matters must have been very desperate be-fore the Act came into force. At a recent dinner \Ir. Lloyd-George himself gave statistics (which we may he certain lacked nothing that could give the most favourable interpretation) showing that the average income earned upon panels was from £250 up to £300.

'I'hat these figures are somewhere about the real average is supported by an analysis given in the "-Medical Press and Circular" of January 14. In an editorial note that journal says :—"It has been so vehemently asserted by certain newspapers that medical men are amassing vast sums out of the insurance patients that it is interesting to have some precise figures by way of counterpoise. On the authority of the 'Bradford Daily Telegraph,' it is stated that there are 126 doctors on the panel of the city of Bradford, and in ninemonths, that is up to October 12th, they have actually received from the Government £26,282 for ordinary and £2021 for domiciliary services under the Act. By a simple process of division it is evident that the average for each medical man thus engaged is re-presented by the magnificent sum •mof £222 for nine months, or some £300 per annum, in return for arduous and responsible work of a highly-skilled nature. As a matter of fact, the actual remunera-tion ranges widely on either side of the £3oo, ill

proportion to the numbers of insured on each panel doctor's list. In Bradford there are six medical men who have over 3000 on their list, six more have over 2000, and thirty-two over woo."

Nor is the panel system popular with the public. According to recent newspaper files an agitation -has been started in favour of a State medical ser-vice, and the correspondent of the Melbourne •'Age" states: "The demand for a State medical service is keenest among those who have been con-sistent supporters of the Act, and it is advocated by the chief newspapers on the Liberal side." The latest platform supporter is Sir John Collie, who is a member of the advisory committee in connec-tion with the working of the insurance Act.

In these columns we have repeatedly expressed distrust for any State medical service, on the grounds that it would in the end produce both an inferior quality of medical practice and medical practitioner. The National Insurance Act is prac-tically a measure of State medical service. Let us take Sir John Collie's opinion of it. In referring to the permission of patients to choose their own panel doctor, he said: "This was a tremendous mistake. A large number of doctors with very inferior at-

tainments put clown their naives. Surely the Go-vernment should have taken some steps to see it was getting value for its nioney...

This is a defect which we insist again lutist be accentuated by a State service. Every one will take the easiest road to the goal of an assured income. And the danger of perfunctory medical service is already apparent. " Lightning diagnosis is a glaring defect of the panel system,' said Sir John Collie. • " The work is scampe-d and much of it hurried through in a way that is positively appalling," and again, "The great hulk of the money provided under the Act is going in the treatment of minor ailments; much of it is hardly snore than first aid."

\\'hen Sir John Collie came to the proposal for a State service as a cure for panel evils he was a:. vague and unconvincing as all the other advocates. "The duty of the State was to provide the finest service possible on the most economic basis." Quite so : but in what department of life has the State ever accomplished such a thing, and why should we believe that its medical service would be any less circumlocutory and unsatisfactory than all other Government departments? "The proper way was to co-ordinate all the present facilities." Quite so, once again, but what do we mean by "co-ordination"? Is it a fact that associated Go-vernment departments are readily "co-ordinated Is it not the experience that wherever faults are found, each "co-ordinated" department is anxious to hand responsibility to the other?

It seems to be overlooked that the panel system is a State medical service, and it appears to exhibit very early the defects that we have already fore-casted. What improvement could be expected under a frankly nationalised medicine remains to be seen.

Meanwhile it may he accepted. in the words of the chairman who presided at Sir John Collie's lec-ture, that "the panel system has proved a failure."

fßrtttSŸ) ebttat gmoctation. VICTORIAN BRANCH.

t1TSTIt.ILASI.t\ MEDICAL CONGRESS. Tenth Session, Auckland, A.Z. (From our own Correspondent.)

The programme of the session was inaugurated on February 14th by a reception given by the President (Dr. A. Challinor Purchas) -and Mrs. Purchas. Special sermons, discussing various aspects of the art of healing, were preached on Sunday -by the Bishop-elect of Auckland (Dr. A. W. Averilll) in -St. 'Matthew's Church; by the Roman Catholic Bishop (Dr. H. W. Cleary) in St. Patrick's Cathe-dral; by the Rev. R. L. Walker, in St. Andrew's Presby-terian Church, and by the Rev. R. Inglis, in Knox Church, Parnell. Owing to the late arrival of 'the Maheno, the overseas delegates were not able to attend any of these services, hut at each of the principal churches there was a numerous representation of the medical profession.

The first of the many functions arranged in connection with the congress took place on Saturday afternoon, when the visiting doctors, who had then already arrived, and the Auckland members of the,.profession, as well as a number of other guests, attended a reception given by Dr. A. Chal-linor Purchas (iresident of the congress) and Mrs. Purchas

February 21, 1914. AUSTRALIAN MEDICAL JOURNAL. 1445

at their residence, St. Aryans, Carlton Gore Road. There was a large and successful gathering, the guests numbering

about 250. Amongst those present were a large number of the resident doctors and several Australian and New Zea-land visitors, and also a number of prominent citizens.

Most of the doctors were accompanied by their wives and

daughters. The guests, after being received by Dr. and Mrs. Purchas,

distributed themselves about the pleasantly-situated

grounds, which, under the influence of an ideal summer's day, looked at their best. Seats were provided around the lawn and in the shady portions of the grounds, and nothing

was wanting to ensure the enjoyment of all. Delicious

afternoon tea and ice creams were dispensed, and an ef-ficient string orchestra discoursed sweet music at frequent

intervals. The function was in all respects a pronounced

success, and formed an auspicious opening for the round of congress week fixtures.

The inaugural meeting in connection with the Medical Congress was held in the Town Hall on February 16th.

The hail was filled with delegates and their wives, and

members of the general public. Amongthose on the plat-form were HisExcellency the Governor (The Earl of

Liverpool), the PrimeMinister (Right Hon. W. F. Massey), the Minister for Public Health (Hon. R. Heaton Rhodes), theMinister for Railways (Hon. W. H. Herries), Hon. Dr.

Pomare (member of Executive representing the native race), theMayor of Auckland (Mr. C. J. Parr), the Hon.

W. A. Holman (Premier of New South Wales), the Angli-can Bishop-elect of Auckland (Dr. A. W. Averill), the Ro-man Catholic Bishop of Auckland (Dr. Cleary), Colonel Logan, A.D.C. (officer commanding the Auckland Military District), Dr. T. H. A. Valintine (Chief Health Officer), a

group of naval officers from the warships in port, and ;dele-gates attending the congress.

His Excellency the ;Earl of Liverpool, who was the first

to address the gathering, read the following cablegram re-ceived by him from the Imlperial Government through the

Secretary of State for the Colonies (Mr. L. Harcourt). —"Please convey to Australasian Medical Congress at its

opening, my bet wishes for the success of its deliberations. His Majesty's Government recognises the importance of contributions which such congresses have made to the ad-vanc -went ofmedical science, not only in Australasia, but generally, and looks forward with interest to the results

of this meeting in New Zealand." His Excellency extended to the members of the con-

gress a *host sincere and cordial welcome. He referred

to the desire always evinced by Their Majesties to assist

the researches of those who were endeavouring to eradi-cate the terrible scourges that afflicted mankind. In con

clusio.. ; ' His Excellency said the delegates to the congress

were closely and eminently connected with medical science in Australasia and elsewhere.

The Prime Minister, who was received with great ap-plause, said he desired, on behalf of the Government and

the people of New Zealand, to extend a hearty welcome to

Mr. Holman, Premier of New South Wales. (Applause.)

The gathering of medical men was of great importance.

Where men were working• to eradicate disease it was the

duty of the State to 'do all it could in the circumstances to

assist them. "On behalf of the 'whole of the people of this

Dominion," concluded Mr. Massey, "I desire to extend the very heartiest of welcomes to our visitors." (Loud ap-plause.)

The next speaker was the Hon. W. A. Holman, Premier

of New South Wales, Dr. A. Challinor Purchas, President of the Congress,

next delivered his inaugural address, and at the conclusion Dr. Macdonald offered 'greetings from the B.M.A., and pro-posed a vote of thanks to the Governor. A vote of thanks

to the President was proposed by Dr Pocklev, of Sydney.

Work in the various sections proceeded with enthusi-asm, and many interesting papers were read. A special

report on "The Feeble Minded," prepared by a committee

consisting of Dr. Beattie Smith (Chairman), Dr. J. S. Yule ((Hon. Sec.), Dr. W. Jones and Dr. H. Sutton, was presented

to congress. Their findings were as follows: — The committee is of opinion that the following is in

general terms 'the direction which legislation to 'provide

for the feeble-minded should take:

• (1) Day schools in large centres to train all children

reasonably suspected of mental detect. These_ will elimin-ate children 'wrongly classed as such. and qualify them for

further education through the ordinary channels. The

identification of the rest they would confirm. (2) Residential schools for children of the same doubtful

class from scattered districts and for children definitely

judged to be mentally defective. Classes of the type found most successful in other lands will be here available for

the purpose of completing the children's training —both manual and scholastic, so far as the latter is found to be desirable and useful. In this class may also be mentioned

the small paying schools. It will be necessary to provide

for the mentally defective children of the more well-to-do

parents, when the latter are unable to provide satisfactory

care and control at home. These institutions could be

worked either separately or in conjunction with the non-paying school.

(3) In connection with the residential schools to some

extent, and probably also by preference in separate coun-try localities, residential colonies with separation of the sexes for the 'permanent care of the feeble-minded on at-tainyya ^g adult age, when not of so low a grade as to call

for confinement in such institutions as idiot asylums. In an addendum the committee says: "The detention of

mental defectives in these colonies will, of course, pre-suppose adequate 'legal safeguards to avoid any possibility

of error; this could be further provided against by peri-odical inspection. Moral defectives might be dealt with to a large extent by these institutions or might require some

special provision. Such colonies exist in England and

America, but are handicapped by the want of legal power

to detain. This shoulld certainly be granted, as otherwise

the worst cases from the point of view of the community

would the allowed to roam at large. The consensus of

opinion of all who have seen the colonies in operation is that the feeble-minded are far happier as well as safer in them than when left to the mercy of ignorant 'parents or a world which has too much to do to make allowances for them, or prevent their misconduct or disaster. The ex-pense of instituting the colonies would undoubtedly be large, yet truly 'economical when the present expenditure on mis-dealing with the feeble-minded in gaols and charit-able institutions is weighed in the balance. By such means alone can the 'State hope to prevent the feeble-minded forming the large proportion they do of our habit-ual criminals, 'drunkards, prostitutes and wastrels, and thus alone with propriety can they be prevented from propogating their undesirable type in the make-up of fu-ture generations."

The report was discussed by the sections interested, and a resolution containing recommendations on the subject

was passed for consideration by congress. There was no lack of entertainment on Tuesday for the

delegates to the Medical Congress and their friends. In the afternoon a party of over 400 made an enjoyable motor trip to Titirangi, as guests of the City Council, on the oc-casion of the opening of the Atkinson botanic reserve.

Over 1000 guests in the evening were present at a gar-den party in the grounds of Cintra. The entertainment

was arranged by the President and members of the New Zealand branch of the British Medical Association. The

gardens were decorated with 2000 fairy lanterns, the effect

being greatly enhanced by the light of the moon. The

military band of the Third (Auckland) 'Mounted Rifles played several selections during the evening, the vocal portion of the programme consisting of quartettes and recitations. The chief feature of the entertainment was

the presentation in costume of the old English and other national dances by various parties of girls. The evening

was an ideal one for an outdoor function, and the gather-ing 'was much enjoyed,

The Minister for Public Health (Hon. R. H. Rhodes) gave a dinner at the Northern Club fora large party of the official representatives at the congress. In addition to the members of the medical profession, there were several

other guests, including the Mayor of Auckland (Mr. C. J.

Parr), the Premier of New South Wales (Mr. W. A. Hol-man), the Speaker of the House of Representatives (Hon. F. W. Lang), the Hon. John B. Nash, M.D. (a member of the New South Wale's Legislative Council), and Mr, Roy Bagnali, M.L.A. for St. George.

1446 AUSTRALIAN MEDICAL JOURNAL. hebruary 21, 1914.

CURRENT LITERATURE.

Venereal Prophylaxis. Mr. Ernest Lane, giving evidence before the Royal Com-

mission said that, i:n his opinion, venereal diseases are at-tended by just as great a mortality as tuberculosis or cancer, and although it was not possible to obtain figures to support this view, it was one which had been more or less frequently expressed by well-qualified persons. He thought that the diseases were somewhat less prevalent than 20 or 30 years ago, but on this point it was very 'diffi-cult to speak with certainty; the statistics of death cer-tified as due to syphilis did not give any idea of the preva-lence of the diseases. Mr. Lane said that, although large subscriptions are given to the cause of combating other diseases, nothing has been done with regard to venerai diseaes, and public money has never been expended ex-cept in carrying out the Contagious Diseases Acts. He laid stress on the necessity for improved and free !hos-pital treatment, and said that every patient suffering from any form of venereal disease ought to be entitled to gratuitous treatment and medicine and to bacteriolgaical and other tests. If it is desired to cure syphilis anT get rid of the disease, anything that would aid early diagno-sis ought to be at a patient's disposal without expense to him. In any scheme for the efficient treatment of the diseases the establishment of night clinics was essential.

On the subject of notification, Mr. Lane said that though he had formerly been in favour of notifying all cases of venereal disease to the sanitary authority, he had now modified his view because he , was convinced that notifica-tion would deter sufferers from seeking proper advice and would lead to increased recourse to quack treatment. Dealing with the question of the education of public opin-ion with regard to venereal disease's, he said that in the first place the infected persons must be instructed. It should be made compulsory for medical practitioner to supply to every patient suffering from venereal disease printed instructions as to the nature of his disease and as to the measures he should adopt to avoid spreading the trouble; copies of these instructions should be sup-plied gratuitously to the doctors. Secondly, he would suggest that all institutions where there are a large num-ber of employees, or institutions such as colleges and uni-versities, ought to have some course of lectures explain-ing the dangers of venereal disease. It was also of the greatest importance that the standard of knowledge of these diseases in the medical profession should be raised; in the past the teaching given in the medical schools was very inadequate, but steps were now being taken in some of the more important hospitals which should lead to an improvement in this respect.

