ffig ist 2. 11)13. AUSTRALIAN MEDICAL JOURNAL. 1147

ALL-STONE ILEUS.

R. A.. STIRLING, M.D.

-v-i ttrgeon to the Melbourne Hospital.)

The complete blocking of the intestinal canal by a gall-stone which has escaped from its original en-vironment by a process of adhesion, ulceratióu and temporary fistula, is so unusual a termination of cholelithiasis as to be almost forgotten in the sum-ming up of probable causes of intestinal obstruc-tion, although Barnard ("Annals of Surgery," August, 1902, p. 161), who had an extensive ex-perience of this condition, laid great stress, from a diagnostic point of view, upon the unusual character of the grouping of the symptoms. The ileus may be the first indication of the trouble. In fully-half the reported cases there have been no symptoms of gall-stone colic complained of—none of the slight gnawing pain at the epigastrium which ushers in the onset of the colicky attack—accom-panied by narked flatulent eructations, gradually growing more and more severe as it shifts its posi-tion of the region of the gall-bladder, and finally disappearing with the same gradually diminishing suffering—not anteriorly, but posteriorly—at any rate in the later stages. :Moller of Copenhagen, who has recently reported 22 cases in his own clinic, states that it is characteristic of gall-stone ileus that the general condition seems to suffer comparatively little, although the bowel may be totally obstructed for three or four weeks. As a rule the pulse keeps strong and regular, •although in exceptional cases the ileus may prove rapidly fatal.

Pain is always a prominent symptom, so is peri-stalsis; although the latter is obscured by large deposits of fat in the •anterior abdominal wall. Vomiting- of blood is not uncommon if the obstruc-tion is situated high up.

The stone may perforate into the colon, whence it has passed on to the rectum and caused symptoms of blockage there—one reason never to omit rectal examination in any case of intestinal obstruction.

It may also perforate into the stomach, and he got rid of by vomiting. It may ulcerate and per-forate the small intestine, or may pass from the small to the large bowel, and in one case the stone was thus expelled after eleven weeks from the commencement of the symptoms.

In only four of Moller's cases could the stone be felt through the abdominal wall. The prognosis, notwithstanding the apparently favourable grouping of the symptoms and.the removability of the cause, is grave. Only four out of tweniv-two of 1 loller's cases survived : the mortality was thus 82 per cent. —six patients were quite elderly and two died from pneumonia; all had suffered two weeks or more from their ileus and were growing constantly • worse under medical measures, so that probably all would have died without the operation.

In 31 cases collected by 'holstein, there were 19 deaths and only twelve recoveries, the heavy mor-tality being due to delay in operating.

'.holstein found the situation of the calculus in 35 cases--duodenum 2, jejunum 7, upper part of ileum 6, lower part of ileum lo, vicinity of ilex-decal valve 7, colon or rectum 3. -

At a recent meeting of the Melbourne hospital . Clinical Society I• showed a gall-stone removed

from the upper part of the ileum of a corpulent wont an aged 67. She was admitted-Avith a pulse

temperature. 96 -deg.. "abdominal - distention, feculent .Vomiting, extreme tenderness with re-sistance over the left side of the abdomen.

For three weeks she has had colicky abdominal paiu, which has much increased during the last three days. during which constipation has become absolute.—For 20 years off and on she had been subject to seizures of biliary colic, but had never had jaundice.

Under anaesthesia it was possible to feel a hard mass beneath the upper part of the left rectus. The abdomen was opened by an incision in the tipper left rectus. She had very fat abdominal walls. The peritoneum was healthy. A, very thick and fat omentunt was displaced and a large oval mass came into view, hard and compact, which was diagnosed as an obstructing gall-stone. The intestine above was very distended with fluid contents—the result of large doses of purgatives taken before admission. The affected loop was drawn outside the abdomen 'and .carefully isolated with packs. a few points of suture being placed in the abdominal incision to further protect the peritoneum.

The wall of the intestine over the -black and roughened foreign body seemed thinned out by pressure, but it was quite impossible to move the obstruction upwards to a less damaged loop. A longitudinal incision was glade over the concre-tion on the free border of the intestine, the incision being a little longer than the stone. The latter was easily removed, in fact. \vas forced outwards by the pressure of • the foetid,' fluid contents of the bowel, which now escaped in a very free stream. The incision was sutured w ith a double row of Lembert sutures, closing securely the opening in the bowel. The patient made a good recovery.

Clutton in the "lancet," 1888, reported a case where he found the concretion arrested just above the ileo-cx.cal valve, and pushed it through the opening into the crecum. It vvas expelled per rectum five days later.

In some cases, owing to the urgency of the symptoms, it may be impossible to satisfactorily suture the damaged bowel ; it may therefore be ne-cessary to stitch the edges of the intestinal incision to the lower part of the parietal wound as a tem-porary measure.

In others the segment of bowel has been found so damaged that resection of the involved loop and stone vas required. _

It is well to remember that if the - mucous mem-brane of the injured bowel is ulcerated from pres-sure, all the symptoms may not at'once subside.

1048 AUSTRALIAN MEDICAL JOURNAL. August 2, 1913.

SOME OBSERVATIONS ON LIME AND ITS EFFECT ON THE SYSTEM.

SYDNEY FERN, M.R.C.S. (Eng.), L,.R.C.P. (I,ond.) .

The problems of the metabolism of calcium salts are receiving a large amount of attention at the present tine. For the last few years this point has been much in my mind, particularly as

- I am inclined to theidea which I have before expressed, that in certain localities the people are not taking sufficient lime into the system. On that account there are tissue changes takinw- place, or failing to take place, which are detrimental both to mental and physical development. To prove this very im-portant point a great deal of data must be pro-duced and strong argument used, as it is generally held that lime is so universally distributed throughout the animal and vegetable world that it would be difficult to avoid taking- in a sufficient quantity for the bodil^ needs.

•

'l'he first point which has great weight in my own mind is that in certain localities where lime is deficient, it is impossible to breed blood horses pure. By that I mean, if a blood stallion is mated with a blood mare the result is what is commonly called a "weed."

In order to get the necessary bone, it is advisable to mate with a heavier horse, with the result that some undesirable qualities are transmitted likewise. In other districts where lime is abundant, this is nut found necessary, and in such places good-boned blood stock may be got from pure parents. Like-wise in coastal districts, where shell-beds help to

-

forut the subsoil, the young stock grows much better and develops finer bone than further in-land.

There are, again, other localities in which the soil is notoriously deficient in line salts, and in which the stock get what is known as "the cripples." 'l'he joints swell and the bones seem to soften and bend; this has been eradicated in some instances by putting down wells and erecting wind-mills, the stock being thus able to make use of the calcium and other salts in the lower subsoil.

These points go to show that it is possible for animals to suffer and deteriorate through not being -able to get a sufficiency of lime. salts.

In dealing with lime, phosphorus must also be taken into consideration, in fact these two might almost be bracketed together.

If animals suffer from a deficiency of line and phosphorus salts, it is possible that human beings may likewise suffer in the same way.

Man, in his primitive state, in all probability had abundance of lime; he drank out of pools and creeks impregnated with earthly salts, clot using a rain-water stored in corrugated-iron tanks. He gnawed bones, ate shell-fish, often, perhaps, pieces of shell, and any grain that was procurable was ground up whole, not as is now common, when

i!

only the centre of the grain is used, and the outer coats containing most of the earthy salts eliminated.

In fact, all the modern methods of preparing foods, particularly cereal foods, throw out the parts which contain the lime and phosphorus salts in greatest abundance.

In regard to phosphorus, the deficiency of which, together with that of lime, and which, I think, is making itself felt in the younger generations, I will quote a passage from the Agricultural Journal, January 1st, 1909, by Dr. Cherry :-

"In regard to phosphoric acid, this is a plant food whose absence gives the character to the vegetation on the poor lands. It is present in very small amounts, amounts so small that from chemical analysis alone much of our soil would be classed by huropean and American standards as very close to the point of inefficiency.Moreover, there is very little difference in the amount found in the surface soil and the subsoil ; frequently, in fact, if clay is met with a few feet below the sandy sur-face the percentage of phosphoric acid at once undergoes a marked increase. I am inclined to think that its peculiarity of the practical identity of the surface and the subsoil is a character which marks off Australian soils from those of the old world, just as 'clearly as the prevailing characteristics of our plants and animals. Very probably, indeed, all these are associated, and because our plants and animals retained the type of those of the mesozoic geological ages in the other continents, our surface soils have failed to become progressively richer with regard to phosphoric acid. Perhaps our climate has had its share in the want of development, but whatever may be the cause, of the fact itself, there can be no question or dispute."

'l'his paragraph is filled with much meaning -, and one is bound to agree in the conclusion that all living - things which inhabit the land as described must in some way be influenced. 1 presume that grasses and herbage vary as regards the amount of lime they are able to absorb, and that .one kind of grass, if grown on a soil rich in lime, will contain more than one grown on a soil poor in lime, and the sane with vegetables.

In the first consideration, as applied to human beings, is the enumeration of the principal sources of line in an ordinary food-supply. Milk is easily first in this regard. In many instances drinking-water contains abundance of lime; cereals, in which it is chiefly in the outer-coating, and vegetables contain lime salts. To emphasise my point, I will deal with circumstances as I find them in my own district, as I am well acquainted with these, and it is under -their influence that I see what I consider the harmful results of the lack of lime in the de-velopment and functions of the body. Being largely a dairying district, practically all the chil-dren learn to milk from a very early age. This is carried out in very muddy and dirty surroundings, even under the best mauagentent, particularly in the winter time. In a really wet winter the 'cow-yards are more often than not knee-deep in muck. \I1 this, together with the smell of the warm milk

ar

August 2, 1913. AUSTRALIAN MEDICAL JOURNAL. l o l'^

• and the cows, soon gives these children a distaste for milk, and it is usual to find that hardly any of them drink it. The result is that they lose one of the chief supplied, of lime. Rain-water is invariably the basis of the water supply. This is stored in galvanised iron tanks, and so another valuable means of the natural supply of earthy salts to the body is lost. As regards vegetables, people living on the land, particularly where they are clearing and burning off, and milking night and morning, have no time for gardening, so go without, except for potatoes and an occasional pumpkin, which is also grown for the good of the pigs.

'i'he flour used for bread has been deprived of its earthy salts by careful milling. - I think, under these circumstances, it must be owned that at least there might be a deficiency of earthy salts entering the system.

In the "Australian Medical Journal" for Novem-ber pth, 1912, I offered some suggestions pointing to the fact that the thyroid controlled the meta-bolism of lime 'in the system. Since then others have been working on the same lines. If this fact be accepted, then Ave should expect to find that people living on an insufficient quantity of lime will have some impaired function of the thyroid gland.

I also draw attention to the enormous number of goitres that are in South Gippsland. This type of goitre, which usually shows some thyrotoxic symp-toms, I attributed (rightly or wrongly) to insuf-ficiency of lime.

As in the large majority of cases, the administra-tion of lime-salts cured or greatly improved them, particularly those in which secondary changes had not taken place. There are also a very large num-ber of people who show impaired function of thy-roid, independent of goitrous swelling. This mani-fests itself by many minor symptoms of thyroid insufficiency which are only recognisable by close observation. These people respond to thyroid extract in a remarkable way. Their lives become entirely different; although they may not have been actually ill prior to treatment, they show a marked change. This is always first seen in the features, the face becoming thinner and more refined. Their activity is wonderfully increased, and from being inclined to brood and worry over things they become bright and happy. This is noticeable in children as well as adults.

It is a surprising fact that one finds no robust, healthy families in this neighbourhood, or, if they exist, their number is small, and I can only bring one to mind. All its members are big milk drinkers. The predominating feature in the children and voung adults is that build of body known as "lanky," with spare chests and limbs. Mentally there is little determination to excel in anything - . Gippslanders are said to be easily picked out in Melbourne by their height. They are inclined to be weedy, like the stock of blood horses reared in the district. A very large percentage show cardiac murmurs, chiefly mitral.

The following brief extracts from case-hooks show the effect of lime on certain individuals:—

Mrs. Q., under treatment for thyrotoxic• goitre with calcium lactate grs. x t.d.s. June 15th : Started

treatment. ,July 30th : Very great improvement, much fatter; headaches and palpitation better, goitre smaller. August 9th : Goitre much smaller.

Miss R., aged 30, under treatment for thyrotoxic goitre with calcium lactate. June 20th : Started treatment. August 1st: Looks splendid, better than she has been for years ; all headaches, which were so troublesoine, have gone; nice fresh color in face; gaining weight.

Miss P., aged 20, under treatment for thyro-toxic goitre. Jun e t 1th : Started treatment. August 6th : Wonderful improvement, no symp_ torts at all now; she never was better iii her life; practically no enlargement of t li ^

mid. August 26th : Can barely feel the thyroid; health perfect, no palpitation, no headaches; gained TO lbs. in the last month.

Miss D., to years, under treatment for very acute attack of thyrotoxic poisoning, with dilated heart. July t6th : Started treatment. Septem-ber tooth : Growing and filling- out most re-markably; height now 4ft. TT ill., on August 8th it was 4ft. min.; previous to this, after being in bed for a month, her clothes were too short for her, showing she must have also grown at least an inch during that time. She gained 61bs. in six weeks. She A-vas on lime-salts and ergot.

Mr. Y., aged .1.6, under treatment for thyrotoxic goitre. July 30th : Started treatment. September 16th : Ouite a changed man ; he has gained two stones in weight since July 3oth, and lost all ner-vousness, and does not feel his heart troubling him at all; can do his work now easily; all his clothes are too tight for him.

Miss R., aged 14, under treatment for goitre; both parents have goitre with thyrotoxic symptoms. September 27th : Started treatment. October 26th : On calcium lactate grs. v . t.d.s.; she has grown %in. since September 27th. November 23rd: Grown another -iii., also filling out. March 8th : Goitre is not visible now, a n d can only just he felt; grown another_ din.

Mr. M., aged 5o. Chronic asthma for many years; has tried all known cures without any result; put on calcium lactate grs. x t.d.s. August 15th : Started treatment. September 20th : Getting quite fat and robust now, has never been better, can work with-out discomfort ; no sign of asthma.

Mr. Y.L., aged 38. cloth lungs badly affected with tubercle; left elbow joint disorganised. The pos-terior surface Of the ulna presented a tuberculous swelling from the elbow to the wrist, from which used to he aspirated a few ounces of fluid oc-casionally. August 15th, put on calcium hypophos grs. x and creosote grs. ii t.d.s. November 15: Gained 15 lbs. weight; hardly any expectoration; arm much smaller, much stronger. December 13: Has gone from Lost. albs. to test. in last 4% months; arm better and cough not nearly so fre-quent. March tst: Put on thyroid extract gr. i t.d.s. as well. May 3rd: He is wonderfully im-proved; the swelling of his arm has gone down, and he has a fair range of movement in the elbow joint. He had been all the time carrying out his usual mode of living and had made no alteration,

1151ß AUSTRALIAN MEDICAL JOURNAL. August 2, 1913.

except for the medicine he was taking. His work was riding round superintending others working.

Mrs. A., aged 64, a very advanced case of phthisis, with high. temperature and diarrhoea. On March 7th, put on calcium lactate grs. x t.d.s., thyroid extract gr. /, and creosote gr. ii. t.d.s. She improved at once on this treatment in spite of her very advanced condition. The skin of her face and hands was hard and heavily creased, suggesting thyroid in-sufficiency. May 1st: Much improved, is able to get about, is sleeping better, spitting comparatively little, much stronger. • Miss G., aged 21, under treatment for goitre.

February 1st, weighed 9st. ; put ón calcium lactate grs. x t.d.s. May 5th : Weighs lost. I2lbs. ; goitre much decreased in size, but not quite gone.

Miss L., aged 21. April Ist, fainted; says she has not been well lately. On examination, no physical signs in chest or elsewhere, but she sug-nested early tubercle, so was put on calcium lactate grs. t.d.s. April 25th she wrote saying she had gained 121ós. and was feeling grand.

Mrs. A[., aged 52. Under treatment for asthma; she also had a goitre, which had never given her any trouble ; she was put on calcium lactate grs. x t.d.s. After taking the tabloids for a month she refused to take any more as she had gained 16lbs.

These extracts from notes tend to show that the administration of lime-salts has a marked effect on certain people, who frequently put on weight and improve in general condition in a surprising man-ner. This is particularly so in certain cases of tubercle, especially when combined with small closes of thyroid extract. The thyroid extract increases general metabolism, and, as nature's method of curing tubercle is by burying it in calcium salts, it is only reasonable to see that the patient has a good supply available. I have used it in many cases, and its effect, particularly in the young, is to cause rapid growth and increased weight. This is very marked in early goitre cases of the type front which develop thyrotoxic symptoms. With such marked results, in spite of being sceptical as to the results obtained by the administration of drugs, one is led to believe that there is a large number of people who suffer in some way from not taking sufficient lime-salts into the system, and this may show itself by poor development, or some de-rangement of the thyroid apparatus which controls lime metabolism, resulting often in the impairment rif the defensive forces of the body against infec-tions. It may he asked whether there is not a countervailing problem of overdosage with lime-salts. If such exist, I have not yet met with it, and the body seems provided with means for deali vng with excess. Possibly, as in the case of iron, only sufficient for use is absorbed however much is plied, while insufficient supply is serious. Mere nry.

Sandwith ("Med. Press," June 25th), in the course of a lecture, says:—

One of the most remarkable facts about mercury is the extraordinary wave of popularity through which it passed in the first half of the 19th century. Who first brought it info vogue as the best of all drugs and who was chiefly instrumental in bringing it out of favour, I do not know.

But it certainly was the most cherished remedy of the late Georgian and early Victorian practitioner. Mercury and bleeding were the almost infallible rule in all and every ailment. if a man broke his arm, he must be bled and huge doses of calomel administered, if he suffered from consumption, rheumatism, typhoid fever, typhus, pneumonia, no matter what the • symptoms, mercury in one form or another seemed as obvious a course as put-ting him to bed.

"Is people sick, they conies to me, I purges, bleeds and sweats 'em;

If after that they likes to die, What's that to me? I lets 'em,"

is said to have been written of a physician of that date. ( Lettsom.)

I have drawn a few quotations at random from some well-known medical writers of that day on treatment by calomel: Thus, in scarlet fever: "Blood was taken from his arm, he was cupped on the temples and took mercury; and in a short space of time was salivated." Again: "1f a person is seized with very acute pericarditis, how un-availing will be our best directed efforts unless they be sconded by a speedy mercurialization of the system?

Whenever the most violent attacks of pericarditis are met with copious venesection, repeated leeching and the rapid ingestion of calomel, few patients will be lost." "When a violent pneumonia has hepatised a considerable portion of the lung no remedy exceeds mercury in value." In jaundice: "We sometimes succeed in rectifying the whole morbid condition by applying a sudden wrench (so to speak) to the biliary organs, by giving half a scruple or a scruple of calomel."

One doctor, in a case of tuberculous hip and knee joints "proceeded boldly, and at once, to try whether the disease might not be arrested in the commencement by rapid mercurialisation." Again, in a case of water on the brain, "A child of 28 months took in nine days 350 grains of calomel (nearly 40 grains a day) with no good results, but `slight salivation.' The child recovered after having been in nearly a comatose state." This physician should have recalled the warning given by Boerhaave, a hundred years earlier, who said: "I can't but think that those persons act somewhat imprudently who order such large quantities of this fossil matter to infants."

That wise old physician, Sir Thomas Watson, lecturing to the students of the Middlesex Hospital in 1843, warned them, however, in treating tetanus or other diseases with mercury: "Wee must take care not to conclude too hastily, that because a patient uses a certain remedy and re-covers, he recovers through the operation of that re-medy: any more than we should conclude, if he recovered during a general election, that the election had cured him. Yet this absurd and unsafe mode of reasoning is for ever employed in regard to disease, by the public and, too often, I fear, by ourselves." In a previous course of lectures, delivered earlier in his career, he had said that "the great remedial property of mercury is that of stopping, con-trolling or altogether preventing the .exudation of coagu-lable lymph; of bridling adhesive inflammation; and if we in our turn could always bridle or limit the influence of mercury itself, it would be a still more valuable resource."

He then proceeds to describe the results in patients where the drug had been continuously used, in spite of obvious signs that the system is being poisoned. "The submaxillary glands and the tongue swell; a prodigious quantity of saliva is apt to be discharged; and in extreme cases the inflamed parts may perish; the cheeks sometimes slough internally; and not the gums and cheeks only, but the throat and fauces, grow red and sore and sloughy."

We can hardly wonder at such :horrible results being produced when we read of doses of 80 grains of calomel being given in 48 hours, of 280 grains in a week, of 140 grains in five days, with innumerable large doses of other drugs in addition.

The lancet, the blisters, the leeches, the generous.bottles of wines and the horrible boxes of powerful pills and black draughts have retired into the background, and are seldom called to our assistance. The skilful nurse, the open windows and wholesome cleanliness have taken their Places; they cannot always bring back health, but at least they lessen the terrors of the old sick room and have brought into it a sweet atmosphere of purity which greatly lessens the sadness of disease.

August 2, 1913. AUSTRALIAN MEDICAL JOURNAL. 1151

augtraYtan fliebtcaC journal 2nd AUG US T, 1913.

THE PROBLEMS OF SYPHILIS.

'l'he death of Sir Jonathan Hutchinson removes a personality whose importance in the history of I ritish medicine is apt to be forgotten. His con-tributions to the study of syphilis are alone suffi-ciently striking and original to ensure him a niche in the Valhalla of distinguished medical observers, and it has to be remembered that he was working without many of the aids, bacteriological and other, which are at the command of modern researchers. Ibis lucid expositions of the condition known as congenital syphilis served to lift some of its mani-festations out of the misty realms of "scrofula," in which, up to his time, they were classed. He was also to the end of his days a firm believer in the efficacy of mercury in the treatment of syphilis, and he was also one of the observers who first re-cognised that arsenic has a powerful action in many syphilitic manifestations. Best of all, Hut-chinson was never sensational. His conclusions were temperately put, even in the face of hostile criticism. In short he is easily the greatest British authority on syphilis that has yet been forthcom-ing, and, after an exceptionally prolonged life of untiring scientific work and practical philanthropy, he has gone quietly to rest.

In the sanie number of the "Lancet" which con-tains Hutchinson's obituary notice, Sir Malcolm Morris enters a plea for an organised movement against the ravages of syphilis, and it serves to mark the fact that the effort of the future will be in the direction of prevention. It is probably true, as the writer contends, that the manifestations of the disease have undergone a change. The former severe types of primary and secondary ulcerations are becoming more and more rare, but the tertiary affections of the nervous system are growing more common, and the group of para-syphilitic affections are being more clearly recognised.

\\Whether the measures usually enforced against infectious disease in general are applicable to vene-real disease is .yet an unsolved problem. It is still

- largely a matter of opinion whether legislative measures are, or are not, advisable. The balance of evidence appears to be against them in practice, if the experience of many 1?uropean communities can be accepted. It is of little use to hold with \kisser that the principle is right, as long as imperfections in administration prevent any appreciable effect. 1?ven Fournier, who approved of the principle, ad-mitted that after a century of regulation syphilis was as common in Paris as in the times before. Sir

alc olni Morris quotes the Melbourne example as a promising beginning- in restrictive legislation, but the essentail results of our own effort are, perhaps, more discouraging at honk than abroad in this respect.

Legislation apart, there is still great and good hope that the spread of venereal diseases may be

effectively checked in incidence by other means. The recent developments of science have taught us that venereal disease is no mysterious manifesta-tion beyond human ken. Now that the organisms are known, there remains to be learnt what is pos-sible of their life history and development, and, when this has been done, there is no reason to think their effects in the human tissues cannot be dealt with upon some such lines as are being demonstra-ted in the case of many other specific organisms. Nor is there any need to be idle while such a de-sirable consummation is being brought about. The laity must he impressed with the truth that the largest measure of its suffering is simply clue to personal carelessness and uncleanliness. While we have no desire to see venereal disease made the subject of public conversation , or jest, as it vvas in Shakespeare's time, there is no necessity for the excessive prudery which makes all reference to sexual hygiene a matter for subdued whispering. It is not by such morbid teaching as the dramas of Ibsen and Brieux that we would hope to effect any public reform. The simple straightforward gospel of cleanliness—cleanliness that is next to godliness —is one by which salvation may be reached, and it has the advantage of being a cheerful creed. While we await a protective or curative serum, there re-mains much to be done in providing abundant access to such simple expedients as soap and hot water, both in public and private, and in inculcating the habit of their employment.

Potez anb Commerit5. The small-pox epidemic continues to ex-

Small -Pox hibit a striking evenness of virulence and attack-rate in Sydney. On an average ten to twelve patients have been removed

to quarantine daily over a period of thirty days, and at the time of waiting this number remains much the same. Ominous indications of a widespread dissemination of in-fection are contained in reports of cases in Queensland, South Australia, and northern New South Wales. The public panic appears to have subsided as suddenly as it arose, and the demand for vaccination has undergone a decided lull, perhaps partly owing to the fact that the first crop of reactions have caused some timidity among those who were shirkers at the first.

The quarantining of Sydney has had the effect of dis-couraging traffic and stimulating vaccination. Otherwise there is no evidence that it has had any beneficial result. It is obviously not diftult for persons leaving Sydney to book from outside the area. The inspection both by land and sea has failed to prevent cases passing into Melbourne and Adelaide. If it be as the authorities asserted, that the proclamation was necessary in order to allow inter-state shipping to be inspected, then the sooner the Act is amended the better.

Some little time ago a number of observa- tions were published which were con- cerned with the treatment of diphtheria "carriers" by means of a spray of cultures

of staphylococcus. In the "Journal A.M.A." for June 14th Alden publishes sixteen cases in which the method had been followed. 1lbst of them were within forty days of illness. In all, a number of other routine treatments had been followed, and the longest period after employing the

Diphtheria "Carriers"

1 t5 _' AUSTRALIAN MEDICAL JOURNAL.

.\ugusi. 2. 1913.

spray to the date of a negative culture was eight days. Alden, who is not apparently a medical man, concludes that in fifteen of the cases the method succeeded after ether treatment had failed, and that no appreciable harm had resulted in any instance. It appears desirable that some more extensive observations should be undertaken in this direction since the problem of treating "carriers" is still unsolved. The information regarding Behring's new antitoxin is encouraging, but so far there has been little outside the daily press. The danger of employing living cultures in any capacity has always to be kept in mind, but upwards of fifty cases are on record in which this spray has been applied and in which no untoward effects have followed.

frítt01j Aiebf caY • 21g5ocf atíon. VICTORIAN BRANCH.

Third Session.

A meeting of the Committee was held at 2.30 o'clock p.m. on Monday, July 14th, 1913, at the B.M.A. Building, 30-34 Elizabeth-street, Sydney. The members present were:—Dr. W. T. Hayward, Dr. F. S. Hone, South Aus-tralian Branch; NIr. G. A. Spite, Dr. R. H. Fetherston, Victorian Branch; Dr. W. W. R. Love, Dr. W. N. Robert-son, Queensland Branch; Dr. W. H. Crago, representing Western Australian Branch; Dr. F. A. Pockley, Dr. G. H. Abbott, New South Wales Branch; Dr. G. H. Abbott also acted as proxy for Dr. Brooks, representing the Tasmanian Branch; Dr. W. T. Hayward acted as a representative of the Western Australian Branch. Mr. A. W. Green kindly offered his services as assistant secretary during the ses-sion.

Election of Officers,—Chairman, Dr. W. T. Hayward, re-elected; vice-chairman, Mr. G. A. Syme, re-elected; hon. secretary and hon. treasurer, Dr. G. H. Abbott, re-elected.

The minutes of the proceedings of Friday, January 10th, 1913, were confirmed.

Sir Alexander :McCormick.—It was resolved that the Committee offer its congratulations to Sir Alexander Mac-Cormick on having had the honour of knighthood con-ferred upon him.

Correspondence: General.—A letter was received from the Acting Hon. Secretary of the N.S.W. Branch, stating that the Council would be pleased to place at the disposal of the Committee any accommodation desired in the B.M.A. Building; also that the Council would like to enter-tain the members of the Committee at dinner. Resolved —"That the Council of the N.S.W. Branch be thanked for its kindness and courtesy."

A letter from Sir David Hardie, thanking the Committee for its letter of congratulation, was received.

A letter was read from Dr. E. Brooks, hon. secretary of the Tasmanian Branch, stating that Dr. E. J. Roberts (General Hospital, Hobart), had been elected as a member of the Committee to represent the Tasmanian Branch.

A letter was received from Dr. E. Brooks, stating that he was unable to attend the meeting, but had appointed Dr. E. J. Roberts his proxy, also that if Dr. Roberts were not present he wished Dr. G. H. Abbott to act for him.

New Zealand Branch and Federal Committee.—The fol-lowing resolution, passed by the New Zealand Branch, and forwarded to the Hon. Secretary of the Committee, was read:—"That, while the New Zealand Branch is fully alive to the advantages of such a federation as applicable to Australia, owing to our geographical position, and the different interests and conditions, and also the difficulties ill the way of obtaining direct and satisfactory representa-tion on the Committee, this Branch cannot see its way to join the federation." It was resolved that the Committee regrets the inability of the New Zealand Branch to join the Australian Branches in the Federation, but fully under-stands the difficulties of the position, and hopes that the New Zealand Branch and the Committee will be able to work in harmony where common action is advisable.

Representation of Western Australian Branch.—The Chairman (Dr. Hayward) reported that he had received a

• letter from the Western Australian Branch, stating that he and Dr. Crago had been appointed to act as repre-sentatives of that branch

Endowment by Government for Medical Research.—In answer to the resolution of the Committee re endowment by the Government for medical research, replies were re-ceived from the Queensland, New South Wales, and West-ern Australian branches. The Victorian Branch explained the ,position in their State. No further action was taken.

Maternity Allowance Act.—It was announced that four Branches had approved of the resolutions of the Commit-tee re the Materntiy Allowance Act passed at the second session of the Committee. The following propositions re-presenting the opinion of the Council of the New South Wales Branch were read:—"(1) That in view of the fact that the medical certificate required under the Maternity Allowance Act is required by the Government for its own protection a medical practitioner giving the same should look to the Government for remuneration for the service as in the case of notification of infectious disease; (2) that it be suggested to the Federal Committee that the Committee approach the Commonwealth Government in the matter with a view to medical practitioners being paid a small fee of, say, 5s., for each maternity allowance medical certificate." It was resolved that the Council of the New South Wales Branch be informed, "That the Committee has further considered the question of charging fees for certificates under the Maternity Allowance Act, and reaffirms its previous resolutions, which have been approved by the branches in Queensland, Victoria, South Australia, and Western Australia."

Medical Agents and Locum Tenentes.—Letters were re-ceived from the Queensland, New South Wales and West-ern Australian branches approving of the resolution passed by the Committee at the second session re locum tenen-tes." No further action was taken.

Warning Notices.—Replies were received from various branches to the suggestion made at the second session of the Committee re warning notices. No further action was . taken.

Income Limit and Model Ledge Agreement.—Corre-spondence re the Income Linìit Clause and the Model Lodge Agreement was read, and the following resolutions carried:—(1) "That in the opinion of the Federal Com-mittee, it is desirable that the Model Lodge Agreement (in-cluding the Income Limit Clause) be brought into opera-tion upon 31st December, but in cases where this is not practicable, that the date be fixed at not later than 30th June, 1914." (2) "That the Federal Committee recom-mends that the countenance and support of the other State branches be given to branches of States upon those Branches bringing into force the Model Lodge Agreement (including the Income Limit Clause)."

Advertising of Government Medical Appointments.—It was resolved—(1) "That the Federal Government be re-quested to advertise in the daily and medical press all vacant medical appointments, and to state the salary to be paid." (2) "That it be a recommendation to the Branches to authorise the Committee to make a similar request to the respective State Governments."

Medical Ethics.—The report of the Committee on Medi-

FORMA TIM OF DIVISIONS.

A Division was formed to include the Goulburn Valley and district. The first meeting was held at Shepparton. Dr. Wilkinson was present on behalf of the Council, and explained the present position of the Branch and pro-fession to a large gathering of members from the district. Dr. Henty, of Rushworth, was elected president, and Dr. Florance hon. secretary and representative on Council.

A meeting will be held shortly at Murtoa to form a new division in the western portion of the State, taking in the districts from Ararat to the South Australian border. The president of the branch hopes to be able to attend this meeting. Representatives from the Ballarat Division have also promised to attend. Dr. Foreshaw, of Stawell, has the matter in hand at present.

FEDERAL COMMITTEE OF THE BRITISH MEDICAL ASSOCIATION IN .tCSTit.Mt.

.\ugust 2, 1913, AUSTRALIAN MEDICAL JOURNAL. 11.53

cal Ethics, considered at the second session, was again discussed, and various suggested alterations and additions, submitted by the branches were considered. After certain alterations and additions had been made, it was resolved that the report (with the additions and alterations) be submitted to the Branches for adoption.

Constitution of Federal Committee and Draft By-laws for the Branches.—The Hon. Secretary reported that the pro-posed constitution of the Federal Committee and the draft by-laws for the Branches had been accepted by the Quensland, New South Wales, Tasmania, South Australian, and Western Australian Branches, and also by the Council of the Victorian Branch, but had not yet been considered by the Branch. The Victorian members of the Committee who were present expressed the opinion that there was little doubt of the ratification by their Branch of their Council's action. It was resolved:—(1) That the Hon. Secretary be instructed to communicate with the Home Association as soon as the Victorian Branch accepts the proposed constitution of the Federal Committee, and to forward a copy of the proposed constitution, and (2) "That the Australian Branches be requested to take the same action."

Representation of Colonial Branches on the Council of the British Medical Association.—After a short discussion it was decided that this matter be allowed to stand over until the constitution of the Committee has been accepted by the Council of the British Medical Association.

(Sgd.) W. T. HAYWARD, Chairman.

July 15th, 1913.

The Committee resumed business at 10 o'clock on Tues-day, 15th July, 1913, at the B.A.A. Building, 30-34 Eliza-beth-street, Sydney. The members present were: Dr. W. T. Hayward (chairman), i\1r. G. A. Syme, Dr. F. S. Hone, Dr. R. H. Fetherston, Dr. W. W. R. Love, Dr. W. N. Robertson, Dr. W. H. Crago, Dr. F. A. Pockley, and Dr. G. H. Abbott (hon. secretary). The minutes of the pre-vious day's proceedings were read and confirmed.

Military :Medical Services of the Commonwealth.. .A let-ter from the Secretary, Department of Defence, was read, acknowledging the receipt of a letter from the Hon. Secre-tary Federal Committee, making certain requests re the military services of the Commonwealth. lt was resolved that the Honorary Secretary be instructed to forward a further letter to the Secretary, Defence Department, call-ing attention to the previous letter, and pointing out that further experience shows the desirability of is-suing a special form of medical certificate for the use of civil medical practitioners in connection with the universal service scheme.

Dr. Fetherston reported that he had mad-e certain in-quiries for the New South Wales Branch re medical area officers, and laid up-on the table the information received.

Naval Medical Service of the Commonwealth.—No fur-ther action was taken in this matter.

Bills to be Presented to Parliament Bearing on Matters Affecting the Medical Profession.--A letter was read from the Acting Honorary Secretary of the N.S.W. Branch stat-ing that the Branch had framed the following resolutions: —(1) "That on the introduction of legislation, the success or otherwise -of which may be dependent upon the mem-bers of the medical profession, the N.S.W. Branch of the British Medical Association has the honour to request that an bill to be presented to Parliament, bearing on mat-ters affecting the medical profession in this State should be submitted to the New South Wales Branch of the B.M.A. for consideration in order that if possible, the success of the scheme may be secured." (2) "That the foregoing resolution be communicated to the proper au-thority in the State Government, and also to the Federal Committee."

After discussion, the Committee passed the following resolutions:—

(1) "That the Committee recommends the different State branches to endeavour to induce their respective Governments to communicate with the State Branch of the B.M.A. before actually introducing any legislation deal-ing with matters in which the medical profession, in its relation to the public is concerned."

(2) "That the following communications b-e forwarded

to the proper officer of the Federal Government—(a) That the Federal Committee of the British Medical Association in Australia, representing all the brauch-es of the British Medical Association in Australia has the honour to re-quest that it be communicated with before legislation is introduced, dealing with matters in which the medical pro-fession, in its relation to the public is concerned; (b) that the Committee would be glad to give any assistance that might be desired, in framing such legislation, and be-lieves that in this way the co-operation of the profession, in subsequent, administration of such legislation would be more satisfactorily assured."

Compulsory Nation-al Insurance in Australia.—Letters were read from the New South Wales and South Aus-tralian branches, requesting that the question of compul-sory national insurance in Australia be considered by the Committee. After discussion, the following resolution was adopted: ''That it be a recommendation from the Federal Committee to each State Branch to establish a, sub-cpnl-mittee to consider the wording of the English National In-surance Act, and to report to the next meeting of the Committee as to how the Act would need to be modified to meet Australian conditions."

Uniform Registration of Medical Practitioners in Aus-tralia.—The question of uniform registration. of medical practitioners in Australia was considered, and certain difficulties in the adoption pointed out. It was resolved that a sub-committee, consisting of Drs. W. T. Hayward and F. S. Hone, be appointed to prepare a. draft model :Medical Bill to be applicable to all the States.

Australasian Medical Congress and the Australasian Branches of the 13.ALA . A resolution of the Council of the South Australian Branch—"That in future the Austral-asian Aledical Congress be conducted by the Australasian Branches of the British Aledical Association," was con-sidered, and the following resolution adopted:--"That the Australian Branches be asked to consider whether, in their opinion, meetings of the whole Association in Aus-tralia should be held at intervals to be fixed, say, biennially."

Attitude of the British Medical Association in Australia towards the Australian Natives Associations—The Queensland Branch requested that the Federal Committee should make a definite pronouncement on certain matters in relation to the Australian Natives Association. After a long discussion it was resolved— "That this Committee has not the power, under its constitution, to make a pronounce-ment as requested by the Queensland Branch."

Expenses of the Federal Committee.-4t was resolved that the Hon. Secretary be authorised to collect (as pro-vided in the constitution of the Committee) from each of the branches a sum equal to 6d. per member of the branch, to meet the expenses of the Committee for the current year, other than the travelling and other per-sonal expenses of its members.

Copy of the Minutes.—It was resolved that copies of the Minutes be forwarded to the members of the Committee, to the Editors of the "Australasian Medical Gazette" and the "Australian Medical Journal," and to the secretaries of the Branches in Australia and New Zealand.

Next Meeting of Committee.-1t was resolved that the arranging of the date of the next meeting of the Comn-mittee be left in the hands of the chairman and h on. secretary.

Votes of Thanks.—It was resolved that a vote of thanks be accorded to the President and Council of the New South Wales Branch for the use of the library for the meetings of the Committee, and also for their kindness in entertaining the members of the Committee. A vote of thanks was accorded to Mr. A. W. Green for the services rendered by him to the Committee, and also to the lion. secretary for carrying out the duties of his position.

The proceedings closed with a vote of thanks to the chairman, Dr. W. T. Hayward.

REPORT OF FEDERAL COMMITTEE ON "MEDICAL ETHICa"

The Federal Committee is of opinion that it is impos-sible to draw up a minute code -of medical ethics that will deal satisfactorily with every conceivable circumstance -of

medical practice in Australia, or that will impose suitable

1154 AUSTRALIAN MEDICAL JOURNAL. August 2 , 1913.

penalties for infringements of such a code. The following Principles are suggested by the Committee as brief general guides. The Council of each Branch will have to decide individual cases on their merits and special circumstances, and determine the penalty of any infringement of ethical principles.

As regards the ethics of consulting practice, the Com-mittee is of opinion that the time is not quite ripe for definite pronouncements on the subject, which is still under consideration in Great Britain. .The more nearly all practitioners conform to No. 10 of the principles sug-gested below, the better.

Suggested "Principles of Medical Ethics." It is unethical for a member of the British Medical As-

sociation in Australia- 1. To designate his practice as based on an exclusive

dogma, such as that of homoeopathy, osteopathy, etc. 2. To prescribe or dispense secret remedies. 3• To hold patients for any surgical appliance or medi-

cine. 4. To advertise, either in the lay press or by card or

circular. The following exceptions are generally permitted by

long-established custom in Australasia:— (a) On commencing practice. (b) On changing address. (c) On temporary absence from practice. (d) On resumption of practice. (e) On succeeding to another practice, death vacancy,

etc. The advertisement in such cases must be as simple and direct as possible, and the num-ber of insertions limited.

5. To permit the publication in the lay press— (a) Of anything concerning disease or its treatment,

in which the authorship is indicated. (b) Of autobiographical or biographical notices. (c) Of advertisements of medical publications.

6. To give testimonials of any medical or surgical ap-pliance or preparation, or of any trade article.

7. To employ, or sanction the employment of any agent or canvasser for the purpose of securing patients.

8. To accept or hold appointment as medical officer to— (a) Any medical aid association or institution, which

touts or canvasses for patients. (b) Any such association or institution carried on by

laymen for their own profit. (c) Any friendly societies' institute where the aggreg-

ate salary averages Per member less than the rate paid in the district by friendly societies to their lodge medical officers.

(d) Any society or institution in a State, if such so-siety or institution have been declared by the Branch of the British Medical Association in the State to be inimical to the interests of the pro-fession.

9. To act as honorary medical officer to any racing, sporting, or athletic club, or any institution which is car-ried on for other than charitable purposes.

10. To divide fees with, or give commissions to medical practitioners, or laymen.

11. To attend professionally a patient under care of another legally qualified practitioner.

Except, in consultation, or as a substitute in cases of emergency or other special circumstances, or when the attending practitioner has relinquished the case, or been dismissed in due form (vide Note 1).

12. To continue in attendance on, or subsequently to attend a patient after seeing him in consultation with the regular attending practitioner, or as a substitute for the latter, unless with the permission of such practitioner (vide Note 2).

13. For a locum tenens to succeed to the practice of his principal, except by purchase or with the consent of the principal or his representatives.

14. To administer anaesthetics for unregistered dentists or any unqualified person.

15. To recommend patients for advice to persons not medically qualified, such as sight-testing opticians.

16. To meet professionally in consultation as assistant, or in any way, any practitioner who has been adjudged by the local branch to have violated any of the above prin-ciples.

Note 1.—Et is customary both in Great Britain and Aus-tralasia, for se-called consultants and specialists to see at their consulting-rooms any patients who desire their opin-ion, and such practice is not generally considered un-ethical—notwithstanding the fact that, when such pa-

. tients, as is usually the case, are known to be under the care of another medical attendant, such practice is not in conformity with principle 10.

The Committee is of opinion, as before stated, that the closer this principle is followed the better, and it is ad-visable that patients who are known to be under the care of another practitioner should be seen by consultants, even at their consulting rooms, only with that practitioner, or when sent with a letter from him, or with his know-ledge and sanction. In a case where this is not prac-ticable the consultant should communicate, preferably by letter, with the medical attendant.

Note 2.—In country and suburban practice where con-sultations are held with and assistance given by general practitioners, principle 11 cannot be followed absolutely, and is generally held to apply to the particular illness for which a practitioner may have been called in to assist. Patients cannot be deprived of the right to choose their medical attendant.

CURRENT LITERATURE.

Bebring's New :antitoxin. The Paris correspondent of the "Journal Amer. Med.

Assoc." writes:—As I said in my last letter, von Behring gives in the current issue of the "Deutsche medizinische Wochenschrift" a detailed report on his new prophylactic against diphtheria. The remedy is a mixture of very strong diphtheria toxin and antitoxin combined in such a Proportion that the mixture shows only a slight, if any, surplus of the toxin when tested on guinea-pigs. Von Behring has previously reported a method of immunising by a combination of toxin and antitoxin, and this was used at many places. The present method, which he regards as completely new, is a result of experiments on all available species of animals which showed that it is im-possible to produce in a test-tube complete neutralisa-tion of the diphtheria toxin. The biologic laws which have so far been thoroughly investigated only in animal experi-ments seem to apply also to man. Von Behring presented evidence to prove the necessity of a method of prophy-laxis more efficient than diphtheria antitoxin. The sta-tistics show, for instance, that in Berlin alone the num-ber of diphtheria cases has increased from 2,997 in 1906 to 11,578 in 1911, and it is apparently still increasing; further, it is known that for more or less justified rea-sons prophylactic injections are not generally used; finally, it is evident that all sanitary measures ordered by the police authorities for the suppression of diphtheria, such as closing of schools, disinfection of houses and persons, isolation of patients, convalescents and bacillus-carriers, have so far had barely noticeable, by no means brilliant, success, notwithstanding the extensive medical and other aids invoked and the burden which they impose on the affected families. From these and similar facts it is easily understood why von Behring is endeavouring with all his energy to introduce his method of vaccination for Prophylaxis of human beings. He states that the remedy will not be given out generally except under stringent conditions for making thorough tests of it. Consequently he will first supply his remedy only to institutions which have medical attendants trained in such work and where there are proper arrangements for experiments on guinea-pigs to test its aseptic character and lack of toxicity. In addition to all this, a physician with experience in exam-ination of the blood for antitoxin content must also be available. Each person to be treated must be examined beforehand, not only for his antitoxin index, but also to learn whether or not he is a bacilli carrier; if so, it is to be determined through continuous observation if the treatment will cause the bacilli to disappear. Periodical examinations of the blood must be made then according to a given method, so that the course of the production of antitoxin and the disappearance of toxin may be deter-mined with sufficient accuracy after the immunizing

August 2, I913. AUSTRALIAN MEDICAL JOURNAL. 1155

treatment has been given. Further, a very care ill record must be kept and duplicates of these records must be sent regularly to the .Alarburg institute; other precautions, be-sides, must be taken. In the meantime the most im-portant thing is not the number of cases treated, but the accurate investigation of the conditions in each indi-vidual case, on which depend the production of antitoxin and thus the success of the immunization, the promptness of its appearance and its duration.

Extra Uterine Pregnancy. Williams (Amer. Journ. of Obstet., June 13th), from the

study of 147 cases, says:— To summarise briefly it is found that: Twenty-eight, 19 per cent., occurred in primiparous

women. Twelve cases, 8 per cent., were illegitimate pregnancies. Forty-two cases, 30 per cent., had a history of previous

abortion; in twenty-six cases, 28 per cent., the preceding pregnancy had terminated prematurely.

The average interval after an intrauterine pregnancy until the extrauterine developed was forty-five months.

The average interval between the two attacks in the seven cases. where the condition was repeated was twenty-four months Recovery was noted for each of the seven-teen cases operated upon in shock.

Sterilisation was performed eighteen times, in eight of these cases the opposite tube had been previously removed.

Thirty cases, 52 per cent., of the fifty-eight cases whose subséquent history is known did not develop any later pregnancies.

Thirty-nine intrauterine pregnancies have developed subsequent to the extrauterine condition, twenty-eight ending at term, eight aborting, while three are at present pregnant.

The extrauterine pregnancy was repeated seven times, a ratio to the intrauterine pregnancies of 1 to 5.5.

Diagnosis in Gastric Cancer.

Fortescue-Brickdale ("Bristol Med. Journ," June) says of gastric tests:—

These may be subdivided into three smaller groups_ 1. Those which show stasis of the stomach contents. These are three in number, namely the absence of

hydrochloric acid, the presence of lactic and other organic acids, and the presence of the so-called Opler-Boas bacilli.

2. In the second group are those tests which show the presence of ulceration, namely the various methods for demonstrating minute quantities of blood in the gastric contents or faeces and the tests for serum albumen in the stomach washings ('Salomon's test).

These tests have been introduced for sonic years, and their value and limitations are now well recognised. The demonstration of stasis or of an ulcerated surface is a valuable additional item in diagnosis, but their presence or absence are of no preponderating or conclusive signi-ficance. They may not even be early occurrences in the course of a gastric cancer, so that no special reliance can be placed on their presence or absence as indications for or against operation.

i. The third group consists of a number of tests for alterations in the gastric contents, due to the special in-fluence of carcinomatous growths.

(a) Gluzinski's Test.—When an ulcer heals or becomes carcinomatous the HC1 fails and a mucous gastritis super-venes. Gluzinski considers that the former occurrence is so rare as to be negligible. The stomach contents have to be removed three times on the same day and tested for free HC1 and total acidity. The published cases do not seem very convincing.

(b) A more simple test is that for dissolved albumins. Wolff states that in simple achylia only a small amount of the albuminous matter iii a test meal is dissolved, whereas in carcinoma a high percentage of dissolved al-bumin is found. The reagent used is phosphotungstic acid, prepared according to a formula devised by Wolff, and is added to a series of dilutions of the filtered gastric contents. If much albumen is present high dilutions will, of course. show a cloudy precipitate and vice versa. The

only difficulty about the practical value of this test is that, though the findings are clear enough in undoubted cases of cancer, the border-line cases are not so easily decided. medium degrees of dissolved albumin may or may not indicate cancer. The finding of very small amounts is no doubt very much against the diagnosis.

(c) It has been suggested that the reason why there is often little free HC1 in the gastric contents in cases of cancer is that the albumens are split up into amino-acids, which combine with more HC1 than the original large protein molecule. However this may be, it seems clear that under certain conditions increased splitting of pro-teins does occur in cancer of the stomach, and this is the basis of the well-known tryptophane test. This test is apt to be interfered with by the presence of blood or bile in

the stomach. Blood in dilution of 1 in 500 may upset the test, and in greater amounts certainly will do so. Regurgita-tion of trypsin from the duodenum and increased protein-splitting by bacterial action may also vitiate this test. Moreover, it sometimes gives a negative result in early cases, and may give a positive result in other conditions, such as ulcer and simple achylia. If a number of tests are made, however, a series of negatives may be taken as very much against cancer. Schryver and Singer, in the autumn of last year, published some observations showing that .a ferment capable of splitting peptone occurred in numerous conditions of severe gastric disease, that it was not char-acteristic of cancer, and was most commonly associated with dilatation and achylia.

(d) The toxicity of the gastric juice to guinea-pigs has also been employed as an early test for gastric cancer. Liveriato injected it subdurally, and found that whereas 1 c.c. from normal stomachs produced no symptoms ; 0.1 c.c. from cancer cases was sometimes fatal. Anaphylaxis was produced by the maximum harmless dose of 0.05 c.c., which never occurred with normal gastric juice. The guinea-pigs were prepared by an injection of extract of carcinoma, and then given subdurally a small amount of filtered gastric juice, obtained threequarters of an hour after an ordinary Ewald test meal. A Marked symptom in the anaphylactic shock produced was a fall of temperature. Control experiments with 'normal gastric juice and with non-sensitised animals were negative. Similar reactions have been obtained by other workers for blood serum, and not only in cancer, but in syphilis, tuberculosis and other diseases. The reaction in any case appears to be against the foreign cells, and not against the specific cause of cancer, whatever that may be. Embryonic cells, other neoplasms, and apparently normal sera occasionally give anaphylactic reactions in the 'sensitised guinea-pigs.