Mr. Lane gave some statistics of the work done at the London Lock Hospital. He showed that during the last 30 years there has been a remarkable diminution in the number of prostitutes treated at the Female Hospital; at the present time the majority of the female patients were very young girls and 13 per cent. of the patients were married women. All the cases in the children's wards and the greater part of the married women were examples of innocent syphilis. In the Male Hospital the 'flew out-patient department opened in 1911 had proved most satis-factory, and the number of attendances was increasing; a new in-patient department was opened in November last, with three wards perfectly fitted with all modern accom-modation for 40 patients.

CORRESPONDENCE.

Metropolitan Chemists' Association. (To the Editor of "The Australian Medical Journal.")

Sir,—There appears to be some misunderstanding about the last letter that appeared in your journal of the 24th January in regard to the "late fee" to he charged by chemists.

"Late fee" of 2s. 6d. should really have read "late night fee" of 2s. 6d., and by this is meant that an extra charge of 2s. 6d. will Ibe charged for being called out of bed to

CÓiCar SllogOCiAtiOn. VICTORIAN BRANCH.

Dr. Stewart Ferguson, 34 Collins-street, Melbourne, Hon. Secretary.

NOTICES.

Medical men are advised to communicate with Dr. S. W. Ferguson before applying for positions advertised by Bullfinch Medical Fund, WA.

AUSTRALASIAN MEDICAL PUBLISHING COY. LTD.

Applications are invited to fill the position of Editor of the "Medical Journal of Australia." The Editor must be a qualified medical practitioner with sufficient journal-istic experience to take entire editorial charge, subject to the Directors' control. Applicants should state whether they are prepared to give their whole time or only part of their time to the work. Salary for whole-time Editor to be £750; for part-time Editor, £ 350. Applications to be addressed to the Secretary, Australasian :Medical Pub-lishing Company Limited, B.M.A. Building, 30-34 Eliza -

beth -street, Sydney, New South Wales, and to be in his hands not later than Monday, 9th March, 1914.

—f Advt.

dispense a prescription after the hour of 11 p.m. (other-wise bedtime).

And a fee of 1s. will be charged for opening the phar-macy to dispense a prescription between closing time and 11 p.m.

Will you please oblige by inserting this letter in the next issue of your journal, so that this matter will be clear to the medical profession.—Yours, etc.

A. L. J. PETERS, General Secretary.

GENERAL.

In the treatment of diphtheria by means of antitoxin, the majority of the best authorities now advocate the use of large doses. The chief obstacle in the way oi' carrying out this policy has hitherto lain in the difficulties and inconvenience attending 'subcutaneous injection of the comparatively large volume of fluid in which the required dose of antitoxin is contained. Hence, attempts have been made to facilitate matters by producing a serum in which a high antitoxin-unit value should be contained in a small bulk. Formerly this reduction in volume depended on the discovery of a horse (or horses) which responded par-ticularly well to the immunising injections, and yielded â natural serum of high potency. During the last few years, however, methods have been devised and developed which make it possible, by means of salt precipitation, to separate the antitoxin-bearing globulin fraction of anti-toxic serum from those proteins which, while adding to. the bulk of the preparation, are devoid of antitoxic value. It is by the latest and most approved of such methods that "Wellcome" Brand Concentrated Diphtheria Anti-toxin is prepared, and in the resultant product 1000 Ehrlich-Behring units are contained in at most 1 c.c. of fluid, as compared with about 2.5 c.c. necessary to present the same number of units in the case of unconcentrated serum. The advantages, both to the patient and physician, of such a reduction in the volume to be injected are obvious.

Although the portion of the serum which is removed in the process of concentration possesses no antitoxic value, it is at least equally responsible with the anti-toxin-bearing proteins for those incidental toxic 'symp-toms which sera may produce in susceptible patients. With its elimination, therefore, the liability or power of the preparation to cause such unpleasant after-effects would appear to be diminished, and this is borne out by clinical experience .

February 28, 19f4. AUSTRALIAN MEDICAL JOURNAL 144p,

TEN CASES OF SPLENECTOMY FOR SPLENIC AN/EMIA.

With Notes oh the Operation and its Indications.

R. A;, STIRLING, M.D. (Surgeon-to Melbourne Hospital.)

Read before the Congress in N.Z.

These notes may be looked upon as a surgical sequel to Dr. Springthorpe's account, at a previous Congress, of a number of cases of splenic anaemia occurring in the members of two distinct families.

I , have • so far operated on ten cases, the last one —a few months ago—recovering very rapidly, al-though the spleen was exceedingly large and ad-herent. The ninth casé died of haemorrhage about twelve hours after operation with almost appalling suddenness; although I had taken special pains by doubly ligating each vessel to prevent such a dis- aster. The only other unsuccessful case was one of Bantis disease, complicated • by ascites—itself a positive contra-indication to operation, and operated on only as a dernier resort—a procedure I am not likély - to repeat, on account of the difficulty of re-straining the hemorrhage, and the lessening of the normal coaguability of the blood. Clamping of the pedicle, for ligatures cut through it with the same ease as a pair of scissors, was effective for fifteen days, but on removal of the clamp, bleeding quickly recurred with a fatal result.

A younger generation has furnished me with the eleventh case in a boy of eight—but I have not yet operated on him.

Although the operation is in these cases almost invariably a severe one, with many pitfalls, and although the resisting power to infection is said to be materially reduced for a few days after splenectomr, in none of the patients were there any signs of post-operative sepsis. It is remarkable to observe how, rapidly the anaemia, the sallow complexion, the listlessness, and the cachexia generally, clear, up after the removal of the viscus,' which from a very early age, has been undermining the health of many members of the same family.

•Although we are quite in the dark as to the real function •of the spleen, there is nothing in their subsequent history that would suggest that they were spleenless; although as some experiments show. such people regularly excrete an abnormal quantity of iron.

The Surgical Anatomy of the Spleen.

In man the spleen shows only a faint trace of the three-lobed organ of varying size and form that is found throughout the mammalian series; while the; .posterior lobe, so large in the kangaroo and other marsupials, is reduced to. a mere projection.

The spleen swings from the diaphragm by its suspensory or phrenosplenic ligament, which forms part of the wall of the lesser omentum; it is at-

tached to the stomach by • the gastro-splenic omen-turn, which extends forward to the greater curva-ture • of the - stomach, -and below 'finites with flee gastro-colic ligament.

'l'he gastro -splenic omentum is a much wider structure than formerly depicted in anatomical plates, with a tendency to curve round -the upper pole of the organ, and containing ,at least . three large blood vessels—the vasa brevia of the splenic artery which pass from the spleen to the stomach. This may be looked upon as the superficial layer of the pedicle, for beneath it and the lieno-renal ligament which proceeds backwards to the anterior surface of the left kidney, there lies, from below upwards ---the tail of the pancreas—not in reality a tail, certainly not a tip, ,but a dead square-shaped end, and the branches of the splenic artery and vein. These number about four, and the lowest is in close juxtaposition -to the pancreatic tail.

If, as is commonly the case, the pedicle is ligated en masse with both its blades enclosed, the pan-creatic ,tail must form a portion thereof, with the result that the ligature is very liable to slip. Moynihan states that in some cases the tail of the pancreas has accidentally or deliberately been in-cluded in the ligature surrounding the pedicle, in order to ensure a firmer hold. Esmarch advises that this should be done if there is any doubt as to the security of the ligature. I lost my ninth case through following this plan owing to the ligature slipping. To prevent such an accident, I now free the spleen from below dividing the lieno-renal liga-ment; ligating also the vessels of the gastro-splenic omentum separately and as far as possible from the stomach, avoiding also the 'supra-renal capsule which always lies exceedingly close to an enlarged spleen. Then I divide the suspensory ligament—the costo-colic and the adhesions to the diaphragm between ligatures or clamps. It is here also that Haemorrhage now or subsequently—and it may be uncontrollable haemorrhage may occur—owing to defective ligation of a branch from the aorta or coeliac axis, arising about the level of the cardia and running- to the left. The spleen can now be rotated out of its bed, and delivered when the splenic vessels are easily secured from behind; the lesser sac of the peritoneum being opened during the ligation.

The splenic vein is very apt to tear, hence carry- ing a ligature en masse is dangerous. When pos- sible each big vessel should be doubly ligated separately with silk, in the face of the stump.

The splenic veins lie below the artery.

G. A. .Wright in 1888 :—"Splenectomy is very dangerous, the chief danger being from haemorrhage and shock; and there being especial danger of bleed-ing from a vessel that passes between the spleen and the diaphragm.. Whether it is altogether an an abnormal vessel -or merely a dilatation of a small vessel existing there I do not know, but it is responsible for the death of my patient and of three others, including a leukæmic patient."

1448 AUSTRALIAN MEDICAL JOURNAL. February 28, 1914. .

The Operation of Splenectomy.

The surgeon should stand on the left side, as he thus obtains a better view of the pedicle, the liga-tion of which is the most important step in this operation.

Step i.—The incision should be made on the outer border of the left rectus, beginning at the costal cartilage and continuing down to or below the umbilicus.

A sterile towel soaked in saline solution is now intróduced, and pushes the intestines into the right half of the abdomen out of harm's way.

Auvray (Presse Medicale, 1905) has recom-mended that the incision be prolonged outwards and backwards over the lower part of the thorax at the level of the 8th space. In this way a flap of the soft tissue is cut, which, when dissected up and turned downwards, freely exposes the cartilaginous thoracic border, in other words, the loth, 9th, and 8th cartilages. These cartilages are then divided with knife or scissors close to their anterior ex-tremities, and freed frornt before backwards and from below upwards, the knife being kept very close to the deep surface during the separation of the underlying soft tissues. Finally the thoracic segment is excised by cutting the cartilages a little in front of the costo-chondral junction. Then, by gently retracting the soft tissues with the fingers, and raising the remains of the thoracic border with a broad retractor, the whole spleen will be ex-posed, and it will be possible to examine its anterior border, the external surface, and the two portions separated by the attachment of the gastro-splenic omentum, of the internal surface, and it will be easily possible to draw down the upper pole.

Step 2.—Separation of adhesions. These render the operation difficult, and it may

be impossible. In my first case, at the close of a long and tedious dissection, I found the large spleen very adherent to the splenic flexure of the colon. Dr. Embley told me that the patient had come to the limit of her endurance. In the final manipula-tion, however, I unfortunately tore widely the splenic flexure of the colon. This was rapidly su-tured. She made a good recovery.

Deal particularly carefully with the phreno. splenic ligament, ligating, if possible, each section with double ligatures before dividing between them. To reach this ligament Jonnesco advises that the operator should pull the spleen covered with a gauze pad, gently to the right, an assistant with his gloved hand raising the ribs and drawing the left edge of the wound to the left, thus exposing the diaphragmatic vault. It is inadvisable to trust to ligature of this ligament after removal of the spleen —it is easier and safer to tie with the organ in situ. The spleen should never be seized with instruments, as the haemorrhage from its torn tissue may be uncontrollable.

Step 3.—Ligation of the pedicle. See Surgical Anatomy.

At times, in very large spleens there is hardly any pedicle. In cases complicated with ascites, the operation is contraindicated as the tissues of the

pedicle become sodden and softened. In one case the ligatures cut through, and it was necessary to use and leave clamps covered with rubber at their ends. I have twice successfully used tamponage to stop haemorrhage.

Step 4.—Revision of the area from which the spleen has been removed and final haemostasis. Bleeding from the diaphragmatic pillar may require a few sutures for its control.

Step 5.—Closure of abdomen in usual way. The following precautions of Jacobson should

be followed:— I. To prevent any tension being exerted on the

pedicle. 2. To secure every vessel. 3. To divide these in a relaxed condition at a

sufficient distance from the ligatures. 4. Not to include the tail of the pancreas. 5. After all the ligatures have been applied, it may

be well for sake of safety to throw one around the whole.

Indications.—The spleen may be removed for the following conditions

1. Splenic enlargements other than tumors can be grouped in three general classes (W. J. Mayo) :

(a) Leukemias, in which the spleen pulp be-comes converted into tissue resembling bone mar-row, and in which the spleen, in common with all the blood-forming organs, rapidly produces white blood-corpuscles of the ancestral type, much as epithelial cells run riot in cancer—a probable re-version to the fretal form of blood.

(b) Splenic anaemia, the type in which the en-largement of the spleen is accompanied by a dimi-nution of and change in character of the red blood corpuscles.

(c) Splenomegaly—an enlargement without marked blood changes, or any apparent serious in-terference with the health other than mechanical.

2. Injury. 3. Hydatid. 4. Wandering spleen on account of the danger of

torsion of pedicle. 5. Malarial spleen under certain conditions. 6. Gunshot wound of spleen. In a case of hydatid of the spleen of enormous

size on which I operated, and sent to me by Dr. M. U. O'Sullivan, some years ago, the patient, a robust and vigorous young man, would only con-sent to operation when pyrexia pain and other signs of commencing suppuration forced it upon him. To remove the daughter cysts it was necessary to make a section through a considerable thickness of the spleen, which presented in the depths of the wound. The bleeding was the most terrific I have ever en-countered, and could only be stopped by tamponage and subsequently ligature en masse of the cut edges of the splenic tissue. The latter is much more friable than hepatic tissue and also more vascular, but fortunately in this case the splenic capsule was thickened and formed a point d'appuis for the sutures.