(e) Attempts have also been made to obtain specific precipitins from the gastric contents in cancer. Alfredo prepared a rabbit serum; by injecting cancer extracts, and this was tested against gastric juice in vitro. Cancer juices were found to precipitate the cancer serum, but apparently gastric juice in other conditions, e.g., ulcer, may produce a similar result.

In reviewing the methods described in this group, it will be noted that they are far more specific in character than those of the first two groups. Gluzinski's ,test is in a way intermediate between this group and the others, as it re-presents a •result of the malignant growth on the secretory processes in the stomach, which, though not specific, is somewhat characteristic. Many possible sources of error surround the tryptophane test, and in early cases it is not infrequently negative. These tests may therefore be con-sidered not sufficiently biological in character, while those depending on the production of anaphylactic shock are, if anything, too biological, and do not rest on a sufficient knowledge of the underlying principles of cellular physiology.

Curious Treatment of Heartache. Henning ("Memphis Medical Monthly," March, 1913)

reports an operation worthy to be called by 'his name since in its therapeutic application it has been conceived and carried out by himself alone. Upon a brother phy-sician of forty-eight years, who was a chronic sufferer from gastroenteritis and severe headaches, the latter com-ing on twice a week and lasting from half a day to three days, Henning performed a unique operation, suggested,

AUSTRALIAN MEDICAL JOURNAL. 1tau5t 2, 1913.

doubtless, by the fact that the patient himself noted that by grasping the back of his neck with the right hand and making pressure his pain would be relieved for a time. Twice were large strips of superfluous skin removed from the neck with great betterment, though the patient has sick-headache occasionally when he does not watch his digestion and lets himself become constipated. The bene-ficial effect from the operation is attributed by Henning to the tightening of the skin and the removal of four pieces, thus supporting the circulation just as an elastic stocking gives support to the varicose veins of the leg. —(Ther. Gaz.)

[We feel this procedure may be usefully pondered over from many aspects.—Ed. A.M.J.]

getu Noottz. "l'ocket Case Book." London: H. K. Lewis.

This is a conveniently-sized book for the pocket, con-sisting of pages for noting cases. Each case is allotted three pages, and figure outlines and temperature charts are appended to each case. Very useful either for students or practitioners.

"Surgery for Dental Students." . C. P. Mills, M.B., F.R.C.S., Eng., and H. Humphreys, M.B., B.D.S. Lon-don: Edward Arnold.

A text-book modelled on the requirements of dental students for an acquaintance with the principles and prac-tice of surgery. Excellently done and well illustrated.

GENERAL.

LORD LISTER MEMORL11, FUND.

The treasurer in Victoria (Mr. R. Hamilton Russell) desires to acknowledge, with thanks, the following con-tributions:—

Amount previously acknowledged .. .. .. £ 16 16 0 Dr. Sampson Greville .. .. .. .. .. .. .. 1 1 0 Mr. Arthur Morris .. .. .. .. .. .. .. .. 0 10 6 Dr. R. E.Short .. .. .. .. .. .. .. .. .. 0 10 6 Dr. J. S. Buchanan .. .. .. .. .. .. .. .. 1 1 0 Dr. S. A. Ewing .. .. .. .. .. .. 1 1 0 Dr. F. Miller Johnson (2nd don.) .. .. 0 10 6 Dr. Wolfenden .. .. .. .. .. .. 1 1 0 Dr. W. Kent Hughes .. .. .. .. .. 1 1 0 Dr. W. R. Boyd .. .. .. 1 1 0 Dr. T. H. Boyd .. .. .. .. . .. .. .. 1 1 0 Dr. J. F. Wilkinson .. .. .. . .. 1 1 0 Dr. T. E. V. Hurley .. .. . 1 10 6 Dr. Henry Laurie .. .. .. 1 1 0 Dr. A. J. Trinca .. .. .. .. .. .. .. . 1 1 0 Dr. R. C. Brown .. .. .. .. .. .. .. .. .. 1 1 0 \Ir. Balcombe Quick .. .. .. .. .. .. .. 0 10 6 Resident Medical Officers Alfred Hospital 1 1 0

At the instance of the German Society for the Prevention of Sexual Diseases, the drama "Les Avaries," by the French author M. Brieux, has been represented in a Ger-man translation in the "Deutsche Theater," which belongs to Herr Reinhardt, the producer of the "Miracle." The drama is based on the sad story of a man who became syphilitic, and it shows the sequelae of syphilis in wed-lock. It is designed to give the public a clear insight into the matter in a more efficacious way than is possible by lectures and pamphlets.

Advertismo occulta is not yet described in text-books, though numerous sporadic examples have occurred within a year. Students of mental diseases would describe it as a form of "exhibitionism." It is an affection of the sense of justice. Recently a well-known surgeon came down with it. A review of the reported cases seems to show that this disease particularly affects surgeons. In brief, advertismo occulta is that form of advertising in the lay press or magazines, of which the subject (hero) is not supposed.to be aware that he is being described.—"Ver-mont Medical Monthly.",

rítíO 2figocíation. VICTORIAN BRANCH.

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

NOTICES.

VICTORIAN BRANCH.--Ordinary Meeting, ist Wednesday in month.

Clinical Meeting 3rd Wednesday in month.

PEDIATRIC SOCIETY.—Second Wednesday in month. EYE & EAR SECTION.-4th Tuesday in Month. MELBOURNE HOSPITAL CLINICAL SOCIE'T'Y.-4th Fri-

day in the Month.

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. A1eg. _.ewers, 65 Collins-street. Melbourne.

Single copies may be obtained from the Manager, at the Medical Society Hall.

PERSONAL.

Sir Jonathan Hutchinson died on June 23rd at the age of 85. He was a splendid example of the individual worker, and was always interested in work. As an out-come of private demonstrations, which he used to give at his own house, the present London Polyclinic was founded, and Sir Jonathan largely built it, and equipped the museum.

Dr. Kent Hughes, who was operated on for appendicitis last week, is now nuite convalescent.

Dr. A. C. Rothera, who is leaving for England, wishes through our columns to acknowledge the kindness of the profession during his residence in Melbourne, and espec-- ,.. ; '^ ea2Jr:4 to the appeal for extension of the Physio-i ai^a1 Laboratory. Dr. Rothera asks that any subscrip-ri:,ns promised to him Personally should be forwarded to

,.,ssor Osborne.

Warning Notices. 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 Fion. 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-tary, B.M.A., 429 Strand, London.

Court Sherwood and A. O. Foresters Launceston. Wellington Mills_ Medicalmen are advised to communicate with Dr. S. W.

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

August 9, 1 913. AUSTRALIAN MEDICAL JOURNAL. 4157

OF VOLVULUS OF THE ILEUM.

J. -YJLASY, M.k.C.S. (Eng.). (lion. Cymecologist to the Perth Public Hospital.)

This case was successfully treated in the Perth Hospital on the 6th July, 1911, by excision and end-to-end anastomosis; but, as the previous his-tory was decidedly interesting, this will be set forth in some detail:--

Airs. I1., aged 29 years, mother of two children, was admitted (4/8/191o) eight and a half months' pregnant and semi-conscious, her pulse being 140, and the urine loaded with albumen. Following on severe headache, she suddenly had a "fit" about 12 hours before admission, and during the intervening period she had had six additional attacks of con-vulsions. The cervix being found well dilated, my house surgeon, Dr. Lillies, delivered her with for-ceps of a healthy child, with rapid temporary im-provement in her general state. Three days later pleurisy and pneumonia developed at the right base, and her general condition again became very grave, the albuminuria increasing, the mental facul-ties getting blurred, and the vision poor; while the respirations were 32, the temperature was raised, and the pulse very quick and feeble. As the uterus remained markedly subinvoluted, I curetted five days after delivery, and removed some shreds of adherent placenta. Site now gradually improved, and was discharged on the 3rd of September, albuminuria being still rather pro-nounced.

A few days after leaving hospital the patient was attacked, more or less suddenly, with pelvic pain, and, after going through twenty-five days of septic fever, was readmitted on the 28th of September to the gynecological department in a critical state, her pulse being 16o, respirations 36, . temperature 103.4 deg., her tongue dry, and the urine loaded with albumen. Immediate operation was performed, the abdomen being opened below the umbilicus after a preliminary curettage. Small intestines wiere found adherent to the lower half of the in-cision, and were separated with difficulty in the attempt to get into the abdominal cavity. Large intestine stretched across the upper end of the wound, and was -densely adherent to adjacent parts. In the process of getting clown into the pelvis ex-ceptionally dense and universal adhesions were en-countered. Finally, a large quantity of fatty-look-ing material (inspissated pus or lymph?) was cleared _out,eleaving an irregular cavity behind the left broad ligament. On following this cavity downwards excessively foul yellow pus welled tip in large quantity, and was mopped up. The uterus was found markedly retroverted and bound down, and so soft and friable that in getting - down to Douglas' pouch it was nearly perforated by the finger. Bleeding on separating adhesions was pro-fuse. A way was at length made to Douglas' pouch, which was opened and an iodoform gauze drain passed through into the vagina. The patient's condition was so grave that salpingectomy was out

of the question; indeed, she required a quart of intravenous saline during operation. In spite of the rather hopeless outlook, the patient recovered, and left hospital with only a small quantity of albumen in the urine.

On the 6th of July, 1911, the patient was re-admitted, suffering from vomiting and severe rig-lit iliac pain and tenderness, which had cone on quite suddenly the previous evening. Up till this she had for several months been feeling singularly well, her only trouble being some constipation. On examination, :I found a dull, somewhat elastic, very tender mass extending front near the umbilicus downwards on the right into the pelvis; there was no abdominal distension, but with an enema no flatus passed. By .the vagina a tender tube-like mass was felt, extending upwards to the right from the lateral fornix, and was evidently continuous with the mass felt in the abdomen; the uterus was fixed in a retroverted position. As the Fallopian tubes had not been removed, it was difficult to be absolutely certain of the diagnosis, although the history pointed somewhat strongly to intestinal obstruction.

Operation.—Twenty hours after the onset of symptoms, the abdomen was opened to the right of the old scar. I at once lifted out of the abdomen and pelvis a stiff black volvulus of the ileum, with a gangrenous odour and involving about 18 inches of the bowel. 'Plie intestines were clamped well clear of the gangrenous bowel, and the volvulus with about three inches of healthy intestine on each side removed. After mopping up a large quantity of bad-smelling blood-stained fluid from the abdomen and pelvis, an end-to-end anastomosis was effected by a double row of Pagenstecker thread sutures. Before the anastomosis could be made, it was found necessary to cut away a band of adhesion about threequarters of an inch wide, extending between the two arms of bowel, which more distally went to form the volvulus. This band appeared to have been the inintediate predisposing cause which led to the volvulus. WW'itli the exception of some pain the day after operation, the patient recovered with-out any untoward svniptoni, although some albu-minuria was still present when she left the hospital.

In November, 19t2, this patient had become pregnant, and was in hospital with symptoms threatening eclampsia—slight albuminuria, anemia, dyspnoca and dizziness. With rest in bed, iron, and a suitable diet she improved, and had a normal confinement on the 5th of November, 1912. A'Vheu discharged from hospital, there was no albuminuria nor casts, no apparent cardio-vascular changes, nor any other obvious evidence of serious renal in-volvement.

'Plie foregoing case was of interest not merely because of the complete recovery from so many grave conditions, but also because of the final very unexpected sequel of pregnancy and a normal parturition. If in operating for the pelvic abscess, the patient's state had not been so extremely critical, it is more than likely, in view of the large quantity of foetid pus, the universal adhesions, and the very friable uterus, that double salpingectoniy

i;,

1058 AUSTRALIAN MEDICAL JOURNAL. August 9, 1913.

'v uuld have been carried out, and the woman ren-dered sterile. At this operation it seemed an utter impossibility that pregnancy could ever come about. The unexpected, however, happened, the tubes exhi-bited a remarkable power of recovery, and the pa-tient gave birth to a healthy child, and is otherwise \yell. This power of diseased Fallopian tubes to undergo natural recovery and permit of pregnancy I have seen in connection with other abdominal coelio-toulies, and naturally raises the question as to whether the time has not come for surgeons to seriously consider whether, in certain instances at least, some means may not be devised by which diseased Fallopian tubes may be saved rather than that the prospect of motherhood should be for ever sacrificed. In occasional cases pus-tubes undergo natural cure by draining into the uterus. Why not try to imitate Nature? The technical difficulties would doubltess be great, but as great or perhaps even greater difficulties have been overcome in other departments of medical art. And it seems to nie something more than a dream to believe that man's ingenuity well ultimately surmount all obstacles in dealing with Fallopian tubes, and thus add fresh laurels to the triumphs of conservative surgery. Should this be so, added force will be given to the apparent paradox that the evolution of surgery means its own extinction.

The subject of diet in health and disease is one of the widest topics that can be chosen for con-sideration, and in a short review it is only possible to touch on some of the most salient points. While one rarely thinks in "calories" in laying down a diet, it is well to know the elementary require-ments for so doing. A "calorie" is the amount of heat which will raise i kilo of water through t° C. Chalmers Watson gives the following tables:—

I gramme Carbohydrate — 4 Cal. 1 Protein = 4 Cal. 1 Fat = 8.9 Cal.

To supply 3,000 calories per diem some such diet as follows would suffice

Breakfast.-2 slices of thick bread and butter, 2 eggs

Dinner.—Plate of potato soup, large help of meat and fat, 4 moderate-sized potatoes, 1 thick slice bread and butter.

Tea. 2 thick slices bread and butter, 1 glass milk.

Supper.-2 slices bread and butter. 2 oz. cheese. Friedenwald and Ruhrah remark that in hospital work the patient's diet is generally chosen by the nurse. This is to some extent true and to some extent unavoidable since the daily menu is not laid before the physician nor, it may be said, before the patient, and in catering for a large number of patients it is not possible to provide for each one the precise items that may be fancied at the par-

ticular moment. There is a compensating factor, however, that meal -time is the only break in the monotony of hospital existence, and patients are less apt to be querulous in hospital than in private practice. Outside the hospital, diet forms an important part of the advice expected of a phy-sician, and the most common question that pa-tients will put after any consultation is, "Is there any particular diet, doctor?" Nothing captivates the patient's mind more than to be strictly dieted, and the number of dietetic cures in existence testify to the fact of the public belief in being confined to particular articles of food. The late Sir William

Roberts was one of the most eminent authorities on diet, and once said at a medical dinner that it was the only occasion on which he could eat what he liked. At private dinners he was certain to meet one or more of his patients, and he felt that they watched him with a critical eye, and took notes as to whether he practised what he preached. The old school of hard and fast dietetic dictators is practically extinct. Since Pavlow's researches were published medical advisers have realised that the patients' tastes have a certain physiological basis, and that some people are able to take with impunity articles that theoretically are entirely un-suitable. Chittenden showed that the proteid in-take of the ordinary diet might be curtailed about one-half. Chittenden is probably theoretically right and practically wrong, and, as Hutchison objects, the physiological minimum may not be the physio-logical optimum, and that Nature probably re-quires a reserve for times of stress; but this not-withstanding, we may accept it as an axiom that the majority . of people eat too much. In this fact lies the secret of success that follows the adoption of various weird diets that are occasionally indulged in, from meat and hot water to nuts and cheese. What happens is that the patient takes less food and benefits for a time accordingly. But the benefit is only for a time, and the prolonged deprivation of a mixed diet leads to great troubles in the direction of aniemia and loss of muscular strength. In the absence of definite indications to the contrary, a mixed diet is most suitable both in health and dis-ease. There are two general states in which starva-tion in any sense is not borne. Tuberculosis must be fed. If a tuberculous patient cannot eat he will die. Neurasthenics, again, do not bear curtailed amounts of food. All neurasthenics may require regulation of food, but the vast majority of instances of neuras-thenia are also examples of under-feeding. Chil-dren require larger amounts of food in proportion to size and weight than adults; and it Limy be said that as a class children will not bear starvation for more than very limited periods. The habitual diet of every patient should be carefully enquired into in all cases where such a course seems desirable. The best method is to go through a specimen day( Very few people will acknowledge to over-eating. The most damaging admission will be that they are "hearty eaters," or that they "enjoy their food."

Having got a fair idea of what the patient is eat-ing and drinking, one can then proceed to alter or amend the scheme. This should never be neglected. or one may sometimes be cruelly embarrassed by

A CLINICAL LECTURE ON SOME GENERAL CONSIDERATIONS OF DIET.

August 9, 1913. AUSTRALIAN MEDICAL JOURNAL. 1059

finding that half the curative dietetic directions are being already carried out and half the remainder are out of the question. For example, it is a counsel of perfection to insist on fish for a person who lives somewhere high up in the Puffâlo moun-tains. Lastly, where diet is of essential import-ance it is well to be specific. Give detailed instruc-tions not only as to kind of food, but amounts and times, and not vague generalisations.

A not uncommon class of patient in private prac-tice is the sufferer from high blood-pressure with-out definite albuminuria or any other definite dis-ease. The subjects are usually city men just past the middle age, of good position, who have "done themselves well" in the matter of food, drink and tobacco for some years tivithout recognising the fact they have eaten and drunk too much and smoked too much, and begin to complain of vague fatigue, headaches, and irritability of temper. They will present a blood-pressure ranging from 140 to 18o, or higher, and there may be no other objective defect discoverable except, generally, over-weight. 'l'he diet here requires restriction, and it requires tact and much firmness to accomplish it, for these patients will not admit their indiscretion, and even if they admit it, will rarely amend it for more than a brief period. It requires special care, and is of special importance to restrict tobacco. These are the people who derive great benefit from a yearly visit to spas and watering places in Europe, or from following any dietetic specialist for a few weeks or m onths because ill such case they eat and drink less. It is probably just here that one may best notice the so-called purin free diet. • Generally, purins are chemical bodies containing the nucleus C5N4 and the most important from the clinical standpoint is uric acid. What the precise patho-logical role of uric acid is is a matter of bitter dispute. Dr. Haig attributes every bodily ailment to its presence. Dr. A. P. buff, an accepted autho-rity in gout, regards it as non-toxic. In practice the "acid" theory has a very firm hold of the public imagination. 1\lany patients have read or heard of Haig's writings, either at first or second hand, and these Will often tell you a great deal about their "acid" symptoms and what measures they take to "get the acid out of the system." Unfortunately even in purin free diet the urine contains purin bodies, which are derived from the tissues. What-ever the ultimateoutcom e of the dispute, there is no doubt that the gouty patient requires dieting; but there is more than a doubt whether a purin free diet is advisable for more than limited periods. A purin free diet would include eggs, cheese, milk white bread, rice, cauliflower, lettuce, potatoes, fresh fruit. These limited diets do not maintain nutrition if persisted in for more than a few months. The diet, in fact, as in all other diseases, requires firstly modification for the particular malady and modification for the particular patient.

In a recent "Lancet" (June 28th) Sir A. Garrod, in an article on the "Dietetic Treatment of Gout," writes:—

"That errors of diet play an important part in the causation of gout is hardly open to doubt, and it is

hardly less certain that a gross indiscretion of diet may provoke its active manifestations. Such con-clusions rest upon the accumulated experience of generations of gouty people. and of their medical advisers; and our advice is influenced to no small extent he the conception which each of us has formed of the nature of gout, and of what should and should not be suitable foods for those who suf-fer from its attacks. There can be little doubt that in their main features the current tenets as to the dietetic treatment of gout rest upon a sound basis, but many details of advice which are given could with difficulty be defended in argument. How in-secure is the footing of many of them is shown by their great diversity. Hardly an article of diet can be mentioned which someone will not be found to forbid."

In his book "Modern Theories of Diet" Dr. Alexander Bryce writes (p. 164):—"In any re-search into the action of purins, the following con-siderations must always be borne in mince: (I) Per-sonal idiosyncrasy has much to do with the diverse results reported, and, in my opinion, this is ulti-mately bound up with the metabolicactivity of the cells, and especially the ability of the cells of the mucous membrane to withstand the onslaught of irritants such as purin• compounds. (2) Small quantities of purin are almost invariably well borne, and only in isolated cases are larger closes not tolerated. (3) The ability to tolerate purins is markedly influenced by diseases—for example, neurasthenia so-called and kidney ailments where the integrity of the convulutecí tubules is doubtful

--yet a malt in perfect health with a so-called gouty tendency may tolerate them badly because they act as irritants to the mucous membrane of the hepatic ducts and produce hepatic insufficiency."

A modern diet which has obtained wide clinical application is that of Lenhartz for gastric ulcer. The patient is kept in bed for four weeks, and for fourteen days must not move from the supine posi-tion. An icebag is kept on the stomach almost continually for a week or ten days. The first day's diet is 7-10 oz. of milk and one eg;, beaten up with sugar. This is given in teaspoonfuls and at no definite intervals. If there has been hemorrhage, everything may be iced; 3Y, oz. of milk and one egg are added daily till about two pints of milk and six eggs are reached. About the end Of the first week raw mince (I oz.) is added. Thereafter boiled rice. The eggs are gradually withdrawn until at the end of the fourth week the diet is a simple mixed one. Bismuth subnitrate is given for the first ten days and thereafte r sulphate of iron. An enema is used every fourth day. There can be no question that this diet suits most cases with some modifica-tion, and in some others is brilliant even in its strictest application. The drawback in practice seems to he a distaste for raw eggs which many people possess. The ice-bag is not essential. but it has a useful vogue in keeping restless patients in one position, and few raise any objection to its presence.

A diet from which good results may occasionally be forthcoming is that known as the Salisbury diet.

116n AUSTRALIAN MEDICAL JOURNAL. August 9, 1913.

The original prescription was a daily administra-tion of four pints of hot water and three pounds of flesh, preferably minced beef. Salisbury's theory was that carbohydrate and fatty foods underwent decomposition with fermentation. fie apparently also had an idea that the less the bulk of food in the intestine the less the opportunity for alimentary toxemia, although that phrase was unknown to him. He therefore cut down the food bulk. Some modern surgeons attempt the same ideal by cutting off lengths of large intestine—alimentary toxemia is the present-day refuge for all distressed diagnos-ticians.

There can be no question of the importance of diet in health and disease up to a certain point; an& there should be no hesitation in admitting that beyond a certain point we have no conception as to what the importance may be. It is possible to recognise certain general principles, but individual idiosyncrasy and differences of metabolism in dis-ease must still be recognised as wa-rnings against dogmatism in diet. Sir A. Garrod opens his most recent writing with these words :—"When we regu-late the diet of our patients, and when we restrict the intake of this or that article of food, we take upon ourselves a greater responsibility than we are wont to realise. Upon the due apportionment of the several constituents of the food depend the growth and well-being of the organism, and when we cut off this or that constituent we are inter-fering with factors of which we are not always in a position to estimate the importance."

Importance of Linie as Food.

Oliver ("Prat.," July, 1913) says:

Lime is. after phosphorus, the next most important inorganic constituent of our bodies, and it is noteworthy that, as regards the absorption and elimination of phos-phorus and lime, these two substances in health bear a close relationship to each other. From the earliest stage of our existence, lime, through its cohesive property, as we have already observed, keeps the cells of the organism together. The coagulable powers of blood and milk, as is well known, are largely dependent upon the presence of lime, and the properties of proteins are seriously dam-aged when the latter are deprived of their lime content.

The need for lime during early life is as great as the need for phosphorus, for lime is necessary to every organ and structure of the body, and is especially required for the building up of bone and teeth. An adequate supply of metabolizable lime is no less needful during adult life, for the irritability and sensitivity of our phagocytes and nerve cells, and the contractile powers of our muscles, depend greatly upon the amount of available lime and the quan-titative relationship of this metal to the others, viz., potassium, sodium, and magnesium. All these metals play an important role in maintaining the rhythmic contrac-tions of the heart, and the functional activity of every muscular organ and structure in the body; consequently it is impossible for us to lay too much stress upon their value. In its direct action it has been suggested that the action of sodium is probably antagonistic to that of lime.

It must, of course, be admitted that our knowledge of the direct and active part which mineral substances play in vital and nutritive phenomena is still very meagre, but the important role which they play indirectly is very evi-dent. They help to maintain a normal composition and

osmotic pressure in the liquids and tissues of the indi-vidual, a function which is of the greatest service to the economy. They are largely responsible for, and regulate, the flow of water to and from the tissues. They increase

the solubility of waste nitrogenous products in the liquids of the body, and thus aid the emunctories in their work. Furthermore, by neutralizing acids, they tend to preserve the alkalinity of the blood, and some of the compounds formed thereby have a beneficial diuretic action.

In consequence of these many-sided actions and re-actions, it is very evident that the mineral content of our food-stuffs is a matter of some concern, and any mis-givings we may have regarding its sufficiency are due to the fact that there is in this century an ever-increasing tendency on the part of manufacturers and traders to tam-per with, and affect prejudicially, many of our staple food-stuffs.

Contradictions of Wassermann Tests. Wolbarst ("New York Medical Journal," Feb. 22,

1913) comments at some length and with much strength upon the variation of the reports of the Wassermann re-action dependent upon the uncertain human element. He admits the specificity of the test and its reliability when properly performed. Men who do the best serological work make errors not impossible or uncommon. Wolbarst states that in the course of a study on which is based his present article, competent, honest serologists have sent him contradictory results on the same sera. One man has reported a serum positive, while another, equally compe-tent, has sent a negative report on the same serum taken at the same moment in another test-tube.

,Wolbarst submits the findings in 37 cases. The blood was obtained in the usual way by venous puncture and permitted to flow in two or three perfectly clean new test-tubes, about 5 c.c. being collected in each tube and sent to the same laboratory. Different names were at-tached. The reports agreed in 26 cases (70 per cent). Disagreement in the findings occurred in 11 cases (30 per cent). Of the latter, in six cases the variation was not very great, there being two cases varying from doubtful to positive, and four cases varying from doubtful to nega-tive. In five cases, however, there was a distinct contra-diction, one laboratory reporting positive and the other negative on the same serum. It is thus seen that in five cases out of a total of thirty-seven (14 per cent.), the serologists flatly contradicted each other as to the result. It will also be observed that certain serologists uni-formly obtained positive results, while negative results seemed to predominate simultaneously at the hands of the other workers. The inference is clear that whenever se-rum is to be examined, the results of the test are subject to variation at the hands of different serologists, and that certain steps must be taken to overcome these chances of variation.

It therefore seems plain that the physician must submit the serum for examination only to such men as will do the work honestly and skilfully according to the most ap-proved methods. Also, the work of any expert should be checked and controlled by one or more equally good ex-perts to whom should be submitted the serum drawn sim-ultaneously from the patient. If the results agree, we are bound by all the rules of common sense to accept such opinion as the sum total of our knowledge on this par-ticular subject. If the results disagree, another . quantity of serum should be subjected either to the same or to other serologists.

Wolbarst completes his article as follows:— The Wassermann reaction is dependent for its result

on the skill and knowledge of the serologist. The results of the test depend in great measure on the

absolutely perfect standardisation of the reagents used; these are subject to variation in the hands of different serologists.

As a result of these differences, diversity in results is not infrequent, but insufficient attention has hitherto been given to this particular feature of the reaction.

It is a gross error to accept the findings of one sero-logist as conclusive, particularly if his result is positive and the diagnosis dependent on his report; his work should be checked up by one or more equally competent workers.

If two or more competent serologists report on a given serum, the majority opinion may be cepted as fairly con-clusive; frequent re-examinations are always of advantage to the patient.

August 9, 1913 :.. AUSTRALIAN MEDICAL JOURNAL. 1161

PSYCHOANALYSIS.

The attention of physicians was first drawn to this subject by the publication in 1895 of Breuer and Freud's "Studies in hysteria." In these and subsequent papers the writers explained a method of investigation which led them to advocate a psychological theory of hysteria in opposition to the physiological conception of the disease enter-tained by most contemporary workers. They con-tended that an exhaustive examination of the pa-tient's psyche or mind or mental content was alone necessary for explaining the aetiology of the dis-order and effecting its cure. Such investigation was said to lead the observer ultimately to certain disturbing factors in the patient's mental life. It was found that these need not necessarily be pre-sent to the consciousness, but that even from a posi-tion in the subconscious or. the unconscious they might exert a pathogenic influence.

Further investigations, especially by Jung of Zurich, lead to a more systematic and convenient routine application of Freud's elementary method. The earlier observer had used the principle of free association, taking the salient symptoms as a starting point. Thus random trains of thought uvere started and followed patiently in the hope of finding some causal psychic condition. Jung intro-duced the association test, sets of stimulus words being used, and the association words rising - in the mind of the expectant patient noted as Well as the reaction time. From the characters of the rela-tions between the respective words and the length of the reaction time Jung- found it possible to draw inferences as to the presence of disturbing factors in the psyche and to set forth his doctrine of complexes. By this name he designates] certain systems of ideas, usually clothed with strong emo-tional tone, often distinctly distasteful to the pa- tient, and possessed of a certain autonomy, or inde-pendence of the stream Of ordinary consciousness. These he considered the causal factors in neuroses.

\lany thousands of such examinations have now been recorded by Freud, Jung, and others of the psycho-analytic school. Freud has elaborated a psychology in which the unconscious and sub-conscious minds are submitted, like the conscious, to minute dissection. Auxiliary to this is his theory of dreams, perhaps the most ingenious of his speculations. From a dream apparently absurd and meaningless is built up, after much subtle reason-ing, a "latent content," always rational and often of pathogenic force.

Pervading all the work of this school is a strik-ing sexual theory. The efficient causes of neuroses, the morbid complexes, ari said to be almost al-ways of a sexual nature and to be the result, in most cases, of an infantile sexual trauma, some shock sustained in early life -in re gird to the introduction of the individual to sexual matters.

21u5trarían AlebíeaY Journal 91/i AUGUST, 1913.

For some time past it has been popular "British Journal to refer to British surgery with a patron-

of Surgery" ising air of modernity as being somewhat out of date. And yet it is almost entirely

due to the work of Treves in the lower, and Moynihan and Mayo Robson in the upper, abdomen, that the surgery of these regions has become intelligible. We rejoice to find at last established "The British Journal of Surgery," a new quarterly periodical devoted wholly to surgical in- terests. The new venture has a very strong editorial coni-

Popular interest in the small-pox epi- Small -Pox demie appears decidedly on the wane, but Epidemic it cannot be said that the outlook is in

any way more cheerful, except for the fact that a considerable number of people have submitted to vaccination. Fortunately the extremely mild character of the disease has been maintained in Sydney and in all cases reported freni -other centres.

The recent experience of vaccination has been marked by some unusual features about which more will doubtless be heard at a later date. In a large number of instances the incubation period has been strangely delayed, and the general course of the local reaction not by any means classical, though more than sufficiently severe. Another happening in a number of patients has been a curiously persistent pain, both referred to the epigastrium and the back and associated with troublesome vomiting.

The -Department of Public Health has been busy issuing and withdrawing circulars to public vaccinators, but it is probable all will end amicably. There is no excuse for the parsimonious attitude suddenly assumed as to the half-crown fee. The department had ample time to have formulated its policy before the scare arose, but -did not subsequently appear able to decide on any policy at all. It has been announced that under the Act there can be no question of reducing the fees, so that the incident may be regarded as at an end.

It is probably scepticism in this aspect of the subject that has deterred British workers from giv-ing until recently much attention to the study of psycho- analysis. No doubt in the interpretation of dreams the assumptions in favour of sexual sym-bolism arc often staggering; and in the published accounts of psycho-analytical examinations there seems to be a great deal of subjective intrusion, probably unconscious, on the part Of the examiner. It would appear, indeed, that often the result re-flects the mental content of the examiner rather than of the patient. and critics have not refrained from this explanation of the consistency of the find-ings. As a method -of examination the procedure is in need of amendment to reduce the intrusion of the observer to a minimum: it may then be of enormous value in the investigation of mind. As a therapeutic measure it has not hitherto established itself very substantially. Hysteria is a disease in which . we cannot at once exhaustively examine and successfully treat the symptoms.

In Switzerland, Austria and the United States psychoanalysis has many advocates : it is not fav-ourably accepted in Germany, in Great Britain, as already stated, it has not vet received much notice. Recent indications, however, show that it will soon occupy an important position in the discussions of British psychological medicine.

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gotez anb Connnentq.

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J!

1162 AUSTRALIAN 'MEDICAL JOURNAL.

August 9, 1913.

mittee under the chairmanship of Sir Berkeley Moynihan

and with Mfr. Hey Groves as secretary. Every name is

of almost world-wide reputation. The publishers are John

Wright and Sons. The first number has an excellent ante type portrait of Lister as a frontispiece, and is illustrated otherwise both in colour and in type: The contents are varied, and include articles on ``Symptomless Renal Haem(aturia" by Newman of Glasgow; and "Gall-Stones" by Darly Power. Other contributors are Sampson Hand-ley, Albert Carless, Robert Jones and Hendle Short. An intenesti.ng feature is short sketches of visits to surgical clinics, and there is a heading "InstructiveMistakes," under which cases of interest are shortly recorded. The number is prefaced by a brief introduction from Sir R. J. Godlee, President of the Royal College of .Surgeons, and it is evident the British surgeons intend to make the

publication a representative periodical. We wish the new journal every success, and commend it to the notice of members of the profession in Australia very cordially.

ßrítí^^ Aieòícat Zigooctatíon. VICTORIAN BRANCH.

Eye and Ear Section.

The ordinary monthly meeting was held at the Victorian

Eye and Ear Hospital on Tuesday, July 22nd, the Presi-dent (Mr. Edward Gault) in the chair. The following cases were shown:—

Mr. Edward Ryan--(1) Reformation of the lower lid;

(2) extraction of cataract in capsule; (3) periostitis of

doubtful origin; (4) spring catarrh of doubtful character.

Mr. A. G. Miller—r(1) Fibroid streaks in retina; (2) membrane on posterior surface of cornea. Mr. Miller was

indebted to Dr. Webster for being allowed to show the

two cases from his clinic. Mr. Ryan, in describing his cases, said that the lid was

drawn right down on the cheek. The mucous membrane was intact. After the operation the wound healed by

first intention. This was the second case he had done.

The case he showed before lost her lid in much the same way. She had an operation in Geelong, which was not successful. Dr. Ryan grafted on several occasions

Thiersch grafts unsuccessfully. Eventually he did the same operation as in the present case, and it turned out

splendidly. The lid was just as good as ever. The opera-tion consisted in bringing down a flap from the forehead,

and making therefrom a new lower lid, and seemed to be

lasting and was a good strong support to the lower lid.

From what he had seen of the other case, the scar gradu-ally faded, and the skin became the same colour, and

there seemed to be no tendency to ectropion in the former

case, and he thought the present case would prove to be

the same. The third case was that of a little child seven years

of age. He was said to have gone to bed perfectly well,

and awoke in the morning feeling pain, and could not open the eyes. The lids were shut on the right side and swollen and very tender, especially towards the inner

side. There was also some tenderness below. The day he saw the child he thought there was pus under the

orbit, and operated, with no result. The child then got

rapidly worse, the lids became much more swollen, the

eyes started to proptose, and became tender at the site of

the former incision. The child was put under an anaes-thetic, the orbit opened, and an ounce of pus escaped. The

child seemed to be very much better, but the eye still

remained proptosed. It looked slightly outwards, the

only limitation of movement being upwards and in-wards. Fundus was perfectly normal. A Wasser-mann and Von Pirquet were done, with negative

results. The child was the third or fourth of seven chil-dren. Mr. Ryan then opened on the site of the old in-cision, went straight down and lifted the periosteum off the orbit. When he got just beneath the orbit, the eleva-tor went into a very large cavity. The lower part was

evidently periosteum that had fallen away. There was no

pus: A drainage tube was put in, the wound stitched up, and the thing healed up, the eye graduall'•y.sttrted to re-cede. movements, got more free,_.. and now,.: . there was no limitation of movement in any direction, and'the eye was

slowly going back to its former normal condition. He also remembered another case, a lady of 60 years, with a grown-up family. She had been very healthy. She went to bed perfectly well, and in the morning woke with both lids very much swollen, and could not open the eye, nor move it upwards, but could move it in other directions. The . skin was quite oedematous; no proptosis; had a dis-. tinct feeling of resistance and intense pain on pressure on the upper and internal part of the eye. A von Pirquet was negative. There was no temperature, pulse unaffect-ed: She was put on Mercury and Pot. Iod.; there was never any pus. The eye-lids were now perfectly well, fundus quite normal, the exematous condition had disap-peared. Still on anti-specific treatment. Whether a guni-mlatous condition of the orbit or not, he did not know. The theory he made was that she was stung by an insect of some kind. There was a history of having been struck with a small bit of wood four or five days before the trouble came on. He had another case of a young man, who was proptosed, but no other symptoms. Regarding the fourth case, he thought members would agree that it was a case of spring catarrh of a modified kind.

Dr. Shuter said he had seen a few cases of m.ucocele, but had not a very complete knowledge. He imagined it to be an intra-nasal trouble. They caused absorption by pressure. He had seen a number of cases in which the frontal and orbital plate of the frontal bone had not united. He remembered one case shown at the Royal Society in London, where it was decided that nothing was of any avail except interference in the nature of a frontal sinus operation, And clearing the whole thing out.

Dr. Sawrey thought the condition might turn out to be an intra-nasal condition.

Mr. Mitchell said that with regard to the conjunctivitis case, he would be inclined to try solid carbon dioxide. Three cases he had treated had responded in a remarkable way to that. The lids cleared up completely. Two appli-cations might perhaps be given, each lasting about twenty seconds. There was no danger.

With regard to Mr. .Miller's first case, Dr. Sawrey said he could not come to any other conclusion than that it must be a peculiar case of rupture of the choroid. One could see the retinal vessels going over every one of the

retinal streaks quite intact. Mr. Miller said that the patient was hit by a hockey

stick. It was not followed by sudden blindness, but by gradual loss of sight. The eye was stated to be weak for some time afterwards. It was long afterwards that he discovered that he was practically going blind. The pa-tient had perception of light in the injured eye.

Mr. Ryan thought it was a condition of choroidal rup-ture.

Mr. Miller said that if the appearances were followed outwards they lost the characteristics of a choroidal rup-ture. There was an irregular white patch to be seen in the retina. He thought probably these streaks were of a fibroid nature, and not choroidal rupture.

The President thought it was more like the condition described as angeoid streaks of the retina, supposed to occur in healed detachments of the retina. The patient saw almost nothing with that eye. It was difficult to ac-count for the loss of visual field by a blow, unless it re-sulted from a detachment of the retina.

Mr. Miller said it was just possible that it might be choroidal rupture near the disc, but some of the other patches were not like choroidal rupture at all. One was a furry-looking, irregular patch.

The .President said it would be interesting if Mr. Miller would show the case at another meeting of the Society, when a larger number of members would be present, and the case could be discussed more fully.

Regarding the second case, Mr. Miller said that the parents ascribed the condition•to injury at birth. He had looked through several journals, and could not find any notes of such a condition. If congenital. he thought it was probably of the nature of a pupillary membrane, formed from the mesoblast. There was always a haze of the cornea that might suggest some defect in Descemet's membrane. That condition was often found in anterior 'synechae.

The President suggested that the case might be shown at another meeting.

August 9, 1913. AUSTRALIAN MEDICAL JOURNAL. 1163

THE HEALTH OF MELBOURNE.

Abstract of Report of the Officer of Health.

The estimated population in the various wards of the city, in the middle of the year, according to the Govern-ment Statist, was 103,330. Adding to this proportion, ac-cording to population, of the inmates of public institutions,

a total of 104,120 is reached. Taking this as the basis of

calculation, it appears that the mortality for the year was

in the proportion of 14.2 per 1,000. As to the past, it may suffice to state that, in the five quinquennial periods, be-ginning with- 1886 and ending with 1910, the lowering of the mortality Tate had been from 19.54 to 16.29, 14.23,

13.96, and .12.8 per 1,000. With continuous improvements in sanitation, there is reason to expect a further lowering

of the death rate in the city, though it cannot be ex-pected that the improvements will be so rapid, now that

the sewerage system has been practically completed with-in the city area.

The mortality from epidemic diseases as a whole was smoewhat higher than recent low averages. The deaths

reported were:—From typhoid, 6; from diphtheria, 32;

from whooping cough, 16; from influenza, 9; from measles,

11; a total of 74, as compared with 41 in 1911. The cases notified under the Act were as follow:—

Typhoid, 52; diphtheria, 414; scarlet fever, 21; the other diseases not being notifiable. In a considerable number of cases it was found, on enquiry, that infection had not been acquired in our district. It is specially interesting to trace the course of typhoid outbreaks in successive

periods, as giving one of the best indications of the sani-tary conditions of the district. The remarkable decline in

the mortality rate of late years is very clearly brought

out in the following table, which shows the average death-rate per 100,000 of population, in successive quinquennial periods from 18S6 to 1910, and in 1911-12.

Death-rate per 100,000 in Successive Periods. 1886-90 1891-95 1896_1900 1901-05 1906-10 1911 1912

Typhoid .. 70 30 28 9 6.2 8.7 5.7

Though the disease is now steadily at a low level of prevalence, further improvement may still be expected, arising from (1) the further extension, till completion, of the sewerage system; (2) the continued guarding of water supply, and the greater use of proper filtration methods; (3) constant supervision of the milk supply; (4) more supervision of patients during and even after convales-cence, especially in the detection and treatment of so-called "carriers."

The importance of tuberculosis, as a cause of sickness and mortality, is greater than that of any or all of the epidemic diseases, since year by year it causes a greater number of deaths than all of them taken together. This is still true, though there has been a great lowering of mor-tality in recent years. The following table, which gives the average mortality per 100,000 of the population, in successive quinquennial periods, and in 1911-12, brings out the improvement very clearly:—

Death-rate from Tuberculosis per 100,000 in Successive Periods.

1891-95 1896-1900 1901-05 1906-10 1911 1912

266 215 195 125 131 107

During the year there was again an increase in the number of cases of tuberculosis notified, objection to notification having largely ceased. All cases are now kept more or less strictly under observation, special attention being given to those in an advanced stage of the disease, as being in the dangerously infective condition. In the case of poorer patients, spitoons are provided f ree of charge where it seems advisable, and directions for their proper use, as well as a circular giving rules for general guidance, are supplied. In case of death or removal, prompt steps are taken for the cleansing and disinfection of at least the room or rooms chiefly occupied. Whenever it is necessary, from the state of repair, steps are taken to have defects remedied. Disinfection, in almost all cases, is by spraying with a strong solution of Formalin or Cyllin, and it is done by the corporation officers free of

charge. During the year 469 rooms were disinfected, and in many the ceiling and walls were thoroughly cleansed and renovated. As cases are now more regularly and promptly notified, in accordance with the Act, and pre-cautions are taken in proportion, we may fairly expect to see the prevalence of tuberculosis, in all its forms, further steadily reduced. But until much fuller provision is made for the isolation and care of advanced cases, the best results cannot be attained.

The number of births registered during the year, ex-clusive of those in the Women's Hospital, was 2,341, as compared with 2.033 in 1911, accounted for chiefly by increase of population. [The infant mortality figure is 106 per 1,000 births.]

The deaths from the chief causes, other than the epi-demic diseases, which really produce a small proportion of the whole, were:--Tuberculosis, 112; diarrhoeal dis-eases, 123; pulmonary diseases (other than consumption),

196; circulatory diseases, 246; nervous diseases, 129; genito-urinary diseases, 159; cancer, 94. The deaths from tuberculosis (11'2) include 88 from phthisis, and 24 from other tuberculous diseases.

When retiring from the service of the corporation, after a period of work extending over more than 27 years, I may be allowed to make a few remarks by way of com-parison with the past, and suggestion for the future. That much successful work has been accomplished can best be shown by a few figu res. Since I entered on office the general mortality rate has fallen from an average of nearly 20 per 1,000 of population, to about 13 or 14. The infant mortality rate has fallen from 186 per 1,000 births to an average of little more than 100. The tuberculosis rate has been reduced from 266 per 100,000 of population to about an average of 100, and the typhoid rate from 70 to

the very low average of about 6. It has thus come about that while typhoid, only a quarter of a , century ago, was a veritable scourge, it is now ' in the way of becoming an

almost extinct disease. JAMES JA•MIES'ON, M.D.

QUEEN'S MEMORIAL ,INFECTIOUS DISEASES HOSPITAL.

Statement Showing Number of Patients Treated at and

Discharged from the Hospital During the Year 1912. Number of patients in Hospital on 1st January, 1912:—

'Diphtheria .. 91 Scarlet Fever .. .. , , , . , , 5 Doubles (diphtheria & scarlet fever) 4

— 100 Number of patients admitted during the year: —

Diphtheria .. .. .

Scarlet fever .. .. 1,791

71 Doubles (dipht'herila & scarlet.fever)

20

Other diseases .. .. .. .. .. .. 100 -^ 1,982

Total treated during the year .. 2,082 Number of patients discharged during the year:—

Diphtheria .. .. .. 1,721 Scarlet fever . . . 52 'Doubles (diphtheria & scarlet fever) 19 Other diseases .. .. .. .. .. .. 98

— 1,890 Number of deaths during the year:—

Diphtheria .. . . .. .. .. .. .. 95 Scarlet fever 0 Doubles (diphtheria & scarlet fever) 1 Other diseases .. .. .. .. .. .. .. 2

98 — 1,988

Leaving a total of .. .. .. .. .. 94 patients in hospital on 31st December, 1912.

hú

l l o1 AUSTRALIAN MEDICAL JOURNAL. .Au gu s t 9, 1913.

CORRESPONDENCE.

Public Vaccinators' Fees. (To the Editor of "The Australian Medical Journal.")

Sir,—On July 7th public vaccinators were "informed that a fee of 2s. 6d. will be paid by the Health Depart-ment for every case of inoculation with vaccine lymph performed by them."

Three weeks later, after these public servants have duly performed the duties required of them under the above compact, they are calmly told by the department that "the circulars issued on 7th and 18th July, 1913, are hereby cancelled."

This, Sir, is a breach of faith, and is doubtless an indication of the treatment we may expect when a National Insurance Scheme is being arranged.

If, however, this hint of things to come serves to rally our forces for the fray the episode will not be without its lesson—Yours, etc.,

PUBLIC VACCINATOR IN THE COUNTRY.

CURRENT LITERATURE.

Fatal Air Embolism, in Abortion.

J. W. Crawshaw, M.B. ("New Zealand Med. .Tourn., Nov.).—The method adopted in the following case ap-pears to be common in New Zealand. Two cases have previously been before the courts.

A woman had had four living children and five or six miscarriages, the last in August, 1911. Except for anaemia from severe haemorrhage at these times, her health was good. On May 17, 1912, the writer was ur-gently called, and on arrival found her dead. In the house was a woman who was very agitated but uncommunica-tive. She said that while her back was turned she sud-denly heard a cry and the sound of a fall, and found the deceased on the floor. She made no movement or effort to breathe.

When the writer arrived the body had been placed on the bed. It was quite warm. There were no external signs of injury. No froth was present on the mouth or nose. The pupils were of medium size and equal. The clothing was unfastened at the front of the chest and was wet. This was due to an attempt made to make her drink some water. The rest of the clothing was not disarranged. The writer particularly noticed that the chemise was tuck-ed into the drawers very tightly and there was no haemor-rhage or other discharge from the vagina. The under-clothing bore no stains and was quite dry.

Necropsy.—The uterus was enlarged to the size of about a four months' pregnancy. It was decided to make a de-tailed examinatio;i of the abdomen first. The liver was first removed. The gastro-hepatic omentum was per-forated and two ligatures were placed round the portal vein, bile duct. and hepatic artery and these structures divided between them. The lower ligature slipped, and the writer was surprised to notice that numerous large bubbles of gas escaped from the portal vein. On detach-ing the liver from the vena cava inferior, much gas es-caped. The liver was slightly enlarged, but on section was normal. The spleen was slightly enlarged but other-wise normal. The uterus vagina, tubes and ovaries were removed en masse. On dividing the ovarian and uterine vessels air escaped from the veins, on both sides, in a continuous succession of bubbles. Pressure on the uterus forced out a considerable quantity of air from their cut ends. The surface of the uterus had a mottled appear-ance, purple alternating with lighter greyish areas. The muscle tissue felt quite soft and flabby, no hardening from rigor-mortis being apparent. On rolling the uterine wall -between the fingers and thumb, a crackling sensation was noticed. On section this was seen to be due to air in the venous sinuses, air issuing from all parts of the cut sur-face on pressure. The external os was patulous, admit-ting the index finger easily. The uterus contained an unruptured ovum, which was separated along the whole of the posterior and lateral surfaces and for a consider-

able part of the anterior surface. The only portion re-maining attached was the upper two-thirds of the placenta with possibly a small area of membrane at the fundus. Although this considerable area of placenta had been de-tached, no haemorrhage had occurred into the cavity of the uterus and no clot was found in the cervix or vagina. These showed no evidence of mechanical injury. The ovum contained a male foetus of about four months' development. The 'heart and lungs were removed together from the chest. On dividing the superior vena cava a large quantity of air escaped, pressure on the heart forcing it out. The right auricle and ventricle were empty ex-cept for a small quantity of frothy blood. Their contents had escaped when the venae cavae were divided. On fol-lowing up the pulmonary artery more bubbles' were found. The artery was opened up into the roots of the lungs and frothy blood was expressed in considerable quantity from it by pressure on the lungs towards the heart. The tri-cuspid and pulmonary semi-lunar valves were healthy. The left side of the heart contained no clot, or air-bubbles, nor were any pressed out of the lungs into the left auricle.

Evidently death had been caused by the injection of air into the uterine cavity, separating the ovum from the uterine walls and entering the uterine sinuses through the open vessels of the placental site. Hence it had travelled by the ovarian and uterine veins into the inferior vena cava and so on into the heart and pulmonary arteries. The presence of air in the portal vein was due to its pas-sage into the superior haemorrhoidal vein by way of the uterine vaginal and external haemorrhoidal venus plexu-ses. The air was probably injected by means of an ordi-nary rubber enema syringe, the nozzle of which was intro-duced into the cervix. Probably a considerable pressure was attained in the uterus, for air was found in the portal vein, the route to which, viz., through the uterine, vaginal and external haemorrhoidal plexuses to the superior haemorrhoidal and inferior mesenteric veins is very in-direct. Probably also the distension of the uterus would set up a uterine contraction, and this would rapidly force the air into the vessels of the placental site. The fact that no blood or clot was found in the uterine cavity also indicated a considerable pressure of ail, for without this pressure separation of the placenta could not have oc-curred without haemorrhage.

Vaccination.

In his book, "Studies in Small-pox and Vaccination," Dr. W. Hanna concludes:—

(a) That the case -mortality in the natural disease, i.e., in the unvaccinated, which ranges fromapproximately 25 to 40 per cent., has been reduced by the power of vaccina-tion to about 3 per cent. in those who have been well vaccinated.