February 28, 1914. AUSTRALIAN MEDICAL JOURNAL. 1449

I look.upon ascites as a distinct contra-indication to operation—also grave lesions of the liver as shown by urinobiluria and jaundice, with their consequent liability to haemorrhage, haematemesis and melena. Marked painful paroxysms denoting perisplenitis and subsequent adhesions are disquiet-ing symptoms, and, of course, the larger the spleen the more difficult frequently its removal. Of all the adhesions, those with the diaphragm are the most dangerous, and in one reported case in removing them the stomach wall was injured and perforated later with fatal peritonitis.

Spleniculi were found in only one of the eleven patients, and were not removed. I'or some reason this patient eighteen months subsequently was not doing well, and Dr. Springthorpe asked me to re-open her abdomen and remove the subsidiary spleens of which two were noticed at the first operation. There was no trace of them, however, and it is probable that the removal of their blood supply by the ligation of the splenic artery caused their disappearance.

Splenectomy seems to have recently been suc-cessful in that medical reproach pernicious anaemia. hlemperer and Hirschfeld report two cases in which they removed the spleen with marked im-provement. Eppinger has also operated in the same way in two cases. I-Ie removed the spleen on the ground that in haemolytic anaemia there seems to be a pathological excessive destruction of the reds in the spleen. The hope that the splenectomy would stimulate the new production of red blood corpuscles was fully realised, although numerous megolocytes remain.

The spleen was not enlarged in any of the six cases of pernicious anaemia reported to date. In Eppinger's cases, after six months the men were gaining in weight and feeling perfectly well. (Therapic de Gegenwart, Berlin.)

If there be marked cachexia with haemoglobin below 4o per cent. the operation is contraindicated. Kopylow, who has removed 13 malarial spleens, has found records of 187 others, with a total mor-tality of 25 per cent.

Blood Changes after Splenectomy.

With regard to the red cells, it was noted that there was a surprising variability from day to day, the fluctuation apparently having no connection with the degree of leucocytosis or the temperature. The results of the final examinations show a less-ened number of red corpuscles. Microscopically the red cells showed at no time any evidence of even a moderate anaerni'a, which is a characteristic result of splenectomy in dogs. An occasional poikilocyte was seen, but no nucleated forms were seen at any time.

The h envoglobin estimations made showed a variability in readings slightly above or slightly below the normal, with an occasional high reading. Roughly, we can say that there was little deviation from normal.

With regard to the leucocytes, it will be noted that at first there was a tremendous increase, so that on the morning after the operation in one case

the number was 110,000. This seems enormously high, but li uhsam has reported a "leucocytosis of 8o,000 after splenectomy for ruptured spleen."

In one case, four days later, the count had fallen to 12,000, Which was the lowest estimate made at any time. The sudden rise to 27,000 the following day was coincident with the onset of pneumonia. From this on the counts remained persistently high, partly on account of the pneumonia and partly as a result of splenectomy, as evidenced by the fact that on the day of discharge from the hos-pital, apparently quite well, the patient had a leu-cocyte count of 20,400.

It was in the results of the differential leucocyte counts, however, that the most interesting features were seen. All the previous cases showed a lymphocytosis some time after splenectomy; here we were able to note the development of the lymphocytosis in the face_ of inflammation, which should normally call forth a polynuclear neutro-philic hyperleucocytosis.

At first practically all the leucocytes were poly-morphonuclear neutrophiles, but as the case de-velops the lymphocytes (adding the large and small varieties together) are steadily gaining, so that 2/ 7/'o9, in the presence of active inflammatory pro-cesses, we find the following count:—

Total leucocytes-34,000. Polymorphoneuclear neutrophili .. 75.6 Small lymphocytes .. .. .. .. .. 15.6 Large lymphocytes .. .. .. .. .. 4.8 Large morphonuclears .. .. .. .. 1.6 Eosinophiles .. 2.4

It is not possible in a paper such as this to furnish tables of all the differential counts made. The one above-is sufficient to show the trend of the develop-ing lymphocytosis, although the figures here given are practically normal. When it is considered, however, that the first counts made showed prac-tically all polymorphonuclear neutrophils, these re-sults, in the Light of the fact that in lymphocytosis developed in previous cases, are practically sug-gestive. One of the previöus cases showing lymphocytosis was found to have "accessory spleens"—they were not found in this case, though looked for.

In these early results, after removal of the spleen, we found no trace whatever of the eosino-philia which occurs frequently after splenectomy. The eosinophile cells remained persistently low, and beyond the fact that an occasional myclocyte and mast cell were seen, no other cells calling for comment were noted.

Summarising the early results after splenectomy, we may say that the two .most interesting features are, firstly, the variability in number of the red cells, with 'h aemoglobin content practically normal and the microscopic appearance showing no signs of anaemia. This would seem to show a lack of balance between production and destruction of red cells consequent upon removal of the spleen, the haemoglobin remaining high to give the necessary supply of oxygen for the carrying on of metabolism. The results seen of cases late after splenectomy seem to show that this balance is recovered.

1450 AUSTRALIAN MEDICAL JOURNAL. February- 28, 1914.

The - second feature of the developing lympho-cytosis, .which also seems from the previous cases to he -eventually controlled: • However, the eighth case has shown it developing in the face of in-flammation, which should" call forth a polymorpho-nticlear neutrophilic leïzêocytosis. This would seem to show that removal "of-the spleen gives a stimulus to the lymphatic appatatits of the body, and causes thereby a hyperlymiphocytosis. - It is interesting to note that in two cases of the series .th'e lymphatic glands throughout the body enlarged on the fourth or fifth day, and remained so during stay in hospital. .'phis last case showed no such enlargement; neither was the symptom em-phasised by Mayo noted, viz., pain in the ends of the long hones.

THE TACTUS ERUDITUS.

J. W. SPRINCTHORPR, M.A., M.D. (Senior Physician to:the Melbourne Hospital, etc.)

In these progressive days, when specialism calls for ever ndnuter and more accurate observation, and when science has invented many subtle instru-ments of precision to mathematically and otherwise mark and record all kinds of movements, it is not out of place to remember that, after all, it is upon our senses' that We depend for all external informa-tion ,and that they are the only known avenues through which external phenomena reach our consciousness.

As regards two senses—those of hearing and sight—though the student, to his permanent loss, is very far from being scientifically trained during his pupilage, it- may perhaps be .admitted that the practitioner regularly makes great and at times sufficient use of his opportunities.

As regards two others—those of taste and smell, we cannot nowadays be said to train them at all clinically, or to use them other than exceptionally and perfunctorily; though we have ample evidence from the lower animals—and Sherlock Holmes—how they are always useful and at times invaluable; and have learnt from Helen Keller how it is pos-sible to recognise places, conditions and persons by smell, - even in the total absence of information through any other sense.

It -is - the purpose -of this paper, however, to raise a plea for the far more thorough training, and far wider use of the remaining sense—that of touch. This is the fundamental, the first developed, the most extended and-the most extensively used of a ll . Like the common and-basal everywhere, it has been pushed out of ifs pre-eminence by the special and the exceptional. The .wonders of the recognised -Queen and Princess, Sight and Hearing, are so acclaimed that the Cinderella, Touch, remains an unnoticed 'handmaiden - in the background. But when the common-looking lamp is rubbed, the re-sponse may 'be, and - often is, miraculous. Thus a Leonardi da Vinci 'fwd's that he can discover with

his fingers beauties in statuary .tob fine ,14är inter-pretation through the eye; and a Helen Keller learns, almost entirely through her fingers, more than most of her American sisters have gathered through all their senses, cultivated during, an ex-tended University training. Similarly we have the blind. telling brass from gold -and expert masseurs performing, wonders in certain - diseases of joints, muscles, nerves, etc., by the same single means.

As a general rule the sense of touch has thus been left simply "to grow," like Topsy. Two recent advances, however—the Montessori system of eÊhic-atibn and -Potting r"s=clinical investigations and advöèàEy-=-have brought its informative value into special prominence. • - - -

In the Montessori system of educating the feeble-minded, remarkable almost incredible results have been obtained, and defectives ih de to take rank alongside, and even in advance; of normal children trained in the usual manner. In this system C the first step is the training of the senses. Touch is specially considered because t'lie -s'en'se- of touch "is the first developed and the first dulled if unculti-vated." By suitable apparatus the child is taught to distinguish, blind-fold, between rough and smooth, subtle gradations of texture, weight, form, dimension, etc., and perform a number of acts that are usually done by reliance. upon other senses. The senses of sight and hearing are, of course, similarly trained systematically. The time will, no doubt, come when some such training of the senses (touch included) will be the introduction to all education. Then the medical student will , enter upon his hos-pital studies thoroughly well qualified - to avail him-self of his tactile 'opportunities. Even in the mean-time, what an increased interest and fund of in-formation would be within his grasp if, from the outset of his hospital - practice, he conducted his clinical work on the same. sound- lines!

This, I take it, should''be -the sustained aim of his clinical teacher. For years I have urged students to, above all else, look for, and -at; and to listen to everything that they cöuld clüzical, normal as well as pathological. As a -basis for this-inia çnrtation, I have always started 'them .on Austin-Flint's Table, which I heard_ brought forward at the London Medical Congress in 188i. - bI r d-eating with heart conditions also led me finally to the Table of Auditory Representation, which I am presenting be-fore this Congress in another paper. Sirhilàrly, with -the sense •of smell, that is: fast -.vanishing as a protective an•d informative ' influence, I always recommend its clinical cultivation by smelling gas, effluvia, pus, excreta, urine, sputa. vomit, etc., as well as odors of every kind. Were all this to be recognised by the student as superior—at this stage —to reading, and far more important than memoris-ing from other people's observation and "clinics," we would, in -my opinion;: have a ba-üd of young practitioners more reliable - and skilful upon a certi-ficate of "having sufficiently availed themselves of their clinical facilities," than at present enter upon practice through the portals of - examination.

In the same manner h.have always recognised the funclam,.eniatlfrpesrtance of - the - tactile sense,

r February a8, 1914. AUSTRALIAN MEDICAL 'JOURNAL 1451

both in its afferent and efferent influence. Gradu- ally during my post-graduate • work in London (1881-3) I became more and more impressed with, and practised the light percussion and reliance upon the sense of resistance which .I learnt from the late Sir Douglas Powell. I next admired, though for long I did not understand, the wonderful results of certain experts—notably the late Sir Thomas Fitz- gerald—whose fingers gave them more and better information than most practitioners' combination of half-trained senses.. This led me to the systematic training of my own fingers, at first along the re- cognised lines so well described in Da Costa's "Physical Diagnosis." Progressively I was pleased to find that I became able myself to recognise what I had previously only envied in others. I was coming Ito my own. Thus, without any knowledge of Montessori or Pottinger, I began experimenting wi th texture of clothing, bedding, etc., size and con- sistency of coins, keys, fragments of various objects, more or less enveloped, near or distant; proceeding through known objects and conditions to the diag- nosis of unknown objects and conditions. All this I -then applied to human anatomical conditions, beginning with the normal, and following up on the pathological, testing and, so far as possible, verify-ing by all other reliable clinical means; attempting to ascertain and correlate through touch what I knew through the other senses, and gradually ex-tending- all this from common to uncommon condi-tions. Surface conditions, from all tactile points of view, infiltrations, due to fat, fluid, gas, etc., in-flammations in time became diagnosable compara-tively easily, and with a greater certainty in many cases than I had attained through the eye. The state of some veins and lymphatics (with associate glands) and the size, state of walls, external pressure, and other conditions of vessels, especially the radial, furnished another exceedingly interesting and profitable study. It is a strange comment upon our neglect in this respect, that the physicians of com-paratively recent times used to recognise some hundred different kinds of pulse, as compared with the dozen or so with which our test-hooks still keep us in touch. It was this that first led me to dispute the manometric claim of the necessary danger of a high blood-pressure (vide my paper in the Inter-colonial Medical Congress, 1908), and led me to divide arterio-sclerosis into stages of velvety extra-muscular, distended, fibroid, and calcareous. A simi-lar testing of tactile impressions from bone led me to recognise ossification—even commencing—in the sterno-costal cartilages, variations in the thickness of synovia, as well as amount of effusion, infiltra-tions, rarification, etc., of bones and joints; so that frequently under the bed-clothes and without lead-ing questions, and apart from osteophytes or irregu-larities of outline, one could diagnose old gouty attacks, etc. I remember also the pleasure with which I found myself able to—generally—diagnose pleural effusion from lobar pneumonia (though much less certainly from pleura-pneumonia) by the feel and the res'is'tance of the part. I began, also, to rely upon picking up the outer border of the heart, the upper border of the liver, etc., in the same

way. For some time, also, I had been experiment-ing With the feel of muscles, poor, normal, degene-rated, slightly or acutely spastic, and the relation-ships, reflex or direct, with related structures or organs. Gradually I found that a large volume of very valuable evidence was thus forthcoming-, fre-quently of a sort that, under other procedures, I had previously missed.

I had found, also, that in reference to dulness and increased resistance, the best results were ob-tained by a mixture of palpation and percussion, drawing the percussed finger lightly towards, over and away from the surface, and at the same time percussing with a variable amount of strength ac-cording to the normal known conditions of the part —but generally very light.

Most of this was, of course, over and above the usual procedures described by authorities such as Da Costa in the orthodox physical examination of pulmonary, cardio-vascular, abdominal, and other conditions by ordinary palpation, percussion and sense of resistance, and its inculcation has been part of my ordinary clinical teaching for some years past.

It was at this stage that I came to know Pot-tinger's work (Muscle Spasm and Degeneration in Intrathoracic Inflammations and Light Touch Pal-patation. He deserves the credit of maintaining and extending the practice and value of light-touch. palpatation, coupled with the sense of resistance. As already mentioned, I personally feel more at home with variable percussion of the finger. Light is kept lightly moving over the different areas. By this means he outlines the cardiac borders, the lungs and many of their lesions, differentiates heart from liver, outlines the stomach, spleen, and liver, many mediastinal tumours, etc.-, in a way and to any extent not generally attempted. He was, also, ap-parently the first to lay special stress on this means of diagnosing from degenerative and spastic con-ditions of the sterno-mastoid, levantor anguli sea puli trapezius, and rhomboid muscles, chronic and acute lesions respectively in the upper part of the same lung. Since reading his work I 'have paid some attention to his connection, but do not feel competent yet to give a definite opinion. -With most of 'his other views, however, I find myself in accord.

From my own -experience, therefore, as well as from these general considerations and the experi-ences of others, I submit that much greater atten-tion than is at present given might well be shown both educationally and clinically to the sense of touch ; that its present haphazard clinical applica-tion should be replaced by thorough, systematic training; and that the tactus eruditus, which conies with experience through such training, may thus be made the means of obtaining always important, and at times, invaluable information in an ever-increas-ing number of diseased conditions—information which may not be procurable in any other manner.

What might not we achieve if we could but apply fingers such as -those of Helen Keller to clinical medicine and surgery?

115' AUSTRALIAN MEDICAL JOURNAL. F'ebrulary 28, 1914.

JI3rtttgb ,^ebtcar ZW50ciattOn. AUSTRALAtia.i\ MEDICAL CONGRESS.

Abstract of Report of the Special Committee on Syphilis.

(From our own Correspondent.)

At a general meeting of the Congress held in Melbourne, October, 1908, it was resolved that the Executive of eaoh Congress be recommended to appoint a Committee to in-vestigate, tabulate and report the facts in regard to syphilis, which Committee may obtain. The Committee to report to

the next meeting of Congress, and be given authority to publish its report prior to the .meeting of Congress if Its investngations should convince the members of the Com-mittee of the necessity for such urgent action.

The Executive of the Congress to be held at Auckland in 1914, appointed a Special Committee in accordance with the standing orders.

• The Committee consists of:—Dr. W. E. Collins (chair-

man), Wellington; Professor L. E. Barnett and Professor D. Colquhoun (Secretary for Otago) ; Dr. W. J. Barclay, Invercargill; Dr. G. E. Gabites, Timaru; Dr. H. T. D. Ac-land, Christchurch; Dr. S. A. Gibbs, Nelson; Dr W. McKay, Westland; Dr. E. E. Porritt, Wanganui; Dr. H. D. Robert-son, Taranaki; Dr. J. W. Williams, Gisborne; Dr. E. A. W. Henley, Napier; Dr. J. Hardie-Neil (General Secretary), Auckland. South Sea Islands: Hon. G. W. A. Lynch, Chief Medical Officer, Suva, Fiji.

The Committee met in Wanganui in February, 1913, and determined to circularise every practitioner in New Zea-land, and also institutions such as mental hospitals, gaols, general Hospitals, old men's homes, and Salvation Army homes. This has been done.

The Committee determined to obtain information as to the prevalence of syphilis in New Zealand, the South Sea Islands, and as to the outside source of 'infection.

With this end in view, the Hon. G. W. A. Lynch was asked to take charge of an investigation covering the ,preva-lence of syphilis in the Fiji Group, of which he is the prin-cipal Medical Officer, Dr. G. Pearce Baldwin was asked to report upon the Cook Islands, and Dr. Arnold Izard upon Tonga. The Committee has had to rely upon general in-formation as regards the islands of Tahiti and Samoa.

An investigation covering Australia would be much bet-ter conducted by a Committee working from one of the cities in the Commonwealth. This Committee has, there-fore, decided to limit its investigations to the condition of affairs in the Dominion and South Sea Islands. As the disease is of such Immense importance to humanity, the subject will no doubt be further considered at the next

Congress. The returns report 1,941 primary and secondary cases

that were seen by private practitioners during the last two years. To these must be added cases met with in insti- tutions.

Auckland contributes 615 from the city and 138 from the outside districts. Wellington, 412 in the city and 23 from outside districts. Christchurch, 252 from the city and 24 from the outside districts. Dunedin, 44 from the city and 14 from the outside districts.

The returns from 301 practitioners, and from general and mental hospitals, showed a total of 1941 fresh infections during the last two years.

In speaking of the returns as a whole, the number re-corded in these returns cannot be taken as an indication of the absolute amount of syphilitic infection. So many cases do not come under the observation of medical men in the primary and secondary stages, when they are readily recog-nised. It is well known that cases which are tided over in the early stages, may show no obvious signs of the disease for years.

It is safe to say that .if all the medical men in the Do-minion had replied, the amount of the disease reported would be at least double, and even then, there would not be shown anything concerning the number of diseases which have their origin In syphilitic infection, nor the number of congenital cases of which it is impossible to get anything like approximate reports even from medical men, although

many practitioners proffer the information that they see them frequently. •

The replies to the question as to the, frequency of syphi-litic infection, as compared with former years, is indefinite, brit, if anything, the evidence points to the fact of it being less frequent. The same remarks apply to the enquiry as to the severity. The evidence again being in favor of its being milder, though the majority report that they are un-able to see that there is any change.

The medical practitioners doing eye work are very in-sistent on the prevalence of Tertiary and Congenital syphi-lis, especially the congenital form. Recent work on the blood test shows that women who hear syphilitic offspring are themselves the subjects of a latent yet personal infec-tion. The detrimental influence on their health and vi-tality requires no elaboration.

Sources of Infection.—'The replies are practically unani-mous that the infection is sea borne. Australia, especially Sydney, being most commonly mentioned, then the South Sea Islands, with a proportion of cases coming from other over-sea routes. We must then ascertain from the informa-tion available, the extent of the disease in the places men-tioned.

With reference to Sydney, it must be recognised in the first place, that a great source of syphilis in Oceania, is undoubtedly the Indian Coolie population of the Islands. There is said to be a fair amount of communication be-tween Sydney and the South Sea Islands by various trading schooners, and direct communication from Melbourne and Sydney to the Fiji Group. Medical Officers state that the East Indies, China, and Japan are also common channels of infection. Sydney has direct communication with these countries.

RECENT AUSTRALASIAN LEGISLATION. A great advance has been made by the addition to the

Statutes in New South Wales of the "Prisoners' Detention Act, 1908," which has had a distinct effect in reducing the amount of specific disease among the class of people affec-ted by the Act, and also among the sailors attached to the Naval Squadron when lying 'in Sydney Harbor.

In Queensland, the Public Health Act Consolidated 1911, Section 132 A, is as follows:—

"132a (2) provides for notification of these diseases. "132a (3) reads:—"No person other than a medical

practitioner or a person acting under the direct instructions of a medical practitioner shall attend upon or 'treat any person suffering from such disease."

The penalty Is not exceeding £50, or six months. "This sub-section shall not apply to a registered phar-

maceutical chemist who dispenses to the prescription of a medical practitioner, or to any pharmaceutical chemist, who under a permit in writing from the Com-missioner (of Health) (which 'permit the Commis-sioner is hereby empowered to grant) prescribes any medicine or drug for any person suffering from such disease, or to any person who under a permit in writ-ing from the Commissioner (which, etc.) sells any proprietary medicine or drug to any person suffering from such disease: provided always that the proprie-tary 'medicine or drug is approved of by the Com-missioner."

In New Zealand there is no special legislation, and ex-cept that in reference to the control of prostitution, there is no Act which affects this particular disease, but it is hoped that the important clause .19, introduced to the Hos-pitals and Charitable Institutions Amendment Act, 1913, No. 56, will be made use olf for the purpose of checking this among other contagious diseases. It is as follows:—

(1) The Governor may from time to time, by Order-In-Council gazetted, make regulations for the reception into any institution under the principal Act of persons suffering from any contagious or infectious disease, and for the detention of such persons in such institu-tion until they may be discharged without danger to the public health.

(2) Any person in respect of whom an order under this section is made may at any time while such order remains in force appeal therefrom to a Magistrate ex-

February 28, x914. AUSTRALIAN .MEDICAL JOURNAL. 1453

ercising jurisdiction to hear such appeal and to make such order in the matter as he thinks fit. An order of a Magistrate under this subsection shall be final and conclusive.

(3) Regulations under this section may be made to apply generally or to any specified institution or in-stitutions.

The Committee recommended:— (1) That syphilis be declared a notifiable disease. That

notification be encouraged, and discretionary but not com-polsory; and that the Chief Medical Officer of Health be the only person to whom the notification he made.

(2) That provision be made through the Hospital Boards to establish laboratories in the four centres where not already exiistent for the diagnosis of syphilis.

(3) That free treatment in the public hos•pital.s and dis-pensaries be provided for syphilitics.

(4) That steps be taken to educate the Mercantile Marine as to the dangers of syphilis, and that provision be made for preventative treatment on the Intercolonial service.

(5) That legislation be enacted against the treatment of syphilitics by unqualified persons.

The following memorandum and resolutions were sub-mitted at the meeting of 'Congress on 'Thursday, at 2 p.m., by Dr. J. W. Barrett, seconded by Mr. G. A. [Syme, and supported by Dr. Worrell and Dr. P. Fiaschi, after consulta-tion with members of the New Zealand committee.

This Congress desires to submit to 'the various Govern-ments of Australasia the following summarised observa-tions and recommendations:—

Venereal diseases are proved to be responsible for a vast amount of damage to mankind, The damage is expressed by ios.s of life (frequently at its prime), insanity, sterility, destruction of family life, inefficiency, and economic waste. The monetary loss to the nation is enormous. The exact distribution of these diseases is unknown, but it is esti-mated by excellentauthority that one twenty-fifth of the population of Berlin, Paris, and New York are 'annually infected. It is fairly certain that 12 to 15 per cent. of the population of London, Paris, and Berlin are .syphilitic, and in addition a much larger number are gonorrhœic. There is good reason for thinking that Australasian cities are affected to much the same extent. 'There are no other dis-eases which cause so much loss to the community.

By the adoption of suitable measures these diseases can be greatly reduced in frequency, and may be wholly sup-pressed. The steps which should be taken are:-

1, The provision, after consultation with the educa-tional authorities, of education for all adults and ado-lescents in the nature, causes, consequences, and mode of prevention of venereal diseases.

2. Provision !of free scientific facilities for effecting the early and accurate diagnosis of venereal diseases, and for testing the results of treatment.

3. The provision of free treatment both in and out door at times convenient to the patient for all those who are unable to make their own arrangements.

4. The passage of legislation providing for— (a) The detention of any prisoners suffering from vene-

real disease until by treatment he or she is rendered in-nocuous. The Prisoners' Detention Act of New South Wales already makes this provision.

(b) The severe punishment of anyone who wilfully or negligently communicates venereal diseases to other peo-ple.

(c) The severe punishment of any one not being a quali-fied medical practitioner who undertakes to treat sufferers from venereal diseases.

This provision is very necessary because of the danger to innocent persons consequent on the unsuitable treatment. of the •infected.

The monetary cost of effecting the eradication of venereal diseases would not be very great; in fact, the expenditure would be very small by comparison with the expenditure resulting from the present wholesale infection of the popu-lace. There is no form of public expenditure which might so truly be described as national and reproductive.

If the steps indicated are taken with wisdom, the results will be:

Diminution of mortality. Diminution of insanity.

Diminution in the expenditure in hospitals and asylums. Increased human efficiency, and better and healthier en-

joyment of life. Note.—The resolutions quoted above embody principles.

Their mode of applioatien would properly be a subject of discussion between the respective 'Governments and the branches of - the British Medical Association.

It has been reported in the daily press that Congress agreed to notification, but this does not appear from our account, kindly forwarded by Dr. J. W. Barrett.

A very successful dinner, tendered to the overseas mem-bers of the congress by the New Zealandmembers, took place at !Cargen on February 12th. The president of the congress (Dr. A. Challinor Purchas) presided over a large attendance.

"The Government of New Zealand" was proposed by Dr. J. W. .Barrett, C.M.G. (Melbourne). Dr. Vaiíntine, Chief Health Officer, in responding, apologised for the absence of the Minister for Public Health (the Hon. R. H. Rhodes).

The toast of "The Visitors" was proposed by Dr. W. C. W. McDowell (Auckland). He expressed pleasure at the pre-sence of Dr. ,T. B. Macdonald (chairman of the Central Council of the British Medical Association in England) and the Hon. W. A. Holman (Premier of !New South Wales).

The Hon. W. A. Holman replied in a humourous speech. He spoke of the pleasure that he had derived from this, his second, visit to New Zealand, which, he said, was favoured by Nature to a degree that aroused the envy of Austra-lians. He said that during the time that he had been in New !South Wales he had endeavoured to establish a co-operation between the medical profession and the Govern-ment in conserving the interests of the public.

Mr. Hamilton Russell (Melbourne) also responded and acknowledged the hospitality extended by the people of Auckland to the members of the congress.

Dr. F. Antill Pockley (Sydney) proposed "The British Medical .Association," which, he said, was the most .potent factor for good in the British Empire. He spoke of the kind hospitality extended to the visiting members of the congress whilst in Auckland, 'and specially mentioned the part that had been taken by Mrs. W. H. Parkes in the en-tertainment of the visitors. -

Mr. J. B. Macdonald (chairman of the Central Council of the British Medical Association in England) and Dr. W. H. Parkes (president of the New Zealand branch of the British Medical Association) replied to the toast.

The Mayor of Auckland (Mr. C. J. Parr) 'proposed the "Austs:alasian 'Medical Congress." The president (Dr.

Porches), in responding, acknowledged the cordial assist-ance that he had received from his confreres in carrying the congress to a successful issue. He expressed regret that illness had prevented Dr. McKay Grant from dis-charging the duuties of treasurer. He proposed the health of Dr. Grant, which was enthusiastically honoured.