(b) That in the unvaccinated, persons at the extremes of life, mainly children under 10 years of age and old People, are those who suffer most, the case

-mortality reach-ing as high as 50 per cent. In the previously vaccinated, no cases are recorded occurring under 3 years of age; under 20 years of age no deaths are recorded, but as age advances the vaccination gradually loses its protective and modify-ing power.

(c) That even when, owing to age, and consequent gradual loss of vaccinal immunity, vaccination is unable to stop the development of the disease, it may modify the extent and character of the eruption to such a degree as to make it so exceedingly mild that in many instances the disease may be undetected.

(d) That the scar-area of vaccination has an important bearing in the severity of the disease; the larger the area the milder the character of the disease.

(e) That the vaccination scar area gets larger as age advances until the 20-30 years age period is reached; it then gradually becomes smaller, in all probability owing to atrophy and the scar tissues.

• (f) That vaccination performed subsequently to infec-tion with .small-pox and up to the date of onset of symp-toms will "take" and pass through its typical course.

(g) That protection is afforded against small-pox by vaccination, when performed within three days after in-

August 9, 1913. AUSTRALIAN MEDICAL JOURNAL. 1165

fection; but this may not be absolute in cases vaccinated for the first tine; the course of the disease, however, will be exceedingly mild.

(h) That there is abundant evidence of the value of vaccination in mitigating the severity of the disease when performed at anytime after infection up to date of onset, and even afterwards.

:Arsenic Poisoning.

candwith (Med. Press and Circ., June 18th) recalls a famous trial thus:—

Symptoms of poisoning before death and leading up to death, and satisfactory evidence pointing to foul play must exist before a suspected person is convicted.

"The one thing," whote Professor William Carter, one of the witnesses for the Crown in the famous Maybrick trial, "and the only thing that is certain, is that arsenic forms no part of the normal human tissues, and that when present in them it must have been introduced from without; but whether introduced felionously or otherwisemust be de-termined in every ease by a consideration of all the facts in connection with it, and not by the opinions of experts on such dubious points as to the length of time possible since the last administration, etc."

The story of this case, which is of great medico-legal im-portance, may he familiar to some of you. Mr. James May-brick, a Liverpool cotton merchant, zet 50, died after two short illnesses, in May, 1889, and the two physicians at-tending him, suspecting arsenical poisoning to have been the cause of the two illnesses and of death, refused to sign the death certificate. His young wife was suspected of having administered the poidon; she was 'charged with murder, and, after a prolonged trial, in which there was much conflicting evidence, ishe was convicted and sentenced to death. The defence made good use of the fact that the doctors did not suspectpoisoning on the occasion of their first consultation on May 7th; when they found the patient suffering from exhaustion after violent and continuous vomiting, which had lasted an entire day, from great thirst, a sensation ,of a hair in his throat and a bad taste in his mouth. He gave an account of an earlier attack on April 27th with somewhat similar symptoms, which he con-sidered to be a severe bout of indigestion. On that oc-casion, after a few days' illness, he had returned to his office, but his doctor took the precaution of advising him to have his midday meal sent in from his own house. That meal had caused the second attack, due, he considered, to the fact that it had been prepared with an inferior sherry. The doctors, after mature consideration and admitting that the conclusion was not altogether satisfactory, decided at first that the patient was suffering from the effects of an indiscretion of diet and that the illness, though dangerous, would probably end in recovery.

On May 9th a second consultation of the two doctors took place, but 'before the consultant, Professor Carter, had seen the patient, Mr. Michael Maybrick, a brother, confided to them some suspicions which the family entertained against the wife. It appeared that Mr. Maybrick, though a healthy man, had lately been subject to attacks of sickness after returning home from visits, that the contrast of his state of health at and away from home was marked, that the wife was unfaithful and was on bad terms with the hus-band, and that just before his last illness she was known to have bought many fly -papers. The doctors had knowledge of these circumstances only from hearsay, they were not justified in coming • to hasty conclusions, but they sur-rounded the patient with safeguards to prevent anyone tampering with his food.

The patient on that day was in much the same condition, but on May 10th he was much .worse with gradual failure âf the circulation, shown by his right hand being white to the knuckles. An opened bottle of meat juice, intended for the patient, was on that day handed to Dr. Carter, who ex-amined it that evening and found it to contain some met-allic irritant, which was afterwards found to he arsenic. This proved the fact that someone was tampering with the patient's food. Ultimately a few drops left in a bottle of medicine and a thin scale of the food dried on to a washed -

om jug , were found on analysis to contain arsenic. All these articles had been handled by the wife. She was also known to have prepared an arsenical solution from fly-papers.

After delirium, lasting about 24 hours, Mr. Maybrick died on May 11th. An incriminating letter written by Mrs. Maybrick to a man was intercepted, and proved without .doubt, not only that she had the strongest motives for wishing to rid herself of her husband, but also that, long before his symptoms appeared very serious to the doctors, she spoke of hint as "sick unto death," and assured her correspondent that there was no fear of discovery.

It was, however, held by the defence, and by a large num-ber of the sympathetic public, that the evidence of arsenical poisoning during life and after death was insufficient to convict, because only small traces of arsenic were found in the organs after death, and great 'pressure was put upon the Home 'Secretary to commute the sentence. The gallows had actually been erected, within hearing of Mrs. Maybrick in Walton .fail, when his decision was .announced and the punishment was commuted to penal servitude for life. "Inasmuch as, although the evidence leads clearly to the conclusion that the prisoner administered and attempted to administer arsenic to her husband with intent to minder, yet it does not wholly e._clude a reasonable doubt whether his death was in fact caused by the administration of • arsenic."

She was liberated after 15 years' imprisonment, and left. England.

This case, like many others of the greatest importance, depended finally upon the verdict of the jury, a body of men without any technical training in law or medicine, who were told by the Judge that, as the medical evidence was conflicting, they must rely upon the medical know-ledge they had "picked up in the course of their general experience." It was for them, therefore, to decide whether the illness of the deceased was a case of gastro-enteritis caused by improper food or one of arsenical poisoning. It is interesting to note that the jury on this occasion con-sisted of "three plumbers, one painter, two farmers, a woodturner, a provision dealer, a grocer, a baker, an Iron-monger and a milliner."

.Arteriosclerosis,

Von Noorden ("Post-Graduate," May) says:- 1. The chief point to bear in mind is that a person with

arteriosclerosis has a smaller working capacity than one with good elastic arteries. One must, therefore, insist that the body as a whole and the individual organs shall not be subjectell to the sane strain as before. If one finds that the sclerotic process involves certain organs more than others, one must particularly insist on rest for them, e.g, the heart, the brain or the kidneys.

2. The question of diet is a practical one, but hard and fast rules do more harm than good. The doctrine that meat favors the development or arteriosclerosis and that the patient can be benefitted by forbidding meat, is with-out foundation. Above all, diet should be so regulated as to avoid all digestive disturbances. Heavy meals are to be :forbidden; excessive gas formation must be avoided; regularity of the bowels is absolutely essential. Any di-gestive disturbance, whether gastric or intestinal, is likely to force the diaphragm upward, cause irritation of the

heart and increase the blood-pressure, and this must be avoided. The pecularities of each individual case must ho carefully studied in order to arrive at a suitable regime. All beverages which irritate the heart and blood-vessels and thus bring about marked fluctuations in blood-pres-sure must be excluded. The patient should be warned not to take too much fluid. About one and one-half liters—including everything in the way of fluid that is ingested—is quite 'enough. The more fluids one allows, the greater the strain on the 'arteries. By a judicious restriction of fluids one often sees an excessive blood-pressure reduced by 20 to 40 millimeters and remaining permanently low.

3. Stimulation of the peripheral circulation is best ful-filled by means of systematic hydrotherapy, which may be employed in a variety of ways, always avoiding such pro-cedures as are followed by rapid changes in the blood-pressure. Carboni dioxide baths and electric baths belong to the same therapeutic category. The proper employ-ment of these methods has a distinct effect in dilating the peripheral arteries and ,thereby facilitating the circulation as a whole. At the same time there is a salutary effect on the nervous system

£32 1 1 0 1 1 1 1 0 0 0 0 1 1 0 10 6 0 10 6 1 0 0 0 10 6 0 5 0 0 5 0 0 5 0 0 5 0 0 5 0 0 5 0 0 5 0 0 10 6 1 1 0 1 1 0 0 10 6

10 6 10 6 10 6 10 6 0 0 1 0

10 6 1 0 1 0 1 0 1 0

0 6 0 0 0 0

ll n6 AUSTRALIAN MEDICAL JOURNAL. August 9, 1913.

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GENERAL.

Pensions for its members and associate members have been provided by the governing boards of the Rockefeller

Institute for Medical Research, and have been financially secured by the generosity of Mr. John D. Rockefeller, who has with this purpose in view increased the endowment of the institute by a gift of securities amounting to about 500,000 dollars. The pension rules which have been adopt-ed provide three-quarters-pay pensions for members of the institute retiring at the age of 65 after fifteen or more years of service, and pensions of from one-half to three-quarters of full pay, according to the length of ser-vice, for members and associate members who retire at 60 years of age. There is also a provision for total dis-ability after ten years of service, and for widows and orphaned children, at one-half the scale on which members of the staff are pensioned.

A Bill has been introduced in France into the Chamber of Deputies requiring every motor-car driver to append to his application for a licence a medical certificate certifying that he has a good constitution, normal eye-sight and hearing, and that he has no organic lesion of the heart, pleural cavity, or kidneys, which could render him liable to sudden syncope; also to establish, as far as possible, his freedom from any neuropathie affection, monomania, hysteria, or epileptic taint.

The Victorian Government intend introducing a bill to effect reforms in the management of the Fairfield Fever Hospital.

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

desires to acknowledge with thanks the following con-tributions:—

Amount previously acknowledged .. . . Dr. Percy Webster .. .. Dr. J. F. Ruda11 .. .. .. .. .. .. .. Dr. Robert Fowler .. .. .. .. . . Mr. Hugo Wertheim . . .. .. Drs. Walter and Vida Summons Dr. H. Osburn Cowen .. Dr. Felix Meyer .. .. .. Dr. Schalit .. .. .. .. .. .. Dr. St. Clair Steuart .. .. .. .. .. Dr. Fay Maclure .. .. . Dr. J. P. Major .. .. .. Dr. M. A. Reid .. .. .. .. .. .. .. Dr. W. F. Orr . . .. .. . Dr. R. L. Rosenfield .. .. Dr. A. Guy Miller .. .. .. .. .. .. Dr. Gibbs .. .. .. .. .. Dr. Box .. .. .. .. .. .. ..

Dr. R. E. Shuter Dr. Harnabrook .. .. .. Dr. Parrish .. .. .. .. Dr. Stanley .. Dr. Leonard Mitchell Dr. E. H. Sawrey .. Dr. McArthur, jun. .. .. .. Dr. A. W. Baler .. .. .. .. . . .. ..

Dr. Mackeddie .. .. .. .. .. Dr. Hugh L. Murray .. .. ..

PERSONAL.

Dr. F. V. Scholes has returned from England and re-sumed duty as medical superintendent at Fairfield Fever Hospital. Dr. Featonby has also returned to Victoria.

Mr. Alan Newton, who has been in London for some months, will return next week and take charge of Mr. Bird's private hospital.

3Brtttfitj llieòtcar afitioctatton. VICTORIAN BRANCH.

Dr. Stewa Uerrguson, 34 Collins-street, Melbourne, Hon. Secre

0G! f' \ r cs

o OTICES.

• arning Notices. ipalmen,.ö

▪

re applying for the position of medical Zgrte.e to_locigeë' at Longreach, Central Queensland, are in-vited Ibéf6re 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-tary, B.M.A., 429 Strand, London.

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.

VICTORIAN BRANCH.---brdlnary Meeting, 1st Wednesday in month.

„ Clinical Meeting 3rd Wednesday In month.

PEDIATRIC SOCIETY.—Second Wednesday in month. EYE & EAR SECTION.-4th Tuesday in Month. MELBOURNE HOSPITAL CLINICAL SOCIETY.-4th Fri-

day in the 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.

According to the Sydney "Morning Herald,” the Kurri Hospital committee suspended Drs. Macarthur and Hal-loran pending a general subscribers' meeting. These gen-tlemen, it is alleged, declined to meet a colleague in con-

sultation because he was not a member of the B.M.A. their patients in the hospital have refused to be treated by the two medical men remaining on the hospital staff.

Dr. J. F. Merrillees has been elected a member of Queensland Branch B.M.A. He is practising at Roma.

The delegates to the Federal Committee were entertain-ed at dinner on July 15th by the Council of the N.S.W. Branch. Dr. Sydney Jamieson was in the chair.

Dr. C. L. Strangman has resigned his post as medical officer at Port Darwin.

Dr. C. L. Boag has been appointed Government Medical Officer for Papua.

Dr. Isaac Jones left for England by the "Orama." Dr. A. C. Rothera was a passenger by the same vessel.

li

^I! i '

uftu-a 16 . 1 913. AUSTRALIAN MEDICAL JOURNAL. 1167

SOME OBSERVATIONS ON SECONDARY f sy

VACCINATION IN MELBOURNE.

",--; „\LTY,R S l M _l I O \ S, (Clinical Assistant, Assistant, Melbourne Hospital.)

For the second time in the history of Australia have there been a general alarm of small-pox and a consequent eagerness for prophylaxis. Opportunity therefore may be taken to place on record some of the results of secondary vaccination. Having been in charge of the government bureau in the • city from the commencement of the demand for vaccination, I have been afforded a better chance of collecting (lata than could be obtained in ordi-nary practice. At the first there was a great rush of patients who wanted vaccination merely as a personal safeguard, but as the alarm subsided the bulk of people presenting themselves belonged to the travelling section of the community. These latter were vaccinated as a personal precaution, and, the public health authorities requiring . ei tificate s, they had again to present them-selves after the vaccination had taken. It is from this latter section, composed of healthy adults for the most part, that the statistical results have been compiled. Practically all had been vaccinated in infancy, and few had been revaccinated.

From the date the record was started every case vvas noted, and, as the percentages came to be almost the same for each day, the results from 1,000 cases are as reliable as if ten times that number had been taken.

Per Cent.

Successful—Mild .. .. 46. 8

Moderate . 34.1

Severe .. . 2.7

Unsuccessful .. .. 164 16.4

Total .. .. .. 1,000 loo 'l'he successful cases are those in which a well-

marked local reaction showed itself, and of these many had constitutional symptoms. This class has therefore been subdivided according - to the severity of the reaction. In the mild group a heaped-up papule developed at the site of inoculation, and this frequently looked like a small red keloid. The patients had no constitutional symptoms and the papule rarely progressed on to the vesicular stage. In some the papule rose abruptly as high as one-eighth of an inch and it was extremely irritable. The moderate group gave, as a rule, feelings of malaise for a few days, and the papular stage passed on to the vesicular and pustular. Many had only a slight inflammatory condition around, but a number presented an arm Nvith a distinct area of brawniness. The third subsection, with an extreme reaction, fortunately was not large. These patients were all confined to bed and completely disabled from work for periods ranging from two days to a fortnight. One young man I was asked to visit had a temperature of 1o3 deg., and was extremely ill with acute pain in the feet and joints generally. 'l'he local signs in the arm were not inflamed and did not suggest a septic contamination. He rapidly

improved after a few drachm doses of l,iq. [lvdrag. i'crchlur.

Seeing that the possibility of septic infection mast not be forgotten, a brief description of the technique that was faithfully followed in every case will be necessary.

A nurse thoroughly cleansed the arm or leg with a volatile antiseptic lotion (methylated spirits 24 parts, ether 6, turps 4). 'Plie arm was rubbed dry with sterilised wool. I made two or three marks with a solid metal scarifier nine inches long divided into three blunt prongs at one end, whilst the other was rounded for clipping into the calf lymph. The instrument vVas sterilised before each application by passing through a spirit flame. The calf lymph was in bulk, and, as required, a small portion was poured out into a watch-glass. .after vaccination the patient was directed to dry the arm thoroughly before a fire or in a breeze. :As a matter of fact, drying before the fire was not satisfactory. for the heat caused serum to ooze out of the scarifications. NO dressing was used, but where necessary a piece of gutta-percha tissue was applied by touching the corners with chloroform.

Discussing the results, it is necessary to state that in every case sufficient lymph. was employed as would ordinarily bring about the desired result. The unsuccessful cases are those in which no reaction at all took place or merely several small papules appeared at intervals along the inoculation marks, and were not of such an extent as to give more than a negligible amount of immunity. Out of twenty-five of these cases re-inoculated there were still twenty-three negative results after the third inoculation.

In a number of the successful cases the reaction was delayed, so much so that many presented them-selves for revaccination. Some of these seemed so inactive that I reinoculated them, and ultimately the first vaccinations, after ten to fourteen days, went on to the vesicular and pustular stages with consti-tutional symptoms. In the cases that took severely there was frequently noted a general soft oedema of the entire arum. In many cases there was no brawniness around the pustules. and the oedema seemed to be clue to the cow-pox virus, and not to any additional septic infection. In a few of the cases there was definite secondary coccal infection, which, as was stated above, came on a week or so after, and undoubtedly was produced by scratching the arm, or in some similar manner.

Of the complications, out of about 15,000 vac-cinations 14 cases of vaccinia eruptions returned to the depot. The vaccination marks were not more severe in these cases than in the others. The rash was of an irritable, papular nature, passing on to the vesicular and pustular stage in about half the cases. The situation in all the cases was on the arms, particularly the inoculated arm, and there were usually a few scattered vesicles on the trunk and legs. In three cases the papules were not numerous, but there was an erythematous flush of the entire arm and the skin was extremely irritable. One man, who had 'not been vaccinated pre-viously, presented a sorry picture. His arms were almost one mass of vesicles and pustules that

468 34 1 27

836

(Paper Read Before the Melbourne Pediatric Society.)

R. L. F'ORSYTH, M.D.

This work has now been carried on for three years and over 300 cases examined clinically and bacteriologically. The bacteriological findings have been fairly constant, and five main types of bacilli are found—

(I) The Shiga-Flexner type, occurs in 25% of the total number, but in the last two years with more skilled work they were found in 33%.

(2) The Gaertner type, occurs in 24%. (3) The Slow Fermenter, pure or mixed with

other classes, occurs in 26%. (4) The Morgan, in 7%. This type was absent

altogether for one season. (5) Various liquifiers of gelatine. These five classes occurred in 8o% of the cases

examined. They might be the cause of, or the re-sult of, the diarrhoea, or they might have nothing to do with it.

It is hard to state in black and white my reasons for believing them to be the cause of the diarrhoea. They do not occur to any significant extent in normal children, nor in hospital children suffering from diseases other than gastro-enteritis. In secondary diarrhoeas they are seldom found, and then only in small numbers. Not only do they occur in 8o% of the gastro-enteric cases, but their presence has distinct prognostic significance. The

1168 AUSTRALIAN MEDICAL JOURNAL. August i6, 1913.

were extremely irritable. He was extremely ill from loss of sleep and malaise. The rash also was present on the ankles and dorsal surfaces of the feet. About a fortnight after the first eruption, a second crop of papules appeared on the forearms, but these were not nearly as severe at the first eruption. In another case the situation of the papules was around the neck and down on to the shoulders. One case, in addition to the papules, showed erythematous blotches all over the body, but again mostly on the arms. The risk of vaccinal eruptions in secondary vaccination seems to be, therefore, about i in r,000.

As to the severity of the reaction, a great deal might be written. The individual reaction had everything to do with the result, for with the same sample of lymph all sorts of vaccinations were ob-tained. The patient's robustness or otherwise seem-ed to have no influence. Sex also was not a deciding factor. Except in young children, whom I have excluded from the statistics, age was of no help in saying whether the reaction would be marked or not. On the whole, it seems that the lymph might still be more attenuated so that the reaction likely to result would be less severe. Vaccination would not then be held in such fear by the general public, and it is possible that public opinion would demand. rather than object to, revaccination at intervals throughout life whenever occasion called for it.

RESEARCH WORK IN SUMMER DIAR- RHOEA OF CHILDREN.

patient's blood agglutinates the organism found in practically every severe case. The main point here is that the bacteriological finding has prognostic value. If we find the typhoid bacillus in certain cases, and if this discovery enables us to prognose a regular course of signs and symptoms, then we have a definite clinical entity and there cannot be much doubt that the bacillus is the cause of the disease. We must, however, consider how hard it would be to diagnose typhoid without enlarged spleen, spots, or Widal reaction.

In the diagnosis of these types of summer diar-rhea I do not trust to agglutination reactions; but when a resident or sister tells nie that "there is a case of Shiga or Gaertner infection in such and such a cot," and when I often find they are right bac-teriologically, I believe that there is a chance of establishing a clinical entity.

In the Shiga-Flexner type the onset is very acute. with diarrhoea severely marked, and often blood-stained motions; the temperature is certainly raised for a week, and perhaps for fourteen days. In three or four weeks the extreme symptom's have vanished and the child is merely a "difficult feeding" case. The urgent symptoms subside or the baby dies. The mortality is 66%. 'l'his list of symptoms is very hazy, but a resident can often diagnose the infection from the baby's appearance and symp-toms, and, moreover, Dr. Stephens finds fairly constant pathological changes in these cases.

In this type the intestine is thickened, the large bowel and the last foot or so of the small bowel are affected. The lymphoid structures are picked out, and often the lymphoid patches are ulcerated, and the mucous membrane eroded and covered with a sticky debris. The spleen and glands are swollen.

The germ found here is practically identical with the ordinary dysentery bacillus, the symptoms and pathological changes are also very similar, and I think we may therefore label 25%, or perhaps 33%, of our cases of gastro-enteritis as "baby-dysentery."

In the Gaertner infections a very few are ex-tremely acute. and these die in a day or i v o with great toxemia and profuse watery stools. These are probably not pore Gaertner infections. 'l'he ma-jority of the Gaertner infections are chronic troubles. .Hy the time they are diagnosed and ad-mitted the baby is fairly exhausted and wasted. 'i'he duration of the trouble is seven or eight weeks; much longer than the Shiga infection.

Post-mortem almost the whole of the intestine is affected. The bowel . is almost transparent, the lymphoid structures are not particularly picked out, the spleen and glands are not enlarg_ ed.

I dare not try to group symptoms round the other three classes of germs found. I do not know the significance of the slow fermenter. In many cases the child is extremely ill and differs little, if at all, from the Gaertner type clinically, but the bacillus isolated ferments lactose in seven, ten or even fourteen days. I am forced to believe that they have a great deal of virulence, and they are probably capable of producing a gastro-enteritis, but their favourite role is, T think, that of "jackal," after the trouble has been started by other germs.

AN ACUTE PNEUMOCOCCAL THROAT INFECTION.

August i 6, 191 3. AUSTRALIAN MEDICAL JOURNAL. 1169

When we turn to the question of treatment my results are, I am sorry to say, mostly negative. Much work has been done on infant foods, but the only point I wish to emphasise is that liquid foods are generally sterile, but food powders are seldom sterile and must be boiled in preparation. I can-not attempt to explain why these cases will not tolerate milk, the toughness of the clot and the difference of reaction are not enough to explain it. The fact remains, that even when past the acute stage and getting along fairly well on a patent food it is extraordinarily difficult to get the child on to milk again, and we must simply reintroduce it tea-spoonful by teaspoonful. Milk is, of course, a foreign serum, and there may be some anaphylactic action.

Many local applications were tried. We found that this class of bacillus lived for months on an alkaline medium, but died rapidly if it became acid. An attempt was therefore made to attack the germ in situ by acid lavages. Strong lactic acid wash-outs were used, but the only result was a little irritation. Protargol and potassum permanganate were also used without ni,ucü effect. The only rational local treatment is, I think, by saline washes, and in the worst cases continuous saline by the bowel was tried, with good results.

Vaccines, autogenous or stock, were used freely. We started by using half-millions and ended by giving 500 millions. No bad effect was ever no-ticed, but the good effect was not obvious enough •to satisfy us. A vaccine presupposes a resistance, and in a baby admitted to the Children's Hospital the resistance is too often absent. Aufogenous vaccines take three days to prepare, and by this time the patient is often dead. Perhaps we handle these germs too roughly—fifteen minutes is often enough to sterilize the vaccines.

The kindness of the Veterinary College's staff allowed me to do some animal experimentation.

In testing the growth of these bacilli on fresh milk I found that its bactericidal properties were very marked for these types of germs. Seven cows were tested; practically all the milks inhibited the growth of all the germs, but some bacilli were killed outright. Sometimes it ryas the Shiga type which would not grow on a certain cow's milk and sometimes it was the Flexner type; each milk seemed to have its owhi peculiar action on each germ. This suggested that each cow had developed a bactericidal property against certain germs it had met in its life history, and as the bacilli met with differed in each case, so differing resistances were acquired. This again suggested that it might he possible to develop these resistances.

Three cows were taken some time before calving, and these were injected with enormous closes of the bacilli. Twenty-one strains were used, and living and dead cultures were injected in increasing quantities. No general reaction took place. After eight weeks of injections the milk was tested. It seemed to have no special bactericidal properties. In the laboratory it killed some of the bacilli and not others, just as any fresh milk would. The milk was used to feed the babies on without . obvious

result. 'l'he serum was next collected from the cows: it agglutinated every germ injected, added to broth it inhibited the growth of the Shiga-Flexner type markedly, Gaertner and slow fermenter were unaffected by it.

For the production of an antitoxin we depend on the violent over-production during a reaction. This reaction was absent, and it is very doubtful if the serum will have much effect. There are 300 ounces ready for trial next season.

The question of the source of infection is a very interesting one.

The examination of milk samples, flies. dairy cloths, and cow dung gave negative results.

C)n the other hand, these bacilli are frequently met with in adults.

In cases of paratyphoid, or food poisoning, they are often present, and, moreover, for months after the acute symptoms have passed a McConkey plate may show 90% of non-fermenters. These cases were definitely ill, but I have also found the bacilli in strong, apparently healthy adults who suffered merely from .a temporary malaise, with constipa-tion.

In typhoid after the tenth day a McConkey plate smeared shows no typhoid bacilli; it is extremely hard to isolate them by this method as the plate is overgrown by these other types of bacilli.

Moreover, in the out-patient department I have had five or six cases of mucous colitis in children, and every case examined has been swarming with these types. We find, therefore, that this class of germ, for which I blame much, if not most, of the summer diarrhoea, appears in adult autoinfections, paratyphoids, typhoids, and perhaps in many ir-regularities of the bowel. It is also common in children's diarrhoeas and chronic indigestions. May it not be present frequently in the out-patient mothers who suffer habitually from constipation and dietetic upsets?

While we blame the milk supply, it is possible that the baby is surrounded by carriers whose re-sistance varies with their age. What may mean a constipated headache at forty might be death at six months. It may possibly he that the foul comforter or the tooth-searching fingers are sources of infec- tion, and not the much abused milk.

W. F. ORR, M.B., B.S. (Hon. Surgeon Victorian Eye and Ear Hospital.)

In the '`Medical Press" of April 23rd attention is drawn to the personal risks of the medical profes-sion in connection with the death of Mr. Etherington Smith, F.R.C.S., of St. Bartholomew's Hospital, who (lied of septic peritonitis, presumably due toinfection from a gangrenous lung upon which he had operated. In this respect the following case is of interest:—

117nß AUSTRALIAN MEDICAL JOURNAL. \ugust i6, 1913.

Mr. O. H., who was suffering from a severe anginal throat, was seen on June 19th in consulta-tion with Dr. A.V. O'Hara. Mr. O'H. had operated on a gangrenous lung (due to inhalation of a portion of the gold cap of a tooth) on June 17th, andattributed his sore throat to infection from this case. The left tonsil was swollen and deeply injected, and this redness and swelling ex-tended well forwards on to the soft palate and faucial pillar. These parts were dotted with dis-crete, round, purulent-looking, interstitial spots, and were covered with a thin whitish exudate. The glands at the angle of the jaw were enlarged and acutely tender. There was a general malaise and disinclination for, and inability to take, food, but no rise of temperature or acceleration of pulse through-out. A culture was made, and 8,000 units of anti-toxin injected as the appearance suggested an acute infection which might • include the Klebs-Loefler `bacillus. The culture tubes showed an extraordinarily rapid and vigorous growth of a pure culture of the pneunlococcus. l"nder local treat-ment the throat appearances commenced rapidly to clear up. A further culture made three days after the first disclosed only a comparatively scanty growth of pneum'ococcus. No other organism was present. Except that the dorsal base of the tongue became denuded of epithelium, and that the glandu-lar enlargement with some tenderness persisted for ten days, there was no other result beyond that the patient felt a good deal shaken. In view of the in-tensity of the local condition and its bacterial character, the probability of the infection having occurred as the patient suggested is considerable and the result extremely fortunate.

Thyroid Surgery.

C. H. Mayo ("Jour. Amer. Med. Assoc.," July 5) from an analysis of 5,000 cases (about 1 simple 4% exopthalmic) of goitre, says:—

In operating on the thyroid, the best exposure to be tained is through a transverse incision low in the neck, the skin and platysma turned together each way from the

incision. Should further exposure be necessary, the stern-ohyoid may be sectioned high in the exposed area to prevent movement of the cutaneous scar and preserve a working muscle. In simple goiters it is best to extirpate a greatly enlarged lobe. If both lobes are symmetrically enlarged, division of the isthmus with double resection of the gland is indicated for the best cosmetic results. Midline encapsulated adenomas should be enucleated with division of the isthmus. Lateral encapsulated adenomas may be enucleated or the whole lobe extirpated.

If symptoms of hyperthyroidism are present, extirpation is indicated. In severe cases of hyperthyroidism, in acute attacks and relapses or exacerbations, the condition should he considered medical until improvement takes place. If no improvement proves manifest under such care, injec-tions of boiling water into the lobes (Porter) may give relief.

During the first three or four months of the symptoms extirpation can safely be made since the heart then is not dilated. If dilated to exceed 1 inch, primary ligation of the superior thyroid vessels in indicated, followed in four months by extirpation. After the first year a much smaller percentage of cases requires primary ligation. A single test ligation on one side may be made in doubtful cases, to be followed in a week by a second ligation or partial extirpation according to the degree of reaction.

The records of a large number of patients in this series

show an average gain of 22 pounds within four months after ligation. These patients were then operated on, a Partial thyroidectomy being done with safety. Following these methods of safety, we have performed 278 operations on cases of hyperthyroidism between deaths. Long-stand-ing cases of simple goiter and adenoma may, by degenera-tion or chronic slow thyrotoxicosis, cause serious disturb-ances in the heart, kidneys and blood-vessels. Especially is this true of patients in middle and advanced middle life. When such complications are present operations are made with considerable risk.

Excluding malignancy, the mortality in operating on goiters is very low. It varies but little at present in the cases of so-called simple goiter, in which class are in-cluded occasional complications, from the cases of so-called exopthalmic goiter with hyperplastic glands. In the early development of surgery, operations on exopthalmic goiters were delayed until serious complications arose with the heart, kidneys or nervous system. This led to a high mortality, which naturally deterred physicians from sending patients to surgeons for early operation. The greater the delay the greater the mortality—hence a sur-gical vicious circle. Our mortality in the first sixteen cases which were, of course, advanced) was 25 per cent.---about the average percentage in other clinics at that time. The mortality at present varies from 1 to 3 per cent. This great reduction in mortality is probably due less to opera-tive skill and technic than Shan to better judgment as to the time and extent of the operative procedure instituted, as well as to the skilled use and rational choice of an anaesthetic. The various causes of mortality are hyper-thyroidism, embolism, pneumonia, hemorrhage, sepsis, etc.

The results of operating on simple goiters are well known to be exceedingly satisfactory. Severe myxedema ir but a rare complication following such operations. especially if the area of the gland nearest the capsule be preserved. The large colloid masses in the interior of these glands represent the great bulk of the tumor but the least amóunt of the working area of thyroid tissue.

Operation in cases of hyperthyroidism appears to give about 75 per cent. of cures, while the remaining 25 per cent. are more or less benefited, according to the degree of complication and the stage of the disease, Probably 10 per cent. have some degree of relapse in from one to three years after operation, usually manifested by the re-turn of symptoms. In these rare cases further operation by ligating the vessels. and in most cases by removal of a portion of the remaining lobe, improves the condition of the patient by reducing the amount of thyroid secretion. Exopthalmos of marked degree and long standing may still be present when other symptoms are cured. This is due

to the gradual contraction of the non-striated muscle which sustains the globe to the anterior supporting orbital fascia (Landstrom). In some cases we have greatly im-proved this condition by removing the superior and middle r.ynl.pathetic ganglions.

If the patient is in a good general condition without complicating conditions, a general anaesthetic. for in-stance, ether by the drop method, is preferred. Ordinarily patients receive 1/6 grain of morphin and 1/150 grain of atropin half an hour before the operation. Nervous patients having exopthalmic goiter may receive 1/200 grain of scopolamin one hour before operation, but without the atropin unless a general anaesthetic is also to be given. Scopolamin is uncertain in its effects, some patients being made worse by its use. Patients suffering from grave complications rendering general anesthesia inadvisable can be carried through extensive operations by free local injections of novocain, 0.5 per cent.; and a combined local and general anesthesia, as advocated by Crile, may be of advantage in many cases. Intrathacheal anesthesia is in-dicated in those cases of scabbard or distorted trachea in which the patient is already suffering from dyspnea, or more especially in those suffering from malignant disease of the thyroid, and complications due to enlarged thymus.

t 1^1^ 1013.

16th AUGUST, 1913.

SMALL-PDX AND DIPHTHERIA.

During the past few weeks the continent of :Ans-tralia has been in a state of excitement bordering on panic as the result of an outbreak of small-pox in tiydney. Commerce has been dislocated, and the whole community inconvenienced and put to need-less expense in endeavouring to deal with an epi-demic that ought never to have arisen. if there is one medical teaching that has been justified by practical experience on the large scale, it is that efficient vac-cination and revaccination will protect a community from epidemic small-pox. Yet certain Australian States have failed in the past to put the teaching into practice, and even at this hour certain Austra-lian statesmen are paltering- with the miserable sub-terfuge of "conscientious objection" as if "con-science" had any more standing in such a relation than in its attitude to paying a penny postage.

The recent public excitement throws a curious sidelight on the public interest in its own welfare. Although the outbreak of small-pox has been fairly

widespread, not a single fatality has been recorded in Australia up to the present. Yet there has been in Victoria, at all events for the last 18 months,

n epidemic disease that has claimed a serious toll of valuable lives. Last week we published a re-turn from the Fairfield Fever Hospital, in which it was set forth that during 1912 no fewer than 1,791 cases of diphtheria had been admitted to this institu-tion, of whom 95 had died. While this ratio is ex-tremely good for the particular malady, and is evi-dence of excellent work at the hospital, there is

something strange in the fact that the public remain

quite passive as to the prevalence of diphtheria, and

works itself into a frantic state of fear as to the possibilities of small-pox.

Frankly, it appears that the diphtheria question has been, and is being, neglected. The Board of Public I Iealth has followed the policy which was attributed to the House of Lords in the days of a former good King George of doing nothing in par ticular, and doing it_ very well. It is said that tlie spread of diphtheria is entirely a "carrier" question. In how many of the 1,791 instances of infection easily followed has the truth of this aphorism been established? It is said that the prevention of the spread of diphtheria in school children is merely a question of taking "swabs." in how Many of more than 2,000 cases in Melbourne last year was the practical verity of this statement upheld? in how many instances was really systematic and exhaus-tive enquiry made into either point?

it is no doubt the fact that the Board has many other matters to attend to, and that the time of its medical officers is fully occupied. But here is the problem—diphtheria claimed 95 lives in a single institution in Melbourne last year. Is it a fact that

"carriers" are chiefly responsible? Is it a fact that more frequent diagnostic "swabbing" would protect school children? These are the points of which we want to be certain, and we ought to spare . no ex-pense which will give us any approach to certainty, and, if such can be attained, no expense that will

maintain the safeguard. AVhiat has been done to establish the certainty? What is being clone? It is not for a moment asserted that the Board ought to find out these things, but there need be no hesitation in affirming that it might try. The an-swer would probably be that such an investigation is the duty of the municipal officials, and that the central authorities could not give the necessary time Neither reply should be regarded as effec-tive. 'l'he point is much too important to be left to local enquiry. which must take a more or less sympathetic view of its own administration. If the central authority is to be executive, then it is sadly undermanned, even for routine work. .But the diphtheria question is worthy of a special effort, no matter if it be at extra cost.

POte5 RI1b C011nnQIlt5.

In view of the present small-pox scare, Small-Pox the following extract from a letter of Lady Prevention Mary Wortley Montagu has a new in-

terest. It was written in Adrianople in 1717, nearly two hundred years ago, and it shows that pathology changes more rapidly than public opinion since some continent, very like Lady Mary's has been recently in evidence:--

"Apropos of distempers: I ani going to tell you a thing that will make you wish yourself here. The small-pox, so fatal and general amongst us, is here entirely harmless by the invention of ingrafting, which is the term, they give it. There is a set of old women who ni+ake it their business

to perform the operation every autumn, in the month of September, when the great heat is abated. People send to

one another to know if any of their family has a mind to have the small-pox; they make parties for this purpose, and when they are met (commonly fifteen or sixteen to-gether) the old woman comes with a nut-shell full of the matter of the best sort of small-pox and asks what vein

you please to have opened. She immediately rips open

that you offer to her with a large needle (which gives you no more pain than a common scratch). and puts into

the vein as much matter as can lie upon the head of her needle, and after that, binds up the little wound with a

hollow bit of shell; and in this manner opens four or five veins. The Grecians have commonly the superstition of opening one in the middle of the forehead, one in each arm, and one on the breast, to mark the sign of the cross; but Ibis bas a very ill effect, all these wounds leaving little sears, and is not done by those that are not superstitious,

who choose to have them in the legs, or that part of the arm that is concealed. The children or young patients

iilay together all the rest of the day, and are in perfect

health until the eighth. Then the fever begins to seize then, and they keep their beds two days, very seldom

three. They have very rarely above twenty or thirty on

their faces, which never mark; and in eight days' time they are as well as before their illness. Where they are

wounded there remain running sores during the distemper,

which i do not doubt is a great relief to it. Every year thousands undergo this operation; and the French amlbas-sadorsays pleasantly, that they take the small-pox here by way of diversion, as they take the waters in other

countries. There is no example of any one that has died in it; and you may believe I am well satisfied of the

1 ^ t _

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alt an 1ti..A.. rT Y........ rT AUSTRALIAN MEDICAL JOURNAL.

1172 AUSTRALIAN MEDICAL JOURNAL. August 16, 1913.

safety of this experiment, since I intend to try it on niy dear little son.

"I am patriot enough to take pains to bring this useful invention into fashion in England; and I should not fail to write to some of our doctors very particularly about it, if I knew any one of them that I thought had virtue enough to destroy such a considerable branch of their revenue for the good of mankind. But that distemper is too beneficial to them not to expose to all their resent-ment the hardy wight that should undertake to put an end to it. Perhaps if I live to return, I may, however, have courage to war with them. Upon this occasion ad-mire the heroism in the heart of your friend, etc., etc."

General For many years a connection between Paralysis and general paralysis and tabes dorsalis and

Syphilis the specific poison of syphilis has been suspected. It is now announced that Dr.

Noguchi, of the Rockefeller Institute, has demonstrated the presence of the Treponema pallidum on the brain of general paralytics. In a discussion upon the announce-ment at the .Johns Hopkins Hospital Medical Society, Dr. L. F. Barker is reported to have said: "I am told that when Professor Erb heard of Dr. Noguchi's discovery he threw up his hands and said, `Hurrah, hurrah! the proof has at last been brought.' Virchow pointed out that while tabes and general paralysis follow lues, they also follow a common cold, for no patient with tabes or gene-ral paresis has a freedom from common colds! Virchow was right, of course, in pointing out the fallacy, but the clinical evidence in favour of the luetic origin of the two diseases was strong. Could he be here to-night he would, I believe, also throw up his hands and rejoice at this de-monstration." Dr. Barker congratulated America on the discovery, and paid a tribute to clinicians for the work done long before any causal agent for syphilis was known. "It is the establishment of such syndromes by clinicians that gives the stimulus to laboratory workers for their researches," and further added, "The fact now definitely established that the virus of syphilis is present in the cerebral tissue of paretics does not conflict with the clini-cal fact that dementia paralytica differs from ordinary cerebral lues."

AE STIt.1LAMIIN MEDICAL CONGRESS.

Teeth Session. The work of the Congress has been divided into eleven

sections, each with his own officers, which will meet and discuss their own subjects as under:-

1. Medicine—President, Dr. Sinclair Gillies, Sydney; secretaries, Drs. W. C. W. McDowell and E. Robertson.

2. Surgery-,President, Dr. Hamilton Russell, Melbourne; secretaries, Drs. Casement Aickin and Gore Gillon.

3. Obstetrics and Gynaecology—President, Sir David Hardie, Brisbane; secretary, Dr. Tracey Inglis.

4. Pathology, etc.—President, Prof. D. A. Welsh, Sydney; secretary, Dr. Milsom.

5. Public Health and State Medicine—President, Dr. J. R. S. Elkington, Brisbane; secretary, Dr. Monk. Subsec-tion Medical School Inspection and Hygiene.

6. Ophthalmology--President, Dr. F. Antill Pockley, Sydney; secretary, Dr. J. C. Pabst.

7. Psychological Medicine and Neurology—President, Dr. Chisolm Ross, Sydney; secretary, Dr. A. N. McKelvie.

8. Diseases of Children and Orthopaedics—President, Dr. H. Swift, Adelaide; secretary, Dr. G. Brunton Sweet.

9. Naval and Military Medicine and Surgery—President, Col. Chas. Ryan, Melbourne; secretaries, Drs. W. H. Parkes and R. Walton.

10. Dermatology, Radiology, etc.—President, Dr. Hers-chel Harris, Sydney; secretary, Dr. Alfred Clark.

11. Laryngology, etc.--{President, Dr. H. Russell Nolan, Sydney; secretary, Dr. W. A. Fairclough.

Each section has from 3 to 5 vice-presidents, and keen and interesting discussions are expected.

Their Excellencies the Governor of New Zealand, the Governor-General of theCommonwealth, the Naval Com-mander-in-Chief Australian Station, the Governors of the

various Australian States and of Fiji and Papua, and the Chancellor of the University of New Zealand have been invited, and have consented to become Patrons of the Congress. The Prince Minister and the Governnment of New Zealand have been approached, and have accorded their countenance and support to the Congress.

Officers of Congress. President, Dr. A. Challinor Pnrchas, Park Road East,

Auckland; treasurer, Dr. N. :McKay Grant, Khyber Pass, Auckland; general secretary, I)r. Bernard J. Dudley, Ep-som, Auckland; associate secretary, Dr. Cyril H. Tews-

• ley, Kingsland, Auckland.

Vice-('residents of Congress.

Dr. J. C. Verco, President Adelaide Congress, 1887; Sir Phillip Sydney .Jones, President Sydney Congress, 1892; Dr. F. C. Batchelor, President Dunedin Congress, 1896; Hon. G. A. Butler, President Hobart Congress, 1902; Prof. E. C. Stirling, President Adelaide Congress, 1905; Prof. H. B. Allen, Melbourne Congress, 1908; Dr. F. Antill Pockley, President Sydney Congress, 1911; Surgeon-General W. D. Williams, Director-General of the Army Medical Services of the Commonwealth; Fleet-Surgeon Henry B. Beaty.

Local Secretaries (N.Z.). Taranaki, Dr. D. S. Wylie, New Plymouth; Manawatu,

Dr. E. E. Porritt, 59 Ingistre-street, Wanganui; Welling-ton, Dr. M. Holmes, Wellington; Hawkes Bay, Dr. E. A. W. Henley, Marine-parade, Napier; Poverty Bay, Dr. A. L. Singer, Gisborne; Nelson, Dr. V. H. Barr, Collingwood-street, Nelson; North Canterbury, Dr. Duncan, Christ-church; South Canterbury, Dr. .J. R. Loughnan, Timaru; Westland, C. G. F. i\Iorice, Greymouth; Dunedin, Dr. New-lands, Dunedin; Southland, Dr. W. Ewart, Invercargill.

Reception and Entertainment Committee. President, general secretary, treasurer, Dr. Eleanor

Baker, Dr. Beattie, Mr. A. Clark, Mr. Gore Gilson, Mr. Tracey Inglis, Dr. Lindsay, Mr. Hope Lewis, Dr. \lakgill, Dr. Milsom, Dr. Murray, Dr. McDowell, Dr. McGuire, Dr. Parkes, Dr. Pabst, Dr. Robertson, :Ur. Copeland Savage, Dr. Somerville, Dr. Sweet, Dr. Tewsley. Dr. Walton, Dr. Wohlmann.

Dr. Dudley, general secretary, has requsted us to draw attention of intending members to Congress to the fact that subscriptions should be paid to the local secretary and that if an application is made through the local secre-tary for accommodation the Executive will make the ne-cessary arrangements. As there will be a large number of visiting bandsmen and sightseers at the same time in the city, accommodation will be at a premium, and the Executive have booked up a large amount of accommo-dation in advance, but it advises application to be made in time through the local secretary. The Victorian secretary i3 Dr. A. L. Kenny, Collins-street.

COMPULSORY V.ICCINATION IN QI'EENSL:AND.

On July 31st the Home Secretary for Queensland ap-proved of additional regulations promulgated by the Com-missioner for Public Health under the Public Health Act. with special reference to the suppression of smallpox as well as checking the spread of certain other diseases. The powers given to the Commissioner to authorise house-to-house inspections, and the medical examination of the in-mates, if necessary, are again included. Power is given to isolate infective or suspected premises until the examina-tion and (if required) effected inoculation prescribed have been made. Force may be used to prevent persons from leaving such premises. 1)t is provided that any health officer or authorised medical practitioner shall have the following powers in dealing with persons in contact with disease or suspected disease: (a) For the purpose of ob-serving whether they are suffering or are likely to suffer from an epidemic disease he may order that they shall be detained for such period and at such place and under such conditions as he may direct, subject to the approval of the Commissioner. (b) In the case of small-pox he may inocu-late any person so detained with glycerinated calf lymph or other lymph proper for the purpose. Any person so

August 16, 1913. AUSTRALIAN MEDICAL JOURNAL. 1173

detained shall not leave, or be discharged from, such place until he, his person, and clothing, and personal effects are free from infectious disease and infection as certified by ahealth officer or authorised medical practitioner in writing to the Commissioner; and it such person is required to be inoculated as aforesaid, until he has been effectively in-oculated; or (c) after disinfection of the person, clothing, and personal effects of such person, and of the premises in which such person resides, or any of these, and if such person is required to be inoculated' as aforesaid, after he has been effectively inoculated, he may discharge such person upon condition that he reports himself to a medical practitioner approved by the Commissioner, and submits to inspection and examination by a medical practitioner for such period, and at such intervals, places, and ;Ames as the Commissioner or health officer shall direct. Where a person is suffering from an epidemic disease there is power to order his removal to an isolation hospital or iso-late him or her at home. Provision is made for disinfec-tion or destruction of clothing. Power is also given to vaccinate prisoners, using force if necessary.

CORRESPONDENCE.

Venereal Prophylaxis.

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

Sir,—'In a recent leader of the Journal you apparently pin your faith to soap and water as a preventive of the spread of venereal disease in the community.

You may know of some method of their application not in general use, but so far as I know the diseases in ques-tion, I may say that I look upon them as quite unreliable remedies.

Those who are familiar with the diseases in women know of the hopeless futility of certainly recognising their presence by inspection or microscopic examination. It is therefore impossible to weed out the women, and the weak-ness of any inspection system becomes apparent.

No, the way to prevent spread is to protect the males. Assume that they will all wander at some time along the primrose path of dalliance. Teach them all openly and candidly about syphilis and gonorrhoea. Teach them to regard every woman intimate with them otherwise than in wedlock as infected. Teach them, above all, that a woman may be gonorrhoeal or syphilitic, or both, without suspecting it in the least. And if they refuse then to use a rubber shield, implore them, as they value their future happiness, to pin their faith to 20 per cent. protargol and 30 per cent. calomel cream applied "immediately after-wards." Of course the soap and water may also be used. —Yours, etc., GENITO-URINARY.

1163 j1300U. Geometrical Optics. By A. S. Percival, MA., M.B., B.C.,

Cantab. London: Longmans, Green and Co.

This book - deals with .a portion of the matter already treated in the author's book on Optics, published in 1899, but with such differences as are necessary to correspond with modern work in the subject. For this and his book on the Prescribing of Spectacles Dr. Percival deserves, and has received, the keen appreciation of all who have to deal with errors of refraction. The present book prac-tically contains all the optics required by an ophthalmic surgeon, facts are dealt with in the clearest possible man-ner, and practical applications of the formulae are nu-merous and useful. A list of all the important formulae is provided at the end of the book, some of universal ap-plication; by a simple transformation formulae for re-fraction can be converted into corresponding formulae for reflection. A.L.K.

We are in receipt of the sixth volume of "Keen's Sur-gery," published by Messrs. W,' B. Saunders and Co., and an extended notice will appear shortly.

CURRENT LITERATURE.

Blood Picture of Mumps.

Feeling ("Lancet," July 12) writes:—

Considerations of space forbid me to quote in full all the figures of my own blood examinations. Only a brief resume of the results obtained can be given. The ages of the patients examined varied from 2 to 38 years; the great majority were between 5 and 15. The day of the disease on which the blood was examined varied from the first to the seventeenth; in the majority of cases the blood was taken between the third and eighth days, when the disease was fully established. Only two cases of the series presented orchitis. At first the red blood cells were counted as well as the white, but as no alteration was found in 12 cases thus examined, in the remainder the white cells only were counted. In every case the total number of leucocytes was enumerated and a differential count made. The results are considered under three heads: (1) The total number of leucocytes per cubic milli-metre; (2) the percentage and total number of lymphocy-tes; and (3) the percentage and total number of poly-morphonuclears. The eosinophile and basophile cell counts are neglected as exhibiting no special changes nor afford-ing grounds for any particular conclusions.

Taking first the total leucocyte count, the highest count recorded was 15,600, the lowest 4600; the average count appears as 9400. A slight total leucocytosis was there-fore established as an average.

Secondly, with regard to the lymphocytic content of the blood, the highest percentage recorded was 68.5, the low-est 30, the average being 48. The highest total number of lymphocytes per cubic millimetre was 8432, the lowest 2117, the average being 4600. A relative and absolute lymlphocystosis was thus established.