Mr. Hamilton (Adelaide) gave 'the 'toast of the secretary of the congress (,Dr. Dudley) and on behalf of the mem-bers of the congress presented him with a purse of sove-reigns in recognition of the excellent manner in which he had discharged his duties. Dr. Dudley suitably replied.

The toast of "The Ladies" was proposed by Mr. Harvey Sutton (Melbourne) and acknowledged by Dr. R. H. Makgili (Auckland). The concluding toast was that of "New Zea-landers," proposed by Dr•..Hornabrook (Melbourne).

A very pleasant and. successful function was brought to a close shortly before 1 a.m. by the singing of "Auld Lang Syne" and the National Anthem.

The ladies visiting Auckland with the delegates to the congress were entertained at a 'theatre party at His Ma-jesty's Theatre.

B.M.A. VICTORIAN BRANCH. A special meeting of the Branch was held at the Medical

Society's Hall on Wednesday, February 18th, the Vice-President, Dr. Honman, in the chair. There was an at-tendance of about 45 members.

Business: -1. Presentation of Treasurer's Annual Re-port; 2. Address by Dr. Fetherston on the work done in the various States with reference to Friendly Societies,

1454 AUSTRALIAN MEDICAL JOURNAL. February 28, 1914.

TREASURER'S REPORT FOR 13 MONTHS TO DEC. 31st, 1913.

Receipts. To Balance from 1912

„ Subscriptions .. .. .. .. .. .. .. ..

„ Discount on Drafts .. .. .. .. .. ..

„ Refund Audit Fee by Med. Soc. of

. ..£128 .. .. 933 .. .. 5

Victoria 1

4 15

4 1

9 0 0 0

£ 1,068 4 9 Expenditure.

By Audit Fee .. .. .. .. .. £2 2 0 „ Organisation .. .. .. .. 23 0 0 „ "British Medical Journal" .. .. 760 2 0 „ Rebates—

Ballarat Division .. 12 6 0 Geelong 5 14 0 Border „ 4 16 0 Bendigo 14 11 0 Goulburn Valley Division .. 1 10 0 Wimmera Division .. . .. .. 2 10 0

Refund to N,iS.W. Branch . 1 1 6 Refund to Queensland Branch .. 1 6 9 Printing .. .. .. .. .. .. .. .. 25 17 6 Stamps .. .. .. . 39 12 11 Metropolitan Gas Company .. .. 5 7 4 Collector .. .. .. .. .. .. .. .. 14 3 4 Typewriter .. .. .. .. .. .. .. 2 18 6 Exchange .. .. .. .. .. .. .. .. . 3 17 5 Stationery .. .. .. .. .. .. .. 2 8 6 Advertising .. .. .. .. .. .. .. 3 9 0 Cable to London . . 0 18 0 "Chemist and Druggist" .. .. .. 0 10 0

Pf Cheque Books .. .. .. .. .. .. 0 6 0 Bank Charge .. .. .. .. .. .. .. 0 5 0 Balance in Bank of Victoria .. .. 139 12 0

£ 1,068 4 9 Audited and found correct—

J. V. M. WOOD, F.C.P.A., Auditor. C. H. MOLLISON, Hon. Treasurer.

15-1-14.

MEDICAL SOCIETY OF VICTORIA. TREASURER'S REPORT FOR THE 13 MONTHS TO

DECEMBER 31st,

Receipts. 1913.

To Balance from 1912 .. .. .. .. .. .. .. ..£123 10 0 „ Subscriptions .. .. .. .. .. .. .. .. .. 602 13 0

£726 3 0 Expenditure.

By Library Clerk .. .. .. .. .. .. £39 0 0 Caretaker .. .. .. .. .. .. .. 28 3 4

PP Audit Fee .. .. .. .. .. .. .. 1 1 0 "Australian Medical Journal" .. 481 8 6 Insurance .. .. . .. .. .. .. .. 3 7 6

9 0 0 „

Library— W. Detmold and Co. .. .. 11 13 6 H. K. Lewis .. .. .. .. 1 0 0

Telephone .. .. .. .. .. .. 5 15 7 Collector .. .. .. .. 9 13 3

ft Stamps 4 8 7 Stove Rent .. .. .. .. .. .. 1 3 9 Printing .. .. .. .. .. .. .. 0 15 0 Electric Light Meter Rent .. 0 13 0

Pt Sundries .. .. .. .. .. .. .. 0 8 9 Cheque Books .. .. .. .. .. 0 4 0 Bank Charge .. .. .. .. .. .. 0 10 0 Balance in Bank of Victoria .. 127 17 3

£726 3 0 Audited and found correct—

J. V. iM. WOOD, F.C.P.A., Auditor. C. H. MOLTISON, Hon. Treas,

15-1-14

j3OOto5.

"Therapeutics, Dietetics and Hygiene: An Australian Text-book. By J. W. Springthorpe, M.A., M.D., Melb.; M.R.C.P., Lond. Vol. I, Hygiene and Dietetics, pp. 604. Melbourne: Jas. Little.

The appearance of a medical treatise by an Australian author is a sufficiently rare event to be noteworthy, and the present workrepresents by far the most ambitious attempt yet made in our own midst. In this work Dr. Springthorpe has amplified his course of university lec-tures in therapeutics, dietetics and hygiene. Rather more than two-thirds of the present volume is devoted to hygiene: a little less than one-third to dietetics.

In the section on personal hygiene, the author has spared no pains to make his treatment comprehensive and exhaustive. Special reference may be made to a de-tailed account of a system of physical culture, with nu-merous illustrations. There is included a description of the Australian system of universal training. Throughout this section, as, indeed, in the whole volume, the aim of the writer to portray the facts of Australian life and pro-pound principles applicable under our conditions is clear, and his object is well attained. In writing of education, he asserts that the physique and health of the present generation of school children is undoubtedly inferior to that of its fathers and mothers. "For this teacherdom is mainly responsible, that teacherdom which neglected the bodies, which never qualified itself to impart the know-ledge of protection from death and disease, and of pre-servation of offspring. The same teacherdom is with us now, resisting the medical inspection of school children as tending to interfere with `departmental policy' or 'departmental discipline' prattling of child-soul gardens

and manufacturing child-body cesspools; spending years in teaching how to model baby-elephants in plasticene and never an hour on how to use a tooth brush; dawd-ling over book learnt nature-study in dark, overcrowded class-rooms redolent with the air-sewage of unwashed children."

In the section on public hygiene are considered gener-ally climate, ventilation, house construction, health in the tropics, and special problems confronting the Australian in regard to diet, clothing, habits and housing. Detailed accounts of the methods of water supply and sewage dis-posal in the Australian capitals form a valuable feature of this portion of the work.

The third section deals with legal hygiene and State medicine, and discusses the public health acts in the vari-ous States, and presents a large amount of statistical in-formation.

The concluding chapters of the book deal with dietetics. To this part Professor Osborne has contributed an ac-count of the processes of digestion.

The author is to be congratulated on this work, which is written, printed and published in Melbourne. At times it may appear that Dr. Springthorpe has transgressed the limits of his subject, for he touches on the discussion of such philosophical and metaphysical questions as the theory of knowledge, the existence of a Supreme Being, of death and immortality. The medical student is per-haps only too apt to overlook these questions, and it is well that they should receive from him some considera-tion. They would, however, be better placed apart in an appendix. The numerous quotations from literature add to the attractiveness of the book. The work is not a text-book in the ordinry sense, and yet any student or practitioner will find it informative and stimulating. There is, unfortunately, no index, but presumably the index to the whole work will appear in the second volume. This is to be regretted, as the volumes deal with inde-pendent subjects and each might have been made self-contained.

F brtlä:ry 28, 1914. AUSTRALIAN MEDICAL JOURNAL. 1455

CORRESPONDENCE.

Insanity and Amenorrhoea. (To the Editor of "The Australian Medical Journal.")

Sir,—I notice that Dr. Hooper's case of "Amenorrhoea Associated with • Insanity" is noted in the- "Lancet" of January, which prompts me to send you some remarks I intended to publish some time ago. Dr. Hooper 'argues that because "other recognised treatment had been un-successfully carried out for four years" the transplanta-tion of three slices from the ovary of another woman met

with a "happy result" There is doubtless much value in the statement that

ovarian secretion is necessary to health, and the epochs

of puberty, adolescence, and the climacteric show this.

There is also a metabolism to he watched 'in the alteration of secretion, the periodic output of which, however, is difficult to estimate, and is dependent On many causes and excitations. It is agreed amongst clinical workers in mental diseases that there is no such thing as "a"m,enor-rhoeal insanity." In such cases restoration of the menses

is to be desired, and treatment is resorted to

very satisfactorily in most instances. In a matter of

this sort one is deeply _concerned with operative inter-ference and alarmed at the probability of surgical inter-ference with the physical 'into-ordination of organs which

are not sufficiently understood. Particularly is this the case when we know that alterations in fnctions and secre-tion lead to, or are associated with signs of mental dis-turbance. In such patients care and time clear up the

trouble for the most part, and when such is not the case

we have forced upon us the fact that altered metabolism -- "Nature's secret workings"—has affected the brain cells

which-ate -defective in resisting "-mower, and here it is the soil which is to blame and which no mechanical inter-ference can alter. It may he easy to report temporarily

successful operations, but it is wise to watch cases with a full knowledge of their history drawn from all sources of information and not to depend only upon that supplied,

in mental cases, frequently by sympathetic relatives with

strong reservations. My own experience in public asy-lums, of insanity associated with ovarian operations has been rather that the condition is not improved 'even when it is not exaggerated. And the belief amongst British asylum physicians is that vaginal examination is objec-tionable. and is frequently regarded by the patient as an assault, and becomes the basis of delusions, even though it be made under an anaesthetic. Turning to the climac-teric insanities we find Sir George Savage saying that "any normal symptom, bodily or mental, which may occur at the menopause, may he exaggerated or become mor-bid." Are we for this reason to resort to operative inter-ference in cases in which there must be a complexity of causes? May we not be 'meddlesome? Do we not know how many cases are recoverable after a time? Do we not know that operation is no bar to in-sanity? Is the gynecologist warranted in operating without fullest avail-able, knowledge of the history and previous treatment which is invariably procurable. A recent case of this kind was seen by me in consultation in the first instance, and subsequently was handed over to my care in a licensed hoùse. C.' M., aged 46, single, forewoman in millinery establishment; first seen in. November, 1911;. presented the history of business worries, nervous apprehensions, misinterpretation öf facts, suspicions of impending harm, and latterly of definite delusions of believing herself to be dead, that her food was drugged, that she must disrobe and be burnt (which she did prepare for), and finally she watched for opportunities to commit suicide by throwing herself out of the train and under a tram car, and it was only when relatives were faced with the consequences of the 'patient's conduct that they consented. to her certifica-tion, trying all they could to minify the indications of insanity and denying very strong information and evi-dences of an alcoholic history. My prognosis was grave, but not unduly alarming, particularly with the alcoholic history.Menstruation had been irregular for some time, alcoholism known - to the medical attendant, and treatment In the country under a nurse carried óttt till it was abso-lutely unsafe. Licensed house care was'" continued for

nearly .a year, with varying success, menstruation being

scant and infrequent; moroäeness and suicidal tendencies

were strongly in evidence, and her language was bad. The

cost of private Dare could not. be continued, even with my

gratuitous attendances for a considerable period, and finally she was removed somewhat improved to her home `ratsher than accept care at the Acute Mental Hospital

kindly 'accorded her. Throughout her stay in licensed

house there were 'all the indications of ultimate, though

delayed, recovery usually found in alcoholic cases. After

removal I learned she had varied .much the same as during stay in hospital, hut did not see her; neither was her old

-medical attendant consulted. I had given opinion against

operation. Operation was, however, performed—ilvaüri-otomy and transplantation with a.professedly good result,

but I have little hesitation in thinking that no benefit-ob-served in this case resulted -from operation.—Yours, etc.,

W, BEATTIE SMITH.

A Remarkable Case of Foreign Body " Iu the Ear.

(To the Editor, "Australian Medical Journal.") The remarkable case of 'foreig ii dy in the nose reported

by Dr. JJAwnp •W.., Barrett,, recalls to ,my memory a case which came ender my -notice ten years ago—that of a

woman who';htid a piece -of window glass in her right ear for a period of ,twenty-seven years without having given rise to any serious mischief. The history I now record is taken from my case book -of that time. -

A.J., married woman, oet 33 years, complained of marked deafness on the right side, in which she could hear but little sound. She stated it had been so for many years, but of late had been getting progressively worse. When about six years -old she was with other children playing with broken glass, a bit of which she h-ad inserted in her right ear. At the time her mother took her to a medical man, who attempted to remove it with -an instrument, but de-sisted lest in doing so he might inflict injury to the ear, advising that it should remain so long as it did no harm. After a time she became deaf, and found it necessary to consult other medical . men; - notto advised syringing, which she did with no effect. She had never suffered from earache or discharge of any sort. -

Examination showed the ear to be filled with wax, evi-dently of long standing„for it was very hard. I prescribed drops -consisting -of liq. potass and glycerine 1.10 used for four nights, after which an ear ,syringe was used with warm water containing soda bicarb. and glycerine. The wax was completely . removed. at the second sitting, when, notwithstanding the noise made by the rushing water,

the glass could be distinctly -and forcibly

heard to strike the ear tray. The glass was triangular, having. One a ,right Angle.f•grmed by sides measuring 5 m.m. and 8 m m. respectively. It was then found that beyond -an inflammatory condition -of the canal and a catarrhal con-dition of the middle ear, which occupied a little time in treatment.. The ear had sustained no serious injury.

Treves mentions three cases recorded by Mason, where a

slate pencil, a cherry stone, and a piece of cedar wood

lodged in -the canal respectively 40, 60 and 30 years. This

bit of glass, evidently the corner of a window pane, was

lodged in the ear for -87-yyyears, ntTvt a bad time-for such-a formidable foreign body,- which no -doubt formed the nucleus

of the wax.—Yours etc., Hawthorn. RICHARD JONES.