Thirdly, with regard to the polymorphonuclear cell con-tent, the highest percentage was 64, the lowest 25, the average being 46. The highest total number was 8195, the lowest 1736, the average being 4400. Thus on the ave-rage the polymorphonuclear cell count was but slightly altered from the normal, and when altered varied inversely with the lymphocyte count.

Of the two cases of orchitis examined, one was a man in whom epididymitis had been the first symptom; the blood was examined on the seventeenth day of the disease, when orchitis was still present, and so far from there being a leucocytosis of polymorphonuclear cells, as Sacquepee observed, the total leucocyte count was only 5600, while the percentage of lymphocytes was 66; in this case the lymphocytes were much increased at the expense of the polymorphonuclears. The second case of orchitis was a boy, aged 13, whose blood was examined on the seventh day of the disease and on the second day of the orchitis; the total number of leucocytes was 9600, the polymor-phonuclear percentage 55, and the lymphocyte percentage 42. Thus the only two cases of mumps with orchitis which I have had the opportunity, of examining presented both a relative and an absolute lymjphocytosis, and did not show the change in the blood picture which previous observers have mentioned.

Three cases of parotitis due to other causes have been examined; in two of these a septic condition of the mouth was apparently the cause, and one was a case of 'so-called post-operative parotitis. In all three cases a marked leucocytosis was present, reaching as high as 36,000; the increase was due to an increase in the polymorphonuclear cells.

From the results of my own observations I think the following conclusions are justified: (1) that the blood in mumps shows definite changes in the corpuscular con-tent; (2) that these changes consist (a) in a slight in-crease in the total number of leucocytes, and (b) in a lymphocytosis which is both relative and absolute; (3) that this lymphocystosis is present on the first day of the disease and persists for at least 14 days; (4) that the occurrence of orchitis doesnot invariably alter the blood picture; and (5) that the changes in the blood are of dis-

in

f s 1174 AUSTRALIAN MEDICAL JOURNAL. August 16, 1913.

äï

r.

ia•,:

inni ^

tint diagnostic value in differentiating mumps from other

inflammatory swellings of the parotid or submaxillary salivary glands and from cases of lymphadenitis.

Staphylococcus Spray,

J. D. Rolleston ("Brit. Journ. Child. Dis.," July) pub-lishes seven cases of diphtheria "carriers" treated by

Schiotz method, and gives an interesting historical sur-vey. He approves the method notwithstanding that a mild

"sore throat" was produced in all:— This method was first introduced in 1909 by Schiotz, of

Copenhagen, who had observed that patients with staphy-lococcus sore throats admitted in error to diphtheria

wards did not contract diphtheria, and that intercurrent

attacks of staphylococcus sore throat expelled pre-existent

Klebs-Loeffler bacilli in diphtheria convalescents. He ac-cordingly inoculated six diphtheria bacillus carriers with

a staphylococcus culture isolated from the throat of a

patient in a surgical ward, who was healthy except for

the condition requiring operation. Three of the patients

were adults, and three children between eleven and thir-teen years of age. In each case the cultures rapidly be-came negative.

H. Page, of Manilla, was the first to adopt Schiotz's

method. After ineffectual use of ordinary throat sprays

and repeated injections of antitoxin he found that two-hourly spraying of the throat with bouillon cultures of Staphylococcus pyogenes aureus rendered the throat free

of bacilli in a few days. In a subsequent paper he relates

how he used the treatment on his own son in con-valescence from severe diphtheria. Release from quaran-tine was delayed owing to timidity in using the spray, the

cultures not being negative until seven days after treat-ment had been begun.

Catlin, Day and Scott, of Rockford, Illinois, next re-ported eight cases of diphtheria carriers in whom they

used this treatment after the ordinary methods of throat

antisepsis had failed. A twenty-four hours' old broth cul-ture was sprayed into the nose and throat three times

daily, and all other treatment was stopped. The bacilli

disappeared in from forty-eight to seventy-two hours.

Two cases were treated by Leary, of Melbourne. In the

first the spray was used on two occasions, with an interval

of two or three days. Several swabs taken sixty hours

after this were negative, and further cultures taken from

the posterior part of the throat five days after spraying

showed only one bacillus. The second case showed nega-tive cultures in forty-eight hours and again four days

later. Lydia De Witt, of St. Louis, carried out experiments

to determine whether an antagonism existed between

Staphylococcus aureus and diphtheria bacilli. Test-tube

experiments showed that the organisms grew well to-gether, and that a killed staphylococcus culture formed a

good medium for the growth of diphtheria bacilli. Experi-ments on rabbits and guinea-pigs showed that though

Klebs-Loeffler bacilli frequently disappeared more quickly

in animals treated with staphylococcus cultures than in

those untreated, this result was not constant. In two

diphtheria patients whom De Witt treated with staphylococ-cus cultures the bacilli reappeared after two negative find-ings had been obtained. She suggested that the apparently

favourable action of Staphyloccoccus aureus is due, not

to an incompatibility between the two organisms, but to a

reinforcement of the normal throat flora. In a case in which diphtheria bacilli had persisted three

and a half weeks from the onset of the disease, R. G.

Wiener, of New York, used a throat spray three times a

day, starting on December the 11th, 1911.. On the 12th the culture was positive, and a spray with twice as heavy a

culture was used. On the 13th the culture, though still

positive, contained fewer organism's. A heavy culture was

used every three hours this day. On the 14th staphylo-cocci only were found in the culture. On the 18th, four days after the last spray, the culture was still negative.

Lieutenant G. B. Lake, of the United States Army Corps,

treated thirteen convalescent cases in an outbreak of diph-theria at Fort Sam Houston, Texas. The throats were

swabbed once a day with the cultures, which were varied

a good deal for purposes of experiment. Bouillon cultures

from six hours to five days old, young broth cultures re-inforced with two or three loopfuls of agar cultures, and

suspensions in broth of agar cultures were all tried. The best results were obtained with bouillon cultures forty- eight to seventy-two hours old grown at incubation tem-perature.

In seventeen cases treated by W. F. Lorenz and M. P.

Ravenel, of Madison, Wisconsin, a nasal and throat spray was used consisting of a fresh suspension of Staphylococ-cus pyogenes aureus in normal saline solution and a broth culture twelve hours old. Three were carriers pure and simple, six had had clinical symptoms, and eight had treat-ment early in the disease. The method was most success-ful in the carrier cases, and less so in the others.

A. J. Bell, physician to the Cincinnati Hospital, obtained a negative culture in two persistent carriers after forty-eight and sixty hours' treatment respectively. He recom-mends that a fresh staphylococcus culture should be pre-pared daily. The first application should be made by the physician, and the remainder of the culture should be used by the patient himself every two hours during the day.

This survey of the literature shows that comparatively few cases have been treated by this new method, the total number hitherto recorded amounting to barely over fifty. With the exception of Leary's Melbourne cases the obser-vations have been confined to the United States, and so far no cases have been published in this country or on the Continent. Up till now no complications have been noted except by Lorenz and Ravenel, who mention coryza, very mild laryngitis and nasal furuncles occurring among their cases.

Chloroform Administration. Highaml ("Ind. Med. Gaz.," July, 1913) summarises in-

structions to assistant surgeons thus:—

To recapitulate, bear in mind these guides:— (a) The corneal reflex: should he absent except in

operations on the air passages. (b) The pupil: should be contracted. Always suspect

a dilated pupil; it may be a harmless phenomenon, but it is usually a danger signal. Do not regard it as unimpor-tant unless it reacts definitely to light, and you have con-vinced yourself to your complete satisfaction from all the other data at your disposal that all is going well.

(c) The breathing: should be regular and not sighing or very light. This is by far the most important guide that you possess. Therefore watch the breathing carefully all the while. Keep your eye fixed on the front of the chest, and if at any time you are compelled momentarily to look away, keep your ears open to catch the breath sounds. Be anxious if you cannot see good regular movements of the chest walls and hear the entrance and exit of the air. On the other hand, do not permit loud and stertorous breath-ing if you can avoid it.

(d) The colour of the lips and face: note the normal colour of your patient's lips before you start the adminis-tration; if it becomes dusky and bluish, take off the mask • and look closely into the cause of this.

(e) The pulse: this should be counted at the commence-ment and any increase in frequency or diminution of

volume noted. This can readily be done as a rule, without disturbing the operation, by feeling the pulsations in the temporal artery, but in any case of doubt one of the radial arteries is usually at your disposal. If you are keeping constant observation upon the breathing, you can afford

to pay less attention to the pulse because as a rule the respiration begins to fail before the circulation in the case of an overdose of chloroform. Nevertheless the pulse should be felt and counted from time to time, and any signs of failure reported to the surgeon to whom the know-ledge of this fact may be of great value.

Examine your patient again the last thing before he leaves the theatre. He should at least have regained his corneal reflex before he is removed. So arrange your ad-ministration that this is the case. It is not desirable that the patient should go back to the ward where probably he will receive no professional attention, still deeply anaes-thetised. It is better that he should come to the stage when he is retching and bringing up mucus, etc., in the theatre rather than that this should occur in the ward where he will be away from your supervision. If you are

Augus1 16, 191 3. AUSTRALIAN MEDICAL JOURNAL. 1175

uncertain towards the conclusion of an operation how much more the surgeon is proposing to do, ask him. He will usually tell you when no more anaesthetic will be re-quired, but if he omits to do so, ask him.

Remember that the part of a surgical operation which a patient dreads is the taking of the cholroform. This is the only part that he will remember afterwards. If you have been sympathetic in your manner and have observed the recommendations given above for starting the adminis-tration, he will tell his friends afterwards that there is nothing terrible in a surgical operation and your reputa-tion as an anaesthetist will be assured. But if his recol-lections are of being held down on the table, motionless and helpless in the vice-like grip of your brutal assistants, while you systematically tried to suffocate him, you will have failed in your duty to your patient and shamed your profession.

MEDIC .1L INSPECTION OF SCHOOL CHILDREN I\ WESTERN _tUSTR.ILI<l.

The Director of Education in Western Australia makes the following comments on the medical inspection of school children in his annual report, which deals with the year 1912.

The scheme of medical inspection provided by the Health Act of 1911 was in force for a few months in that year, and for the whole of 1912. Under this scheme special medical officers, who give their full time to the work, and are assisted by nurses, are engaged for the metro-politan and the Kalgoorlie-Boulder districts. For the rest of the State, in areas controlled by local health authori-ties. the Medical Officer of Health becomes the Medical Officer for Schools. In the remaining areas the District Medical Officers act in the same capacity. By this or-ganisation it was hoped that every school child would be examined at least twice during his school career, once shortly after he is admitted and once shortly before he leaves. The system has not yet been working for a sufficient length of time to enable a final judgment to be pronounced upon its adequacy. When a school is in-spected for the first time every child undergoes an indi-vidual examination. This makes the inspection a very lengthy process. At subsequent visits only those newly admitted and those about to leave will be examined, apart from special cases selected for re-examination by the me-dical officer or brought forward by the teacher. The num-ber of schools that can be inspected in a year should thus be considerably increased as time goes on. But, even when full allowance is made for this, it seems doubtful, from the experience of last year, whether the whole field can be covered by the present system, though the work of the year represents a very great advance upon anything that has been done before. Taking Government and private schools together, it appears that 135 out of 668 schools were medically inspected, that is, about 20 per cent. of the whole number. Taking the number of children on the rolls, the proportion is a little higher. Out of 48,423 chil-dren, 11,369 were examined, or about 23.5 per cent. From the figures at present available, it appears that about 71.5 per cent. of the children examined were reported as in some way defective, most of the defects being connected with the teeth. Excluding dental defects and uncleanli-ness, the number reported as defective is about 9 per cent. The figures showing how many of the others were Medical Officers act in the same capacity. By this or-included on the grounds of dental defects, and how many on the grounds of uncleanliness, are not yet available. It is evident that medical inspection is in itself com-paratively useless unless followed up by remedial measures. The principal difficulty is to secure that adequate treat-ment follows upon the notification of defects. This diffi-culty is, of course, greatly increased in the case of a thinly-scattered population, where a visit to a doctor often entails a long and expensive journey. In older countries, where population is dense and where free treatment is readily obtained by those who cannot afford to pay, neg-lect to comply with medical instructions given after me-dical inspection is often made a punishable offence. The figures here are at present, incomplete, but so far as can he ascertained, action is known to have been taken in about 23 per cent. of the cases reported,

GENERAL.

A correspondent in the "Lancet" gives the following:—°1 append the complete running cost of an S h.p. Renault car from Dec., 1911, to May, 1913, during which time the car covered 12,560 miles. There was no involuntary stop until 12,080 miles had been run, when the block pinion in the back axle sheared as the result of an accident, the cost of replacement and reassembling being £3 :10s. The Michelin tyres have done more than 8,000 miles each with-out retreading, which is largely due to the use of the Harvey-Frost Vulcaniser. The petrol consumption was 31 miles per gallon. The mechanical repairs include one new ball race, renewal of pinion in back axle, relining side-brakes at 12,08o miles, and rebushing steering radius rod. The engine and gear-box have never been cleaned or adjusted and are still running well. Running cost:—Petrol, £30; tyres, £15 15s. 3d.; lubricating oil, £2 15s.: grease, Gs.; insurance, £6 5s.; licences—car (one driver), £2 ls. 6d.; mechanical replacements, £2 10s. 6d.; back axle (accident), £3 10s.; £63 3s. 3d.; depreciation, 20 per cent. of cost of car, £45; total, £108 3s. 3d. The cost of running the car, including depreciation, works out at slightly under 2 1/4d. per mile. Wages are not included, since they would vary in different places. I should add that 1 also possess a 13.9 h.p. Renault which has run 23,000 miles, the cost being 5d. per mile. It is of interest to note that the cost of running a car exactly twice the horse power is rather more than twice as much.

Messrs. Burroughs, Wellcome and Co. have added to their list "Tabloid" I-Iypodermic Morphine Hypophosphite in products of four strengths. Morphine Hypophosphite is a salt possessing qualities which render it particu-larly suitable for use in hypodermic medication when a concentrated solution is desired. It is perfectly stable, is practically neutral in reaction and has the remarkable solubility of 1 in 3 of water. In clinical use its great solubility is a point of decided value, and it has been found to act well and promptly, without causing pain at the point of injection. The gr. 1/4 and gr. 1/3 strengths are issued in tubes of 20 and the gr. 1/2 and gr. 1 strengths in tubes of 12.

The properties of the lactic ferments contained in Lacto-bacilline are well known, and innumerable cases have been Published in support of the very remarkable biological method introduced by Professor Metchnikoff. Multiplying in the intestine at the expense of the alimentary sugars the lactic bacilli elaborate nascent lactic acid which ar-rests intestinal putrefactive changes and hinders the 'de-velopment of infective germs without in any way inter-fering with the normal functions of the intestine. The treatment has for effect to substitute a salutary for a noxious flora. Professor Metchnikoff, however, has shown that these results are only obtainable on condition of mak-ing use of pure selected lactic ferments, and Lactobacilline is prepared strictly in accordance with his method. The Glycobacter bacillus discovered by Professors Metchni-koff and Wollmann is an amylolytic ferment which trans-forms amylaceous matters present in the intestine into sugar (starch, celltilose, etc.). In contrast. with all amy- lolytic ferments hitherto known, Glycobacter carries this transformation to its extreme limit throughout the ali-mentary canal. By thus transforming substances which have escaped the action of the intestinal juices, it promotes the accomplishment of digestive and nutritive processes. It therefore presents per se very valuable qualities which enable its sphere of usefulness to be defined. Professor Metchnikoff and Wollmann have demonstrated the bene-ficient transformation of the intestinal milieu in subjects placed on a dietary comprising Glycobacter, and inci-dentally they noted a narked reduction in the proportion of urinary indoxyl. It follows that its employment is especially indicated in the very numerous cases in which the faeces are found to contain incompletely digested starch (starch granules stained blue by iodine), and, also, whenever there is reason to suspect that starch' digestion

ds

le ■

1176 AUSTRALIAN MEDICAL JOURNAL. August 16, 1913.

is inadequate in consequence of a diet containing large quantities of farinaceous elements. Glycobacter, more-over, like Lactobacilline, is absolutely innocuous, and its use is free from the slightest inconvenience.

According to a return available by the Commonwealth statistician (Mr. G. H. Knibbs), there were 52.177 deaths in the Commonwealth during 1912. The death-rate was 11.23 per 1,000, as compared with 10.66 in 1911. Most of the deaths recorded during last year were due to the fol-lowing causes:—Typhoid fever, 619 deaths; malaria, 17; measles, 19; scarlet fever, 41; whooping cough, 301; diph-theria and croup, 754; influenza, 386; cholera nostras, 5; other epidemic diseases, 224; tuberculosis of the lungs, 3,146; tuberculosis meningitis, 215; other forms of tuber-culosis, 327; cancer and other malignant tumours, 3,537; simple meningitis, 749; cerebral haemorrhage and soften-ing, 2,176; organic diseases of the heart, 5,267; acute bron-chitis, 460; chronic bronchitis, 1,053; pneumonia, 2,107; other diseases of the respiratory system (tuberculosis ex-cepted), 1,863; diseases of the stomach (cancer excepted), 457; diarrhoea and enteritis (under two years), 3,248; ap-pendicitis and typhlitis, 347; cirrhosis of the liver, 426: nephritis and Bright's disease, 2,188; senile debility, 4,124; violent deaths (suicides excepted), 3,236; suicides, 632.

A recent publication supplies—as far as it goes—some curious information in the favourite recreations of medical men. Golf is an easy first, and the list very well shows how varied are the tastes of our professional brethren. The figures are: Golf, 250; tennis, 131; fishing, 112; shoot-ing, 89; motoring, 87; cycling, 81; yachting (including sailing, rowing, boating), 65; cricket, 52; photography, 52; gardening or horticulture, 44; literature, music, walk-ing, each 41; travelling, 32; hunting, 30; swimming, 23; riding, 22; billiards, 18; mountaineering, 17; football, 16; chess, 15; natural history, 13; painting, 12; archaeology, 11; skating, 10; curling or bowling, sketching and stamp collecting, 8 each; 7 each to bridge, hockey, and drill (or Territorial work) ; croquet 5 and ski-ing, 5; 4 each to car-pentering, farming, languages, driving, collecting (curios, prints, china), athletics, book-hunting or col-lecting, ornithology, geology, claim 3 for each; and 2 each for acting, archery, fencing, poultry breeding. One entry only appears under each of the following: Astronomy, aviation, .bookbinding, carving, falconry, fire brigade, genealogy, handball, mathematics, modelling, printing, rest, scouting.

The Melbourne "Age" recently dilated on the improved work to be done by the State doctor. The following is from the "Medical Press":—A recent East London in-quest on a journeyman baker, aged 38, suggests some seri-ous reflections. The young man was insured, and the panel doctor in attendance ■filled in the weekly certificate, giving rheumatism as the cause of the disease. Shortly before the patient's death another medical man was called in, and he stated in evidence that he at once recognised the disease from which the deceased was suffering as acute tuberculosis of the lungs. On the other hand the medical man in attendance stated that he had notified the medical officer that the disease was tubercular. It is difficult to believe any responsible medical man would have ex-pressed the views as to the nature of a medical certificate attributed to the doctor in question by the "Daily Express." "When I first saw the man he spoke of chronic rheuma-tism. People say anything to get a certificate. The mere fact of something being on the certificate—which, I may remind you, is not a medical report—does not mean that he has got that complaint." The coroner, himself a me-dical man with every sympathy for members of his pro-fession, animadverted severely on the conduct of the me-dical man who, after attending deceased for months, cer-tified him as suffering from rheumatism. "There can be no doubt," he said, "that if the man had been properly examined and his complaint diagnosed, it would have given him a chance to get better." The fact, elicited at the inquiry, that the medical man concerned had some 2,000 patients on his panel, affords no excuse for neglect of that work which has been contracted for in precise terms with the Government.

TI3rítíit fliebícar agooctatíon. VICTORIAN BRANCH.

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

NOTICES.

Warning Notices. 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.L., 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-tary, B.M.A., 429 Strand, London.

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.

VICTORIAN BRANCH.—Ordinary Meeting, 1st Wednesday in month.

„ Clinical Meeting 3rd Wednesday in month.

PEDIATIRIC SOCIETY.—Second Wednesday in month. EYE & EAR SECTION.-4th Tuesday in Month. MELBOURNE HOSPITAL CLINICAL SOCIETY.-4th Fri-

day in the Month.

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 1454 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 advertisement applica-tions should be addressed the Manager, "A.M. Journal,” Medical Hall, Brunswick-street, East Melbourne.

PERSONAL.

Dr. A. G. Colquhoun has purchased a practice at Yass, N.S.W., and will begin work in that district next month.

In an article published last week the quotations attribu-ted to Sir A, E. Garrod should read Dr. A. E. Garrod.

A joint meeting of members of the medical staffs of St. Vincent's, Alfred and the Melbourne hospitals will be held to consider the present method of appointing resident medical officers.

The .Stawell Hospital advertises for a resident medical officer. The position was held for many years by Dr. Ait-ken, who has taken up private practice in Stawell,

E ist 23, 1913.

CASE OF OTOGENIC CEREBRAL ABSCESS.

COI I \ 1tL1:I1I1', 11.1)., F.R.C.S.I. (Aural Sur- . geon, St.- Vincent's Hospital) ; and ALEX. I,f \V ERS. AJ.R.C.S., Eng., L.R.C.P., Lond., D.P.H. (Physician to In-patients, St. Vincent's

hospital).

'l'hc patient, a boy of 16, was admitted to St. Vincent's hospital under the care of one of us (A.L.) on _April 23rd, 1913. He had been seen by I)r. Edward Rvan outside, who recommended hint to hospital. 1lis history on admission, taken by 1)r. C. F. 'fucker, read as follows :-

"Four weeks ago patient got a frontal head-ache of a continuous nature and radiating all over the head. Pain is as severe now as at onset.

"Eight days ago he vomited eight times during one day and a number of times since.

"On about half-a-dozen occasions since onset of the headache has noted a dimness of vision, most marked in left eye. General health shows nothing of note. Seven days ago he noticed that his right arm became weak and paralysed so that he could not hold his pen. On day of admission the right leg became helpless. This lasted ten minutes. On a number of occasions noticed that after sitting for a while he becanie very giddy and weak in limbs, and everything was whirling round.

"F'amily history unimportant. Examination of heart and lungs shot-vs noth-

ing abnormal. The patient stutters in speech, a defect which has been present for ten years, and he can voluntarily produce an internal squint of the left eye, an accomplishment which is

ni to his family. 'l'he pupils were equal and reacted normally. Tongue was protruded in straight line. Some slight weakness of right arm and leg. 'l'he right biceps and triceps jerks more marked than left. Knee jerks were not much altered, but right slightly more marked. The superficial abdominal reflexes less marked on right than left side. _A well-marked right llabinski reaction. No sensory alteration. Temp. 99° pulse 6o. resp. 20, 1> . I' , ioS. The patient has suffered from otorrhwa in left ear for four years.

"Urine Sp. G. 1009, alk., no alb., no sugar." l (A.L.) saw the patient for the first time on

\ pril 24th. i ie was a very bright and intelligent lad, and answered questions readily. 1 considered that the reflexes, both superficial and deep, were dulled on the right side. I could detect no paresis of the right side, and was not satisfied that I could elicit a Ilabinski on the right side. There was no sensory disturbance. There was no discharge from the left ear and no tenderness or swelling over the mastoid region, nor had there been any symptoms recently of ear trouble. Through the courtesy of Dr. E. Ryan I append his private case-hook note of the ocular finding:—

1177

„24 l 13 V. h. — 6/5, V.L. = 6/9 Pupils unequal, the right pupil beeing the larger. Both pupils act briskly to light and consensually; the outlines of both discs are "woolly"; there is more swelling of the left disc than of The right, with marked engorgement of the retinal vessels. is hypermetropic over -{- 3D."

.although the condition presented several possi-bilities, the first thing appeared to be the necessity for excluding- any otogenic origin, and I asked 1)r. J. Murphy to examine the ear and do anything he thought advisable. He very kindly saw the patient the same day, and his own account of his first operation is as follows

On 24/4/13 1 was asked by Dr. 'sewers to see a patient ill one of his wards at St. Vincent's hospital whom he suspected to have some intracranial com-plication of ear disease. 'Plie patient, a boy, R.11., æt 16, was bright and intelligent, but complained of severe headache frontal and occipital. 1-le had left otornccea which had existed for four years, and on examining the left ear I found a polypoid mass of granulation tissue protruding- through the upper part of the drum.

Functional testing of the ear showed an intact inner ear, but disease of the middle ear.

'there was no tenderness over the mastoid, or, on percussion, over the temporo-sphenoidal lobe or cerebellum. O n sitting him up and on standing-up he because giddy and sick, and on rotation he soon became giddy and sick, so that the direction of his nystagmus was not accurately determined.

Operation was decided on. I trade the usual post-aural incision (\V'ilde's), cleared out the mas-toid cells, opened the mastoid antrum, and then removed the bridge of bone between the antrum and meatus. 'I'he polypi could be seen attached to the tegmen tympani; this was removed, and the -egmen tympani and about half an inch of the adjacent Done was removed to expose the meninges. The wound vvas now swabbed with t in 20 carbolic lotion, then .1 opened the Jura .neater and passed a narrow scalpel upwards and forwards for three-qaarters of an inch into the temporo-sphenoidal lobe of the brain ; it was withdrawn —n o pus came. 1 then passed it directly upwards into the brain and withdrew it, but main no pus. 1 then re-inserted the scalpel upwards and backwards into the temporo-sphenoidal lobe and withdrew it, but still no pus. I then put a drain tube in the mastoid wound and sutured up.