CURRENT - LITERATURE.

Caesarean Section.

In "•the • 'American Journal Obstetrics” (Dec. 1913) Dr. Asa B. Davis reports the result of a study of a consecutive series of cases in wh h he justifies the views he has long hei!di

in thirteen years I . lias performed 193 sections with a Maternal mortality c nine and eight-tenths per cent., that of the first o h::ndred cases being fifteen per cent. Over one-half the ( " ,^Atlis have been due to sepsis, not in-

1456 AUSTRALIAN MEDICAL JOURNAL. February 28, lglq

frequently acquired through examination and instrumen-tation prior to operation; four deaths followed section for desperate eciamptic conditions. The foetal mortality has been sixteen and nine-tenths per cent., over one-half being among premature children dying because of the maternal conditions that made delivery imperative, e.g., hemorrhage and eclampsda; the remainder is made up of the stillborn.

In addition to the commonly acknowledged indications for section, the author has operated with success when the child has been unduly large, for accidental hemorrhage, in impacted face presentations, for the intertia following ventro-suspension, for tonic uterus. and for placenta pre-via in the presence of active hemorrhage, a viable child and an undilated cervix. The maternal mortality in cases of eclampsia has been high, namely, twenty-six and seven-tenths per cent. Twice the operation was performed with success for prolapsed cord; in each case the cervix was long and only partially dilated. "It is doubtful if any form of vaginal delivery would have saved these children." When the interests of the child alone are considered, the value of ante-mortem Casarean section upon the mori-bund mother is apparent.

In three cases, rupture of the uterus at subsequent labor has occurred. The first case ruptured in the thinned lower uterine segment; in the second, the rupture was small and at the lower angle of the incision; in the third and fatal case, the rupture was extensive and took place directly through the fundus, where the earlier incision, because of spinal deformity and consequent anterior dis-placement of the uterus, of necessity had been made. To obviate the danger mentioned, great care in closing the incision should be exercised and spontaneous labor in future pregnancies never awaited but section performed shortly before or at its onset.

The author 'insists that the skilful operation, when in-dicated, not only entails little risk but gives promise of great usefulness in decreasing the still-high obstetric mor-bidity. This view is held and vigorously asserted in spite of the frequent criticism that a desire to establish a record in operative cases prompts the author's ardent ad-vocacy of the operation.

The operation advised by the author may be summarised as folilows:- -+Incision into the uterus is carefully made, the organ being steadied by an assistant and brought up to but not through the abdominal incision which is direct-ed upward from the umbilicus; ,membranes and placent a .

are separated manually from the uterine walls; the former then are ruptured, pads preventing the escape of liquor amnii and blood into the abdominal cavity; the child is delivered by breech extraction through the uterine in-cision of six or eight centimeters: sutures placed at either end of the incision make it possible gently to raise the uterus and remove placenta and membranes; the in-cision is closed with a deep, interrupted layer of number two chromic gut through peritoneum and muscle, and a continuous layer of number one chromic gut drawing the peritoneum over the deeper layer and completely burying the same. The usual method of closing the abdominal wound is employed and the customary post-operative care given.— (Albany :\led. Annals.)

GENERAL.

In the State of Wisconsin a law framed to promote eugenic marriages has had the effect of putting an end temporarily to weddings of all kinds. It prescribes a medical certificate based upon the Wassermann test as a necessary prelim:i.nary to every union, and fixes the fee at which the medical man consulted is to supply the required document at what would amount to 12s, in our coinage. Those acquainted with the purchasing power of money in the United States will estimate the value of such a fee, and the medical profession has refused in a body to accept R. The aid ,of the law courts is being invoked owing to the attitude of 'the medical men, and it is pointed out that not only would the application of the Wassermann test be part of the consi:d:eratlon ,for the payment of 12,s., but that in the whole of Wisconsin not ;more than 25 practitioners would be found capable of applying it.

f3rltiÍ51) AlPÓÌCar a55uciatíuri. VICTORIAN BRANCH.

Dr. Stewart Ferguson, 34 Collins-street, Melbourne, Hon, Secretary.

NOTICES.

The Ordinary Monthly Meeting will be held at the Medi-cal Society Hall on Wednesday, March 4th, at 8.30 pan.

BUSINESS : 1. Dr. D. Kennedy will read a paper on "The Early Diag-

nosis of Pulmonary Tuberculosis." 2. Dr. R. H. Fetherston will show Specimens of Malignant

Diseases of the Uterus and Gynaecological Tumours.

3. Dr. G. C. Mathieson and Dr. R. Webster will show Pathological Specimens.

4. Dr. Alan Newton will show further X-ray plates of Fracture-dislocation on Cervical Spine without symptoms.

C. STANTON CROUCH, Seefeta r>

Warning Notices. New South Wales.

Medical men proposing to apply for the pusitjou of me-dical officer to friendly society lodges in âtly ,pa kt-ei South Wales are requested to communicate *Uh l the Hoir Secretary, B.M.A., 30-34 Elizabeth-street, Sydney, or with -î Dr. S. W. Ferguson, Hon. Secretary, Victorian ltrancr B.,M.A.

AUSTRALASIAN MEDICAL PUBLISHING COY. LTD.

Applications a re invited to fill the position of Editor of the "Medical Journal of Australia." The Editor must be a qualified medical practitioner with sufficient journal-istic experience to take entire editorial charge, subject to the Directors' control. Applicants should state whether they are prepared to give their whole time or only part of their time to the work. Salary for whole-time Editor to be £750; for part-time Editor, £350. Applications to be addressed to the Secretary, Australasian Medical Pub-lishing Company Limited, B.A.A. Building, 30-34 Eliza beth-street, 'Sydney, New South Wales, and to he in hi hands not later than Monday, 9th March, 1914.

— [Advt.

We are in receipt of "Paris Medical," a weekly journal. The number before us—that of December lst, 1913 ----pis num-ber one of the fourth year of publication. To English rea-ders the form of the journal is novel, as it combines special-isation and variety in an interesting manner. The present number is devoted to the diseases of children, and contains a number of articles of interest to both physicians and surgeons. A description of an ingenious method of bone -

grafting in Pott's disease by means of a strip taken from the inner border of the scapula is worthy of special men-tion. A good review of the year's literature in pediatrics may also be specially commended. A prospectus announces the subjects to be treated during each month of the coining year. Variety is given by historical articles, reports of societies, clinics, etc. An unusual feature in medical journ-alism is the Inclusion of a number of humorous drawings of medical interest. In lighter vein also is an article on wet-nurses in the seventeenth century, including an inter-esting discussion as to whether it is desirable or otherwise for wet -nurses to be permitted the enjoyment of the physical pleasures of love.

Attention is called to the advertisement appearing in this issue of St. Luke's Hospital, corner of Queen's Road and Leopold Street,Melbourne. This hospital is con-ducted by Misses Munro, Campbell and Gemmell, who de-sire it to be made known that it is not controlled by any doctor, but is open to receive patients from any medi-cal practitioner,

Aberdeen, K. G., Leongatha. Adam, B. J., Ivanhoe. Adam, G. Bothwell W., Collins Street. Adamson, J., 'Sunshine. Adey, J. K., Asylum, 'Sunbury. Agnew, James Fra-ncis, Erin -Street,

Richmond. Aitchison, Alexander Smith, Albert

Park. Aitchison, R., North Brighton. Allan, E. B., Elsternwick. Allen, H. B., The University. Allen, Sydney H.. Carlton. Alexander, Lilian H., 17 Murphy

Street, 'South Yarra. Alsop, C. J., Bairnsdale. Altmann, C. A., .South Yarra. Amers, James, Collins Street. Anderson, Alfred Victor Millard, Col -

lins Street. Anderson, C. H., St. Vincent's Place,

Albert Park. Anderson, G. G., Women's Hospital. Anderson, J. F., Woodend. Andrew, J. iE., Hawthorn. Andrews, W. A., East Melbourne. Andrews, Win., Bast Melbourne. Argyle, S. S., Kew. Armstrong, G. W., 24 Collins Street. Atkinson, Geo., 18 Gellibrand St., Kew Atkinson, J. L., Birchip.

B•age, Charles, Collins Street. Baird, J. C., Dalyston. Baldw in, Gerald R., Warrnambool .

Balfour, .Lewis Jahn, Hawthorn. Barrett, Edith H.,South Melbourne. Barrett, James W., Collins Street. Baxter, J. M., Camberwell. Beamish, F. S., St. Vincent's Hospital. Beckett, T. G., 132 Nicholson Street,

Fitzroy. Begg, W., Korumburra. Bennett, F. G., Prahran. Bennett, J. H., St. Arnaud. Bennie, Alex. Bruce, Armadale. Bennie, Peter Bruce, Collins Street. Berry, R. J. A., Melbourne University. Bill, George, Euroa. Birch, Lewis John, Oakleigh. Bird, Frederic D., Spring Street. Black, A. G., Carlton. Black, J. J., 92 Victoria Street, Carlton Blakie, J. L., Surrey Hills. Blaubaum, H., St. Kilda. Boake, W., 294 Glen-ferric Road, Haw -

thorn. Bona, Percy A., Maffra. Booth, Mary, Women's Common Room,

Medical School, Sydney. Bottomley, W. F. S., Fitzroy. Box, John, Union Road,Surrey Hills. Box, M. H., Footscray. Boyd, T. H., Richmond. Boyd, W. R., Richmond. Bradford, W. A., North Fitzroy. Brenan, A. J., "Mount Ievers," Park -

ville. Breton, H., Terang. Brett, John 'Talbot, Collins Street. Brett, Percy G., Hawthorn.

Brown, Alfred A., Sanatorium, Green Vale.

Brown, R. C., Windsor. Brown, Thomas W., University Club. Brown, W. H., Co1ac. Brownell, W. F., Euroa. Bryant, H. W., Collins Street. Buchanan, J. S.. Collins Street. Buick, James, Joihuont. Bull, Richard Joseph, Melbourne Uni-

versity. Bullen, N. J., Melbourne Hospital. Burns, F. J., Carlton. Burton, W. H., Richmond. Butchart, J. E., Austin Hospital, Hei-

delberg.

Cahill, H. J., Flemington. Calhoun, James, Donald. lC'al .lander, R. S., Royal Park. Cameron, W. J., Mildura. Campbell, Colin, Portland. Campbell, D. A., Yarra Bend. Campbell, J. C., Hopetoun. Campbell, S. J., Melbourne University Catari.nich, J., Asylum, Kew. Cave, F. W., Outtrim. Cave, M., Wallace Avenue, Toarak. Chambers, R. W., Women's Hospital. Clarke, R. M., Alfred Hospital. Clayton, W., Hawthorn. Clendinnen, L. J., Hawksburn. Clucas, Elizabeth, 448 Burwood Road,

Hawthorn Cohen, B. W., Mansfield. Cole, Frank Hobill, Rathdown Street,

Carlton. Golqu'hou'n, K. G., 171 Moore Street,

Moonee Ponds. Connell, E. J., Warrnambool. Connor, IS., Coleraine. Cook, L. R., Melbourne Hospital. Cooke, John, Prahran. Goldner, E. R., 433 'Taorak Road, Too -

rak. Costeiloe, M. J., 291 Church Street,

Richmond. Coto, D. S., Koroit. Cowen, Alfred, Dnouin. Cowen, B. iS., Canterbury. Cowen, Herbert Osburn, Kew. Cox, F. E., "Ronda," Walsh Street,

South Yarra. Craig, W. B., Warrnamboal. Craig, Walter Joseph, Box Hill. Crelli'n, B., Abbotsford. Crivelli, Marcel, South Melbourne. Crooks, A. A., `Maroonäah," 'Chapman

Street, North Melbourne. Cream, is. P., 127 Collins Street. Crowley, C. G., 12 Malvern Road, Mal-

vern. Cumpston, J. H. L., Director of Quar-

antine, Melbourne. Cusoaden, G., Collins Street. Cuscraden, W. G., Preston.

Daly, L. B., Women's Hospital. Daly, U. A., Gisborne. Daniel, C. J., Elstern i'iok. Davenport, Arthur F., St. Kilda.

F`ebruary 21, 1914. AUSTRALIAN MEDICAL JOURNAL.

BRITISH MEDICAL ASSOCIATION

(VICTORIAN BRANCH).

LIST OF MEMBERS. Davies, F. L., High-street, Malvern. Davies, M. C., Violet Town. D-avis, Wm., 55 Barkly St., 'St. Kilda. Deane, J. E. J., Essendon. De Garbs, Mary, The Hospital, 'Tiboo-

burra, via Broken Hill. Degenhardt, A., Northcote. Denehy, W. J.,'Tooronga Road, Malvern Denton-Fethers, P., 28 -Collins Street. De Ravin, E. A., Kew. Deravin, Arthur F., Casterton. Deravin, W. E., Canterbury. Desailly, Julian -Gilbert, Cam'perdown. Devine, H. B., Collins Street. Dickinson, G. D., Moonee Ponds. Donaldson, Wm. H., Drummond Street,

Carlton. Douglas, R. O., Ben:digo Hospital. Dormes, R. 1M., 127 Collins Street. Downie, Thomas T., Clifton Hill. Dawning, H. D., 34 Geelong Road,

Footscray. Downing, J. H., Kyneton Hospital. Doyle, L., St. Vincent's Hospital. Drake, F. J., Mitcham. Drew, Thomas M., Cobden. Duncan, R. B., Kyneton. Dunhill, T. P., Calkins Street. Dunkley, F. E., Oakleigh. Dyring, C. P. W., Coburg.

Fadie, James, Balaclava. Eastwood, F. H., Collins Street. Eccles, Jacob V., Collins Street. Edelston, Mary E., 55 Park Road,

Middle Park. Edwards, F. P., Woomelang. Ellis, Constance, Wattle Tree Road,

Malvern. Embelton, D. M., 'Children's -Hospital. Embley,Edward H., Latrobe 'Street. -Es'ler, A. W., Williamstown. Ewing, S. A., Collins Street.

Fairley, J. F., 175 Mioore Street, Moonee Ponds.

Farmer, Paul Ward, 'Collins Street. Faulkner, W. C., 'Sunbury . Felstead, J. G. R., Nhill. Ferguson, Stewart W., 'Collins Street. Fetherston, R. H. J., 4 Collins Street. Fetherstonhaugh, Chas., Williamstown Flanagan, P. J., Moonee Ponds. Fleming, C. H. W., St. Arnaud. Meaning, H. H., St. Arnaud. Fleming, John, Dorset Road, Croydon. Fogarty, J. P., Chelsea. Forrest, H. S., Alfred Hospital. Forsyth, R. L., Surrey Hills. Forsyth, W. A., Koroit. Fyffe, Edward Henry, Gore Street,

Fitzroy.

Gamble, M. F. H., Kew. Gandevia, N. B., 34 'Collins Street. Garnett, W. S., c/o Dr. Reid, Rich -

mond. Gault,. Edward Leslie, Collins Street. Gawne, F. J., Jeparit. :Gibbs, Richard H., Colac. Gibbs, N., 34 Collins Street.

AUSTRALIAN MEDICAL JOURNAL. F"dbru'ary 2I, 1914.

Glassford, J. G., Bairnsdale. Glawrey, Mary, Ouyen. Godfrey, C. G., S. Brunswick. Gordon, John, Lygon Street, Carlton. Grant, Andrew, Murrumnbeena. Grant, David, Collins Street. Gray, F. A., Middle Brighton. Gray, J., St. Vincent's Hospital. Green, A. I., 53 St. Vincent's Place

West, Albert Park. Green, F. W., Korumiburra. Green, H. F., 218 Punt Road, South

Yarra. Greenham, D.. P., Corryong. Greig, Jane Stocks, Education Depart-

ment. Greig, Janet Lindsay, Fitzroy. Grevi1le, S. J. R., South Melbourne. Griffith, Christopher, Berwick. Griffith, J. De B., iSomervillg. Griffith, J. V., Melbourne Hospital. Grindrod, W. C., Mordialloc. Gross, Radhel H., St. Kilda. Groves, W. '.R., Kyneton. Gutteridge, E. W., Alfred Hospital.

Hagenauer, G. A., Sale. Hagenauer, H. A., Traralgon. Halford, G. J. A, B., Malvern. Harbinson, J. W., Brighton. Harkness, E. E., Lang Lang. Hanse, W. T., tSandringham. Hayes, H. F., Warragul. Hayes, J. B., Hamilton. Haynes, A., Richmond. Hearne, W. W., South iM,elbourne. Heffernan, E. B., Heyfield. Henderson, A. V., Burke Road, Cam-

berwell. Henderson, J. Hunter, Warrnambool. Henderson, 'Mary A., Toorak. Henderson, N. 'R. , Mildura. Henry, L., 6 Alma Road, St. Kilda. Herlrtz, H., Cheltenham. Hewlett, H. ;M., Fitzroy. Hicks, John H. C., ,Becac. Hiller, K., Collins Street, Hodgson, G. J., St. Kilda. Holland, E. A., Watdhem. Holmes, H. I., Warrnambool. Holmes. Mervyn J., Port Darwin. Honman, A. V., Melbourne Hospital. Honman, Andrew, Spring Street. Hood, Lionel J., 'Toorak Road, South

Yarra. Hooper, J. W. D., Collins Street. Honnalbrook, R. W., Malvern. Horne, George, Clifton Hill. Howard, G. T., Collins Street. Howard, Henry, Queen's College, St.

Kilda. Howden, R., Leongatha. Huckell, E. R. V., Toorak Road, South

Yarra. Hughes, A. H. A., 166 Victoria Street,

North Melbourne. Hughes, W. K., Collins Street. Hughston, Robert Wilson, 122 Orrong

Road, Armadale. Hurley, T. E. V., Melbourne Hospital.

Lredell, C. L. 'M., Collins Street.

Jackson, James, Collins Street. James, William Arthur, Kew. Jamieson, D. D., 'Thora. Jamieson, James, 12 Lambert Road,

Tomsk. Jermalne-Lulham, F. S., 133 Collins

Street. Joel, B. C., Collins Street. Johnson, Frederick Miller, South Mel-

bourne.

Johnston, J. H., Alexandra. Johnson, M. B., c/o W. E. Druce, 418

Chancery Lane. Jana, Jacob, Richmond. Jena, J. L., iBarkly Street, St. Kilda. Jones, D. E., 'Collins Street. Jones, R., Power *Street, Hawthorn. Jones, W. Ernest, Toorak. Joske, A. S., Prahran. Joyce, A. F., Moorabbin. Jude, F. J., 1Mildura.

Keane, F. E., Glenferrie. Kellaway, C. H., Melbourne Hospital. Kelly, Jas. P., Carisbrook. Kennedy, J., Collins Street. Kenny, Augustus Leo, Collins St. Keogh, Eustace Julian, 'South Yarra. Kerr, James, Orbost. Kilpatrick, W., Newstead. Kilvington, Basil, Camberwell. King, H. K., Heidelberg. Kitchen, J. J., 239 Cotham Road, Kew. Knight, Glen Album, Port -\relbourne.

Laidlaw, D., Hamilton. Lambert, Thomas Edwin Llewellyn,

'Collins St. Lamble G., Queen's College, Carlton. Lanvphier, A. M., Yarra Junction. Lane, R. M., Footscray. Lang, M., Collins St. Langlands, F. H., Collins St. Langley, A. T., Ringwood Langley, F. E., Dandenong. Langmore, P. V., Berwick. Latham, L. 'S., Collins St. Laurie, Henry, Brighton Road St.

Kilda. Laurie, W. -Spalding, Hampton. Lawrence, H. F., Collins St. Lawton, F. B., Melbourne Hospital. Laycock George L., Windsor. Leary, T. G. S., !Sandringham. Lee, H. B., St. Vincent's Hospital. Lee, John Robert, Collins St. Lemon, F. A., Armadale. Lethbridge, R. W., Sunbury. Lowers, Alexander, Collins St. Lewers, H. B., "Olontibret," St. Kilda

Road. Ley, G. J., Warragul. Lillies, Herbert, Armadale Lind, W. A. T., Cotham Rd., Kew. Lindsay, E. H., Bealiba. Lloyd, H.Cairns, Collins St. Looney, F. H., Wonthaggi. Loosli, Robert James, Camberwell. Lorimer, G. N., Camberwell. Loughrey, Bernard, Elgin St., Haw-

thorn. Lowe, Wm., Bell Street, Coburg. Lynch, M. E., Collins St. Lyons, IM. M., Port Fairy.

Macansh, W., Brighton. MacCoil, Donald S., Collins St. MacDonald, A., Salle. MacDonald, A. (junior), Sale. Macdonald, V., Collins St. Macfarlane, A. A., Receiving House,

'Royal Park. MacGillicuddy, Daniel Florance, Rich-

mond. MacGill4cuddy, M. P., Richmond. Mackay, C. V., Collins St. Mackay, Edward Alan, Toorak. Mackay, N. J., Wordsworth Street, St.

Kilda. Mackeddie, J. F., Collins St. MacKenzie, A. S., Naval Depot, Wil-

liamstown.

Mackenzie, J. F. C., Clifton Hill. :MacKenzie, Wm. C., Collins St. \facLaren, W. W., Balwyn. :v[aelean, Hector Rath, Williamstown. \laclure, F., 127 Collins St. Mailer, :Melrose, Collins St. Mailer, R., 151 Collins St. Marsden, W. C., Trafalgar, Major, James Perrin, Wellington St.,

Windsor. Makin, F. Humphrey, Warrnambool. Manly, R. A. A., Werribee. Marsden, C. E., North Melbourne.

Marshall, C. C., St. Kilda. :Afathieson, G. C., Melbourne Hospital. \laudsley, Henry, Collins St. Maxwell, Chas., Frankston. Meade, F. G., Melbourne Hospital. Meares, A. G., Hopetoun Rd., Malvern. Mendelsohn, D., Northcote. \lerrillees, J. S., Hawthorn. :Meyer, Felix, Collins St. Mitchell, L. J., 4 Collins St. Mollison, C. H., Collins St. Montgomery, J. P., Terang. Moore, W., Flinders Lane. .\lorlet, C., Alfred Hospital. Mbrlet, J., "Melrose," Domain Road,

South Yarra. Morris, Arthur, Collins St. Morris, J. N., 27 Auburn Road Auburn. Morrison, Reginald Herbert, Toorak. Morton, David Murray, Collins St. Morton, F. W. W., Collins St. Morton, R. L., Fitzroy St., St. Kilda. :Morton, W. A., Merino. Moss, William Joseph Alleine, Ken-

sington. .Muir, W. C. C., 377 Church Street,

Richmond. Murdoch, D., Romsey. \lurphy, John, High St., Kew. Murphy, Thomas, St. Kilda. .Murray, H. L., Collins St

McAdam, Robert Louis, St. Kilda. :A[cAree, F. E., Middle Park. McArthur, A. N., Collins St. McArthur, G. A., Eye and Ear Hospital .UeClelland, W. C., Church St., Middle

Brighton. .\IcCreery, J. V., Collins St. McDonald, S. F., Children's Hospital. McGee, J. H., Collins St. McInerny, J., North Fitzroy. McLean, Donald, 167 Bay St., Brighton McLean, J. S., Morwell. McLean, T. A., Traralgon. ,McLorinan, M. H., Clayton. .McMahon, J. J., Kew. :McShane, C., Fairfield Hospital.

McWilliams, H. H., Mildura. Nance, F. L., \lelbourne Hospital. Nankervis, A. W., Colac. Nattrass, J. H., 85 Spring St. Naylor; A. G. E., Loch. Neal, L. A., 364 King St., Melbourne Newman, Francis Alexander, 83 Col-

lins St. Newton, H. A. S, 41 Spring St. Nicholas, J. J., Melbourne Hospital. Nicholls, G. G., Korumburra. Nihill, J. E., Collins St. Noonan, T. P., East Malvern. Noyes, A. W. F., Collins St. Nyulasy, Francis Armand, Toorak.

O'Brien, .John Aloysius, Hawthorn. O'Brien, J. W., North Brighton. O'Donnell, N. M., North Melbourne. Officer, David McMaster, Collins St.

February 21, 1914. AUSTRALIAN MEDICAL JOURNAL.

Oldham, E. P., Mansfield. Oliver, C. J., Pakenham. Orchard, W. H., Port Fairy. Ormond, J S. :Malvern. Orr, Wni. Francis, Collins St. Osborn, H. H., East Malvern. Osborne, Wm., A., .11elb. University. Osier, W. D., Willaura. Ostermeyer, Wm., Carlton. O'Neill, J. J., St. Vincent's Hospital. O'Sullivan, E. F., Church St., Rich-

mond. O'Sullivan, F. U., South Melbourne. O'Sullivan, M. U., Collins St. Owen, A. G., Canvperdown. Parer, P. A., 37 Princes St., Fitzroy. Park, C. L., Diamond Creek. Parker, R. A., Cottesbrook, Glenroy. Paton, D. M., 151 Collins St. Paton, J. S., Lismore. Perl, M. M., Collins St. Pern, H., Yarram. Pern, N., Leongatha. Pern, S., 16 Collins St. Perrins, R. B., Rainbow. Perry, Charles, Prahran. Pestell, J. H., Brunswick. Player, Chas. Richard, Malvern. Plowman, S., Frankston. Potter, W. L. Port Melbourne. Potts, W. A. B., Harrow. Powell, A. H., Colac. Praagst, G. D., Murchison.

Quick, B., Collins St. Quirk, Thomas A., St. Kilda. Rail, John A. A., 22 Park St., St. Kilda Read, F. 'M., Rokewood. Reid, G. i\i., Branxholme. Reid, A., Collins St. Reid, P. M., Richmond. Reid, R. G., Elsternwick. Reid, W. A., Sale. Rhodes, T., Albion St., Surrey Hills. Richards, B. R., Box Hill. Ridley, S. F., Oakleigh. Rigby, George Owen, Kyneton. Riordan, Thos. F., Northcote. Rivett, Olive M., Bairnsdale Hospi-

tal. Robertson, A. S., Bairnsdale. Robertson, A. W. D., Collins St Robertson, E., Health Department. Robertson, Ernest, M., Mansfield. Robertson, Margaret H. A., infectious

Diseases Hospital. Robertson, W. 1,., :Melbourne Hospital. Roche, C., Children's Hospital. Rosenberg, David, 216 Church St.

Richmond. Rosenfield, R. L., Port Melbourne. Rosenthal, J., Camberwell. Ross, D. M., Cam'perdown. Rudall, J. F., Collins St. Russell, R. H., Spring St. Rutter, J. H., Yarram Yarram. Ryan, C. S., Collins St. Ryan, Edward, Collins St. Ryan, James Patk., Collins St. Ryan, R. W., 36 Merton St., Albert

Park. Ryan, Wm. B., , Bacchus Marsh.

Sabel!berg, C. J., Port Melbourne. Salter, A. C. H., Portland, Salts, Richard, Kilmore. Sarwrey, E. R., Collins St. Scantlebury, George James, Chelten-

ham. Schalit, Moise A., Wellington St.,

Windsor. Scholes, F. W., Fairfield Hospital.

Scott, E. N., Hamilton. Scott. J. A., Hawthorn. Scott, John D. K., Finch St., East

Malvern. Scott, T. W. Terang. Semple, John, Kilmore. Seton, M. C. C., ,24 Collins St. Sewell, S. V., Collins St. Sexton, H., "Koombahla," Toorak

Road, Toorak. Shaw, A. E., Healesvilie. Shaw, C. G., 28 Collins St. Shaw, Patrick, Asylum, Kew. Sheahan, J. G., Brunswick. Shelton, J. G., 33 Collins St. Shelton, P. G., c/o Dr. Rosenfield, Port

M elbourne. Shields, Oswald C. G., Yea. Short, R. E., Lilydale. Shuter, R. E., 16 Collins St. Silberberg, M. D., 54 Collins St. Sinclair, T. W., Town Hall, Melbourne Skinner, G. H., Casterton. Sleeman, James Henry, Portland. Sleeman, L. O., Wonthaggi. Sloggett, H. P., Albert Park. Smeal, J. A., Melbourne Hospital. Smith, Charles, Rockley Road, South

Yarra. Smith, Julian Augustus Romaine, Col-

lins St. Smith, William Beattie, Collins St. Somers, Jas., L. E., Mornington. Southey, M. V., Melbourne Hospital. Southey, W. G., Molesworth St., Kew. Speirs, N. L., Clifton Hill. Spargo, E., Alfred Hospital. Spowers, Edward A., East Melbourne. Spring, J. F., Essendon. Spring, John P., 107 Rathdown St.,

Carlton. Springthorpe, J. W., Collins St. Stanley, H. Riddell, Collins St. Stapley, W., Veterinary School, Park-

ville. Stawell, R. R., Spring St. Steel, W. H., Brunswick. Steen, J., Asylum, Yarra Bend. Stephens, C. V., North Melbourne. Stephens, H. Douglas, 2 Collins St. Steuart, R. St. 'C., !St. Kilda. Steven, Alex., Alma Rd., St. Kilda. Stevens, P. A., Melbourne Hospital. Stewart, D. E., Brunswick. Stillwell, Effie, Patna, India. Stirling, R. A., Lonsdale St. Stone, Grace Clara, Collins St. Strahan, E. A., Carlton. Strong, Robt. Henry, Collins St. Sturdee, Alfred H., Northcote. Summons, Walter E., 54 Collins St. Summons, W. H., 131 Collins St. Sutherland, B. M., Moonee Ponds. Sutherland, R. T., Collins St. Sutton, Chas. S., North Carlton. Sutton, Harvey, Trinity College, Park-

ville. Sweetnam, F. A., Penshurst Sweetnam, Win. Francis, Mortlake: Syme, G, A., Collins St.

Tait, J. T., Melbourne Hospital. Talbot, S. W., "Matlock House," Dan-

denong Road, Caulfield. Taylor, A. E., Dandenong. Teague, D. G. M., Hamilton. Thomas, Elsie L, Fairfield. Thomas, H. D., Caulfield. Thomas, J. C., Canterbury. Thomson, H. Barry, 110 Collins St. Thomson, J., Williamstown.

Thwaites, J. S., South Melbourne. Travers, G., Elsternwick. Trinca, A. J., Hawthorn. Trood, C. J., Prahran. Troup, J. K., North Melbourne. Trumpy, David, Warragul. Tucker, C. F., Brighton. Tulloh, W. E. ,Omeo. Turnbull, H. H. 85 Spring St. Tuthill, J., Metung. Tymms, A. S. +M., Queen's College,

Carlton.

Upjohn, W. E., c/o Dr. • Cole, Carlton. Utber, F. L., Power St., Hawthorn.

Vance, W. B., St Kilda. Vaughan, A. P., Box Hill. Vogler, H. H., Yarra Glen.

Watkins, A. 11., Wont+haggi. Watson, R. F., Melbourne Hospital. Wawn, R. N., Prahran. Webb, F. E. Williamstown. Webb, J. R., Footscray. Webster, P. S., Spring St. Webster, Reginald, Melbourne Hospi-

tal. Weigall, A., Cheltenham. Weigall, G. C., Elsternwick. Weigel, R. E. Elsternwick. Weir, Albert A., Terang. Weld, J. C., Dromana. West, G. R., Kaniva. Whitford, A. S., Alfred Hospital. White,, A. E. R., Spring St. White, Edward R. 84 Collins St. Wilkinson, A. M., Glenferrie. Wilkinson, John Francis, Collins St Wilkinson, W. C., South Preston. Williams, H. J., 25 Blyth St., Bruns-

wick. Williams, John, Collins St. Willis, J. R. I,., c/o Dr. Willis, Mal-

vern. Willis, T. R. H., Malvern. Wilson, A. M., Women's Hospital. Wilson, H. C.„ Foster. Withington, R. C., Bunyip. Woinars.ki, G. H. T. Z., Hospital for

Insane, Mont Park. Woinarski, S. E. A. Z., Mornington. Woinarski, V. J. E. Z., North Mel-

bourne. Wolfenden, J. H., Dunolly. Wood, Arthur Jeffreys, Collins St. Wood, F. A., Cressy. Wood, W. A., South Yarra. Woollard, H, H. Hospital for Insane,

Kew. . Young, A: S., High St., Northcote. Young, J. W., 311 Church St., Rich-

mond. Yule, John Sandison, Collins St. Zwar, Bernard Traugott, Collins St.

BALLAIU'I' DIVISION.

Barker, W. H., Hospital for Insane, Ballarat.

Barrett, Wm. A. H., Skipton. Bennett, H. V., B;allarat. Blaubaum, A., Dalian.

Campbell, A. B., Ballarat. Champion, E., Ballarat East. Chaplin, W., Ballarat. Courtney, C. A., Learmonth. Cnnningha .m, P. H. Talbot.

Dane, P. G., Ballarat East,

AUSTRALIAN MEDICAL JOURNAL. February 21, 1914.

Davies, W. E., Ballarat. Deane, Edward W., Park Road, Mary-

borough. Dennis, C. E., Ballarat. Donaldson, J. B., Linton. Eadie, G. A., Beaufort. Forster, Arthur E. B., Chines. Garde, G. E., .\laryborough. Gardiner, J. M., Ballarat. Gerrard, N. J., Ballarat Hospital. Grimmer, C. G., Avoca. Grover, H., Ballarat Hospital. Gutheil, Emil, Ballarat. Hardy, C. H. W., Ballarat.

Jackson, Allan G., Beaufort. Johnson, W., Avoca. •

Kelly, M. F., Ballarat. Langley, A., Ballarat. lAddle, Percy H., Day lestord. Longden, F. R., Buninyong. Loughran, H. G., Daylesford. Malone, W. C. L., .\Iaryborough. Miller, W. F., Maryborough. Mitchell, J. T., Ballarat. Morrison, W., Ballarat. McGowan, A. G., Ballarat. Richards, J. K.; Ballarat. Rogerson, Henry, Hospital for the In-

sane, Ballarat. Middle, Reginald G., Daylesford. Scott, G. A., Ballarat. Scott, R., Ballarat. Sleeman, G. F., Creswick. Sloss, W., Ballarat. Spring, W. A., Ballarat. Steele, L. R., Ballarat. Trewhella, W. J., Daylesford.

Vale, Grace, Ballarat. Wilson, T. A., Creswick.

BENDIGO DIVISION. Anderson, T. C., Eaglehawk. Atkinson, H. L., Bendigo. Barnard, J. F., Kerang. Boyd, J. D., Bendigo. Gafford, H., Eaglehawk. Cordner, H., Bendigo Hospital. Deravin, Garnet W., Inglewood. Deravin, H. A., Bendigo. Dunlop, S. H., Charlton. Eadie, J. McI., Bendigo. Ffrost, A. E., Golden Square. Gaffney, A. E. B., Bendigo. Gaffney, F. C. B., Bendigo. Gaffney, C. B., Bendigo. Gray, Colin, Malden. Green, T. E., Bendigo. Greer, Claude, Sea Lake. Hamilton, R. H., Bendigo. Hill, A. M., Castlemaine. Hutchinson, F. E., Echuca. Jackson, H. E., Bendigo. Jacobs, Morris, Pyramid. Johnson, C. H., Kerang. Ker, T. C., Bendigo. Lease, C. R., Rochester. Legge, F. R., Swan Hill. Long, William John, Bendigo. Lyons, A., Eaglehawk. Matenson, P., Quambatook. Maxwell, K., Castlemaine. Merrillees, C. R., Pyramid Hill. Moss, M. K., Echuca. McEniry, J. J., Kerang. MacKenzie, J. G., Kaneira. Nankivell, A. Y., Cohuna. Owen, Frederic J., Heatheote.

Penfold, O., Bendigo. Plante, G. R., Swan Hill Rail, W., Wycheproof. Rockett, P. J., Bendigo. Rowan, J. J., Ultima. Sandison, A., Rochester. Simpson, C. J., Heathcote. Smithwick, G. W., Eaglehawk. Stewart, C. A., Wycheproof. Stoney, R. B., Echuca. Taylor, G. U., Wedderburu. Thompson, J. L., Castlemaine. Webster, E. E., Boort. Wilkinson, A. N., Inglewood. Williams, M. L., Bendigo. Wilson, N., Elmore.

GEELONG DIVISION.

Bell, J. B., • Geelong. Clarke, P. G., Portarlington. Cole, G. E., Geelong hospital Croker, P. A., Geelong. Darby, G. R., Geelong. Eddie, A W., Winchelsea. Elvins, H. F., Geelong. Fetherstonhaugh, R. T., Geelong. Grimwade, A. S., Geelong. Kennedy, D., Geelong. Kennedy, T. J. M., Geelong. Harwood, A. W., Geelong. Moreton, F., Geelong. [organ, A. W., Geelong.

McCallum, G., Geelong. McPhee, 11. G., Geelong. Newman, F. J., Geelong. O'Brien, J. A., jun., Geelong. Pacey, F., Drysdale. Piper, J. E., Geelong. Pollock, J. Queenscliff. Small, J., Geelong.

BORDER DIVISION. Anderson, J. H., Benalla. Barrington, A. E., Benalla. Boyes, W. I., Wangaratta. Bush, Hubert S., Rutherglen. Decker, Wyatt Bristow, Wangaratta. Makin, R. A., Wangaratta Hospital. llbsworth, R. H., Benalla. Harkin, C. F., Chiltern. Harris, John Richards, Rutherglen. Henderson, J. L., Wangaratta. Hollow, J. T., Asylum, Beechworth. Horgan, J. P., Yarrawonga. Jamieson, S. C., Yarrawonga. Joynt, Oswald, Wangaratta. Kidd, L. S., Bright. Magee, C. C., Tungamah. McLay, R. G., Wangaratta. Nish, J. A. D. Banana. Patterson, J. H., Tallangatta. Ratz, M. W., Tungamah. Schlink, R. H., Wodonga. Skinner, D., Beechworth. Sutton, E. R., Myrtleford.

WIMMERA DIVISION. Aitken, W. L., Stawell. Bird, R. K., Natimuk. Black, J. P. M., Horsham. Bonnin, F. J., Ararat. Brown, T. F., Ararat. Cade, D. D., Murtoa. Connolly, H. A., Warraaknai.eal Donald, B. P., Warracknalual. Duguid, C., Minyip.

Forshaw, W. J., Stawell. Foster, Bryan, Horsham. Fox, J. R., Stawell. Hayman, F. D., Ararat. Ingham, J. H., Dimboola Irving, Harold, Glen Thompson. Matthews, J. T., Ararat. Morris, E. S., Asylum, Ararat. Naylor, R. G., Ararat. Philpott, A. J. W., Ararat. Rabi, H., \lurtoa Read, S. D., Horsham. Ryan, T. F., Nhill. Shanasy, T., Nhill. Trogear, W . G. H., Warracknabeal.

GOUi.BI.R\ VALLEY DIVISION. Christie, Charles, Rushworth. Cook, H. W. J., Shepparton. Davies, Leslie, Nagambie. l'lorance, J. W., IMooroopna Harbison, J. A., Numurkah. Harcourt, C., Kyabram, Heily, J. V., Rushworth. Kelly, Joseph P., bookie. Kennedy, J. T., Cobram. Keyes, F. J., Nathalia. Ley, Mark A., Tatura. McKenna, J., Shepparton. Morton, J. C., Seymour. Spence, H., Numurkah. Strangman, Thomas, Seymour. Welchnran, J. A. C., Shepparton. Wight, J. C., Kyabram.

,ASSOCIATE MEMBERS. Lyle, T. R., Melbourne University. Martin, Charles James,

tute, London. Masson, D. Orme, Melbourne Univer-

sity. Spencer, W. Baldwin, Melbourne Uni

-versity. Stuart, T. P. Anderson, Sydney. Williams, Surgeon Major-General,

Melbourne.

SUSPENSE LIST. Fowler, R. Gardner, M. C. ' Hutton, J. R. t 01. I. Jones, Isaac. Kerr, F. R. Lemon, R. D. Lillies, G. L. Macintosh, W. I. Martin, F. B. Miller, A. G.

N:Milligan, E. T. C. O'Leary, R. D. - Patterson, S. W. Pinnock, Dudley. Weihen, A. W. Wettenhall, R. R.

LIFE MEMBERS OF THE MEDICAL SOCIETY OF VICTORIA.

Barrett, J. W., Collins St. Bird, F. D., Spring St. Fletcher, A. A. Jackson, James, Collins St. Lawrence, H. F., Collins St. Lawrence, Octavius Vernon, Haw-

thorn. Morton, F. W. W., Brunswick St.,

Fitzroy. Penfold, Oliver, Bendigo. Thomas, Walter, Christchurch, New

Zealand.

[Aster Insti-

1/4

Will members kindly notify the Secretary, Mr. C. Stanton mistakes or alterations of addressee.

Crouch, Medical Society's Hall, East Melbourne, of any

Library Digitised Collections

Title:

Australian Medical Journal 1914

Date:

1914

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http://hdl.handle.net/11343/23180

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Australian Medical Journal, February 1914

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