The patient's condition was little altered as the result of the operation, and he still complained of intense frontal and occipital headache, which was partly relieved by antipyrin and caffein, but re-quired morphia subsequently. He also vomited at intervals. The condition of the reflexes remained unaltered. There was much more marked reaction on the left than the right side. The right L-'abinsk.i was still indefinite. There was no apparent loss of power in the right leg or arm, and the usual facial movements showed no loss of power in right side. The point of interest was now whether the left-sided re fl ex exaggeration was, in fact, a homolateral

AUSTRALIAN MEDICAL JOURNAL.

1178 AUSTRALIAN MEDICAL JOURNAL. August 23, 1913.

exaggeration which might have suggested a cere-bellar focus of trouble. In the absence of any definite localising symptoms I (A.L.) advised delay in further operation. In this condition the patient remained till May 4th (nine days after the first operation), when Dr. D. Grant kindly saw him. Dr. Grant considered there was very slight but definite paresis of the right side of the face. He found the right reflexes less marked than the left, and was not certain as to a Babinski. He advised the expectant attitude should still be maintained. On May 7th the boy's condition was markedly worse. He was lying curled up in the typical "cerebral" attitude—his speech was some-what affected, and he was very apathetic. The temperature was normal, as it had been throughout, and the pulse 70 per min. On this date for the first time the right reflexes were exaggerated, and there was a definite right-sided Babinski. It was difficult to be sure of the amount of facial paresis, and I did not then, or at any other time, feel convinced that it was present. A note of the ocular condition on this day by Dr. E. Ryan reads:—

LE.: Great deal of optic neuritis 6D of swelling. R.E.. „ f) ), f7 31 Jf

After consultation with Dr. J. Murphy, it was agreed he should explore the temporo-sphenoidal region again, and, if nothing was discovered, should proceed to a cerebellar exploration. His account of the second operation is appended :-

Operation 7/5/'I3.—The patient was given A.C.E. by Dr. Doyle, and about three minutes after the patient ceased breathing; his colour was good and his pulse full and bounding. Artificial respira-tion was resorted to, and, after a couple of minutes, stopped, but he would not breathe; this was tried again three times, and each time it was stopped the patient would not breathe. As the pulse was full and strong, I concluded that the cessation of respiration was due to intracranial pressure in-creased by taking ether; so while 'Dr. T. Ryan, of \hill, who wa.present, and Dr. Beamish continued artificial respiration I turned down a flap in the temporal region over the left ear and trephined, removing a /-inch circle of bone ; this opening was enlarged with biting forceps. The dura bulged, it was opened, and the brain bulged into the wound. The cerebral veins were very engorged. I passed a sharp-pointed forceps into the temporo-sIphenoidal lobe of the brain, to the region above the ear, and opened them out; immediately there gushed out about 8 to io ozs. of foul-smelling, greenish pus.

A rubber tube was put in the abscess cavity and brought out through an opening in the hase of the flap. About this time the patient showed signs of natural respiration. The wound was left open. Artificial respiration was kept up for about a quarter of an hour after reaching the ward, and as he was breathing well himself then it was .dis-continued. Next day the wound was draining freely; pulse 120, poor volume and tension. The day following he improved; pulse Too, and in about four days the tube was pushed out by intracranial pressure; the wound was draining well, but a

hernia cerebri developed, which in a few days at-tained the size of an orange; this was treated . by daily applications of absolute alcohol, and twice a week I touched the raw surface with a stick of nitrate of silver.

The hernia gradually reduced in size and the wound healed, so that when we saw the pa-tient early in August the hernia had dis-appeared altogether. There was no bulging of the scalp whatever; the wound had perfectly healed, al! that could be seen was the scar. The boy was quite clear mentally, and showed not the slightest sign, except his scar of the experience he had undergone. Moreover, his discharging ear has entirely cleared up.

SOME CLINICAL PHENOMENA OF THE TRANSVERSE LESIONS OF THE SPINAL CORD.

S. V. SEWELL, M.D. (Physician to Out-patients, Melbourne Hospital.)

Some few neurologists still remain to cast doubt on the condition of the deep tendon phenomena and epicritic reflexes in cases of complete transverse lesion of the spinal cord. Although for the most part the view first advanced by Bastian and so vigorously opposed by Gowers now .gains almost general acceptance, namely, that the reflexes below the level of the lesion are entirely abolished, and that this abolition is not due to a secondary de-generation of the lumbar sacral segments of the spinal cord. Certainly in three cases of complete transverse lesion that I have observed and examined pathologically there has been entire loss of epi-critic reflexes and deep tendon phenomena below .the level of the lesion. The boldness of Bastian's view and the opposition with which it was originally received is readily understood when one realises that experimental trans-sections of the spinal cord above the lumbar enlargement in all animals other than man are followed by exaggeration rather than diminution or loss of tendon phenomena. Ilow-ever; it is rather suggestive that trans-sections in the higher apes are followed by at least temporary absence .and prolonged diminution of tendon pheno-mena below the level of the lesion. The loss of tonus and consequent abolition of tendon pheno-mena depends on a block being established be-tween the affector mechanism and the anterior horn-cells of the spinal cord, which are the final common paths of the whole affector mechanism.

In lower animals the cross connection between primary proto-neurons and anterior horn-cells is well laid down, and if a block occurs in the higher arcs, such as is produced by a transverse lesion of the spinal cord, the affector impulses are, as it were, shunted across this lowest, or first, arc of the central nervous system to the anterior horn -cells; thus, these cells receive per unit of time a greatly increased number of impulses, and as fast as they receive them pass them on to the muscles with

August 23, 1913. AUSTRALIAN MEDICAL JOURNAL. 1179

which they are connected, with the necessary result that these muscles become hypertonic. Accord-ingly the deep reflexes are increased.

In human beings this lowest arc is of com-paratively slight importance, and the cross connec-tion between posterior roots and anterior horn-cells is not well laid down, the functions of this lowest arc being practically entirely absorbed by the great cerebellar proprioceptive arcs which constitute the second level of the nervous system. Thus it is necessary for affector impulses to travel at least as far as the region of Dciters' nucleus before being transformed into effector impulses, and from here to pass down the cord to the anterior horn-cells which they activate. Accord-ingly if this second arc of the nervous system is blocked, as is necessarily the case in a complete transverse lesion of the spinal cord, the anterior horn cells cannot receive sufficient impulses per unit of time to maintain their activity. Hence the resulting ihypotonicity and loss of deep reflexes which is observed below the lesion in cases of com-plete transverse lesion of the spinal cord.

The superficial epicritic or extero-ceptive re-flexes also disappear in complete transverse lesion of the spinal cord ; however, these reflexes are absent in all cases of involvement of the pyramidal tract above the dorsal region, and characteristically when the (leep tendon phenomena are exaggerated. 'these reflexes do not in any way belong to the proprioceptive mechanism, and their arc of main-tenance is through the cerebral cortex. Accord-ingly, if the effector mechanism of the cerebral cortex be interfered with, either in the ascending frontal convolutions or in the pyramidal tract itself, these reflexes are abolished; or it may be that, as shown by the rigidity, the proprioceptive impulses, being in possession of the final common path, the extero-ceptive stimulation simply allies itself with the proprioceptive impulse and brings about no alteration in status quo, and, therefore, no objective reflex manifestation. Thus the importance of uni-lateral diminution or absence of these superficial reflexes is equal to that of unilateral exaggeration of deep tendon phenomena in determining lesions of the effector mechanism of the cerebral cortex. In this connection it is of extreme importance, when investigating clinically, the condition of the superficial abdominal reflexes, to see that only the superficial structures are stimulated, because other-wise the recti abdominales may be stretched, and exaggerated proprioceptive reflexes thus obtained in cases where the true superficial reflexes are ab-sent owing to the pyramidal tract involvement pre-sent. The exaggeration of deep tendon phenomena in these cases of pyramidal tract involvement is explained by the fact that the blockage ill the highest, or cerebral, arc of the central nervous sys-tem leads to what may be termed a shunting of a largely increased number of affector impulses through the proprioceptive arcs, thus the anterior horn-cells receive many more impulses per unit of time and accordingly the musculature becomes hypertonic, a condition so frequently observed in cases of partial transverse lesion of the spinal cord,

clue to pressure anaemia, since the pyramidal tracts are much more affected by pressure and malnutri- tion than those of the proprio-ceptive mechanism..

Of all the clinical phenomena associated with transverse lesions of the spinal cord, the disorders of, micturition and defarcation are the least clearly understood. Very few authors have even attempted to bring these phenomena into line with the iii re recent physiological observations. In three cases which I have had the opportunity of observing the disturbances noted were, first, a condition of re-tention of urine with great bladder distension re-quiring regular catheterisation for from one to two weeks, and following on this a, ; condition of flow

"incontinence with contracted iiia(lder, where the bladder could not be induced to hold more than from two to five ounces of fluid, even if that fluid were delivered from a height of several feet. By the courtesy of Dr. W. R. Boyd, some time ago I saw a case of complete transverse lesion of the spinal cord at the level of the 5th cervical segment in which this condition of flow incontinence still persisted six weeks after the accident.

In this connection the work of Elliot is of great importance. This observer was able to cíembnstrate a definite reciprocal synaptic mechanism controlling the musculature of the trigone and sphincter area on the one hand and the general bladder muscula-ture on the other. Thus, if the general bladder musculature is in a state of contraction, the trigonal and sphincter areas are in a state of relaxation and vice versa.

Elliot found some variability in different animals. but for the most part that on stimulating with a weak current the pelvic nerve arising from the 211d and 3rd sacral segments, rhythmic contractions of the general bladder musculature were induced, xvith a gradual summation of effect, and when these contractions were sufficient to raise the intra-vesical pressure beyond a certain amount there was a simultaneous relaxation of the sphincter area with consequent emptying of the bladder.

A strong current produced spastic contraction of the general bladder musculature with active re-laxation of the sphincter area.

On the other hand, stimulation of the fibres of the hypogastric nerve arising from the upper lum-bar segments of the cord produced immediate re-laxation of the general bladder musculature and active contraction of the trigonal and sphincter areas. This effect was produced 'by a strong stimulus even when the general bladder muscula-ture had been rendered hypertonic by just previous stimulation of the pelvic nerve.

It is reasonable to assume that association fibres within the cord connect those two centres, and that 1\1cDougall's drainage theory may be applied to explain the control of micturition. Thus during voluntary micturition the synaptic resistance round the anterior horn-cells of the sacral centre is reduced, with consequent drainage of energy from the lumbar centre. In this way the function of the hypogastric nerve is inhibited. On the contrary, when micturition is voluntarily inhibited, the im-

1180 AUSTRALIAN MEDICAL JOURNAL. \ngust 23, 1913.

pulse flowing from the cortex lowers the synaptic resistance in the region of the anterior horn-cells of the lumbar centre, determining a drainage of energy from the sacral segments with resulting activation of the hypogastric nerve and inhibition of the sacral centre.

In health the auxiliary muscles of micturition, namely, the abdominal muscles and the muscles of the perineum, which are quite definitely r aider voluntary control, are of great importance in start-ing micturition and, tinder stress, in inhibiting it ; but these are in the same flaccid condition as the

• other skeletal muscles below the lesion, and are therefore not considered in this paper.

On examining pathologically these cases of trans-verse lesions of the spinal cord the degeneration on either side of the anterior median fissure of fibres, which are probably of thalamic origin, can he well traced to the third sacral segment. The fact that these fibres disappear between the fifth lumbar and third sacral segments, when considered in conjunction with the fact that no pure pyramidal tract lesion, however extensive, gives rise to any disorder of bladder function, strongly suggests that the fibres of this tract convey impulses controlling bladder movements and, therefore, the function of micturition. Accordingly it is suggested that the cerebral control is by way of the cortico-thalamic relay tract. Again, the fact that so many tumours and other lesions of the frontal lobes are associated with incontinence of urine further suggests that the path of control is fronto-thalamic thalamo-spinal.

The initial retention following transverse lesions • of the spinal cord is probably a result of shock,

together with the fact that the patient is completely anaesthetic below the level of the lesion.

During the period of shock the bladder becomes overdistended with urine and, since the patient does not complain, this fact is usually overlooked till all tonicity of the bladder musculature is over-come by dilatation. A considerable time neces-sarily elapses before tonicity is regained. Sooner or later, however, this atonic condition is replaced by a condition of hypertonus of the general bladder musculature and flaccidity of the trigonal and

.sphincter areas, and the patient suffers from a flow incontinence.

To explain this state it is necessary to assume a well-marked crossed connection between affector and effector mechanisms in the spinal cord. Thus it would seem that the crossed connection in human beings between posterior roots and anterior horn-cells subserving this elemental function is analo-gous to that existing between. all the posterior roots and anterior horn-cells of lower animals. Accordingly, in complete transverse lesions of the spinal cord, spasticity of the bladder musculature necessarily occurs in the same way that spasticity of the general body Musculature occurs in lower animals.

It would seem that this crossed connection is best laid down in the sacral centre since the de-trusor mechanism is in the ascendancy in cases of transverse lesion. On the other hand, I have a case under my care in which, as

the result of a blow from a falling tree, many of the roots of the canda equina were permanently damaged, all forms of sensation being still completely . lost bilaterally over all the sacral segments. The accident happened eleven years ago, and, as would be expected from the above considerations, the patient has suffered from retention of urine ever since, the catheter being used three times daily.

I have recently had the opportunity of observing a case of transverse lesion of the spinal cord clue to cystic formation between the lumbar and sacral centres concerned in the function of ,micturition, but can find no record of the bladder manifestations of such a case in the literature; nevertheless it is interesting to specu-late concerning the results of such a lesion. All co-ordination between the two centres is necessarily at an end, and the sacral arc being now free from upper neuron control the general bladder muscula-ture would necessarily tend to become hypertonic, and since the perineal muscles, which are of great importance in voluntarily holding up the act of micturition, are at the same time flaccid, the still active lumbar centre apparently cannot, .under voluntary effort, cause a strong enough contraction of the sphincteric and trigonal areas and sufficiently counteract the tendency to spasticity of the general bladder musculature to prevent incontinence of urine. The mere raising of intra-abdominal pres-sure by voluntary contraction of the abdominal muscles is sufficient to start the detrusor mechanism working, and so a pseudo control may be estab-lished, while the patient is still actually unconsci-ous that-the urine is passing owing to the anaes-thesia present, but for the most part a reflex in-continence persists with small amounts passing fairly frequently as the result of the excessive tonicity of the general bladder musculature.

Perhaps it is not unreasonable to conclude from the above considerations that the bladder mechan-ism is a reciprocal one controlled by the lumbar and sacral centres which are connected together within the cord by association fibres_, and which - are themselves under voluntary control of the cerebral cortex whose impulses pass to these centres by way of tracts on either side of the anterior median fissure of the spinal cord.

Moszeik describes a method with which, he says, one is almost certain to woo slumber with success. On going to bed assume a comfortable attitude in which every muscle is relaxed, but not the attitude in which you are ac-customed to go to sleep, but something resembling it. Every movement, coughing, Yawning, are strictly re-pressed, especially the desire to turn over. The same at-titude is maintained without change, constantly resisting the longing to move or turn over. As a rule by the end of fifteen or twenty minutes of this persistent maintenance of the same attitude, you find yourself growing very drowsy and then, just as the desire to turn over becomes absolutely uncontrollable, you turn with the least pos-sible effort and assume the position in which you habit-ually go to sleep, and natural sleep follows at once. This method seldom fails, he states, and should be given a thorough trial, at least, before resorting to a drug to bring sleep,

\11 g-tlst 13. I()1.3• AUSTRALIAN MEDICAL JOURNAL. 1181

RLigtraYtatY liflebtcar journal 23rd AUGUST, 1913.

SPIROCHIETA PALLIDA AND GENERAL PARALYSIS.

Of all forms of insanity, general paralysis is probably that which is most clearly comprehended by the practitioner of medicine. It presents a fairly definite symptomatology and in most cases some objective changes are more or less readily de-monstrable in respect to phenomena usually in-vestigated in ordinary clinical examination. There is sufficient constancy in the clinical course and complications of the diseas e and in the Morbid changes shown at autopsy to warrant its recognition as a well-defined clinical and pathological entity. Owing- to the great fre- quency of general paralysis. and its fatal character there has been abundant opportunity for the investigation of its etiology. That a cer-tain part in its causation is played by syphilis has been established by many workers. The conclu-sion has, in fact, been held by medical opinion for a number of years, that syphilis is an invariable antecedent of paralytic dementia. llut the ten-dency has been to regard the etiological problem as too complex for this fairly simple solution. Other factors are felt to be necessary to explain the development of subtle cerebral degeneration long after the primary infection, and so both tapes and general paralysis have been classed as para-syphilitic diseases.

Since the discovery of the spirochæta pallida as the causal organism in syphilis, much attention has naturally been directed to the search for this micro-organism in the brain of patients suffering from general paralysis. In our last issue appeared a notice of a meeting of the Johns Hopkins Hospital Medical Society, when several speakers extended to 1)r. Noguchi, well known for his original work on the cerebrospinal fluid, congratulations on having discovered the •piroch•te in such a case. It may be added that Noguchi's results have appeared in the "Journal of Experimental Medicine." Until his own report is more generally available, com-ment of any critical value is not possible. It has to be judged in the light of con-firmatory work, showing that the organism may be constantly- present: In a later paper ("Journal A.M. A.," July 13) Noguchi, describing his experi-mental work, says: "The results indicate that typical syphilitic scleroses containing Treponema palliduum have been produced in the testes of two rabbits by the inoculation of an emulsion of the brain obtained from a paretic individual." Should Noguchi's conclusion be generally confirmed, this will be the first instance of the demonstration of a micro-organism as the cause of a form of insanity. Other organisms have been claimed, for example the diphtheroid bacillus of Ford Robertson, as the cause of this very disease, but the claim has •not been sustained.

It is possible that from this work may result some advances in the treatment and in the diagnosis of general paralysis. It is recognised, however, that a purely satisfactory treatment is not likely to be attained, as cerebral neurons once degenerated can never be replaced or restored, even though the cause he removed. It is well, further, to re• member that even at present the diagnosis in a doubtful early case may usually be settled by ex-amination of the cerebro-spinal fluid in which a positive Wassermann reaction and a marked lymphocytosis may be found.

goto anb COUuneuto. A mild sensation has been introduced

Mr. Knibbs into the situation as regards the small-and Vaccination pox epidemic owing to the publication of

some figures by the Federal Government Statistician, Mr. G. H. Knibbs, on the subject of vaccina-tion. The accuracy, or inaccuracy, of 3ir. Knibbs' "con-clusions" cannot here be discussed for the reason that the sources from which they are compiled would have to be consulted, and after that is done it would require a mind specially trained in dealing with large masses of figures to grasp the possible margin of error.

This question apart, however, it is not unjust to stig-matise Mr. Knibbs' action in publishing these statements at the present time as extremely ill-advised. The Federal quarantine officials have been called upon to deal with an epidemic of small-pox, and they have, in accordance with accepted medical teaching, advised a policy of active vac-cination. This policy the Government, as in duty bound, have endeavoured to forward in every direction. Without any apparent warning the Federal Statistician publishes statements calculated at least to seriously disturb the advice of the medical department. Mr. Knibbs night have waited until public anxiety was less strained. He might have waited in hope that the present experience would afford him some fresh evidence, but most emphatically ought to have waited from the knowledge that the duty of publishing such debatable material at the present time was not his own, however much he believed in it. Mr. Knibbs' figures will not affect medical opinion or practice, but there is no saying what harm they may not do in the public mind.

* • There are still a few self-opinionated individuals who vociferate their belief that the epidemic in Sydney is not small- pox because it is so mild. These mild

manifestations were well known to Jenner, who wrote in his original publication the following account:—"There are certainly more forms than one, without considering the common variation between the confluent and the dis- tinct in which the small-pox appears is what is called the natural way. About seven years ago a species of small-pox spread through many of the towns and villages of this part of Gloucestershire: it was of so mild a nature that a fatal instance was scarcely ever heard of; and consequently so - little dreaded by the lower orders of the community that they scrupled not to hold the sanie intercourse with each other as if no infectious disease had been present among them. I never heard or saw an instance of its being con fluent. The most accurate man- ner in which I can convey an idea of it is by saying that had fifty individuals been taken promiscuously and infected by exposure to this contagion they would have had as light and mild a disease as if they had been in- oculated with variolous natter in the usual way. The harmless manner in which it showed its-elf would not arise from any peculiarity either in the season or the weather, for I watched its progress upwards of a year without perceiving any variation in its general appear- ance. I consider it, then, as a variety of the small-pox."

Small-pox.

I I S) AUSTRALIAN MEDICAL JOURNAL. August 23, 1913.

In the "Australasian Medical Gazette" Dr. Vaccination Hipsley, of Sydney, publishes a note on Symptoms. a number of cases in which severe ab-

dominal pain had occurred in recently-vaccinated subjects, and of such suddenness and severity in some patients as to suggest the possibility of grave intestinal emergency. He states that acute pancreatitis was brought to his mind in more than one instance, and that a curious feature in almost allcases was the sudden onset. The same phenomenon has been observed in Mel-bourne, and in a note was mentioned a fortnight ago in this column. In these patients another curious feature was the time of development in relation to the inocula-tion. Nearly all were ten, or more, days after the date of vaccination. We have been unable to find any refer-ence in literature which exactly covers these cases. Vomit-ing is not unusual, as an accompaniment of the febrile reaction, but epigastric pain of a persistence and severity which necessitated morphia is not chronicled as a recog-nised symptom. We can scarcely subscribe to the figures given by Dr. W. Summons as to the frequency of vaccinia eruptions, which appear to have been much commoner than in his experience.

Notwithstanding the vast number of vaccinations re-cently done at all ages and under all conditions, there has been nothing resultant which in in any way justifies any lymph scare. Neither is there any reason to suppose that vaccinations have not been carried out with every possible care. Reactions are as varied as the individuals who are vaccinated.

Tßrítí^^ fliebícat aizoctatton. VICTORIAN BRANCH.

NEW DIVISIONS. A meeting of members interested in the proposal to

farm a new division of B.M.A. in the Wimmera was held at Murtoa on Wednesday evening, August 13th. Present:

Drs. Hayman, Bonnin and Brown from Ararat, Fox and

Forshaw from Stawell, Foster and Read from Horsham,

Rabl and Cade of Murtoa, Duguid from Minyip, Ingham

from Dimboola, Cook from Rupanyup. Dr. Honman, of

Melbourne, and Dr. Sloss, Ballarat, were present to assist.

After Drs. Honman and Sloss had explained the pre-sent position in regard to medical politics, and emphasised

the need for better organisation amongst members of the

profession, a motion was unanimously carried that a new division to be known as the Wimmera division be imme-diately formed. The division to include Glen Thompson and the towns on the Melbourne-Adelaide line and its branches from Ararat to the South Australian border.

It was decided to hold ordinary meetings quarterly at

Ararat, Stawell, Murtoa and Horsham in rotation. The

day of meeting to be Wednesday immediately preceding

full moon in November, February, May and August. The members present then formed themselves into a

committee and proceeded to the election of officers. Dr.

Hayman was unanimously elected president, Drs. Fox, Rabl and Read vice-presidents, Dr. Forshaw secretary, Dr. Foster treasurer; Drs. Bonnin, Cade, Duguid, Tre-gear, Shanassy and Ingham, members of local council. Dr. Bonnin was chosen as representative on general council.

The rules and bye-laws of Ballarat division were adopted

till next meeting. The meeting terminated with vote of thanks to Drs.

Honman and Sloss for being present to advise and assist.

Dr. Cade, of Murtoa, entertained visiting members at

dinner before the meeting.

THE CAS;!: AG:IINST THE PROPOSED "BILL FOR THE REGISTRATION OF SIGHT-TESTING OPTICIANS."

(Published by Direction of the Eye and Ear Section, Victorian Branch, British Medical Association.)

On the suggestion of the then Acting Premier, Mr. Murray, aConference between gentleman representing the Medical profession, the Victorian Optical Association,

and representative opticians outside the Association, was

held at the rooms of the Association, The Centreway,

Collins-street, on the evening of Monday, July 21st, 1913.

Present on behalf of the Eye and Ear. Section of the Victorian Branch B.M.A.:—President, Dr. Edward Gault;

Dr. F. W. Orr (for Dr. J. W. Barrett), Dr. A. L. Kenny,

Dr. P. Webster, Dr. Leonard Mitchell, with IIr. H. H. Baker (President of the V.O.A.) and Mr. Wm. Nett (Secre-tary), several members of the Council of V.O.A., and Mr.

Ingram, i\lr. Alfred Nott, and Mr. Heath, opticians, not

members of V.O.A.

A very frank discussion took place of the points at

issue between the medical profession and the opticians in

relation to the proposed "Bill to Regulate the Practice

of Sight-testing Opticians."

It soon became clear that the disagreement was funda-mental, involving the entire purport of the Bill, and was not one of title merely.

Clauses 8, 9, 10 contain the pith of the Bill.

Clause 8 says:—"Subject to this Act any sight-testing

optician shall be entitled to practice sight-testing in any part of this State."

The opticians claimed that an optician who has com-plied with certain educational requirements to be laid

down by the Board of Registration constituted by the Bill will be qualified to test sight and prescribe glasses. They ask Parliament to say this in the Bill, and to say it with-out any qualification whatever.

Oculists denied the competence of opticians to test sight in a large number of cases.

1. Absolute accuracy would be ensured if the control

of the patient over his own eyes is abrogated by the use of

drugs (atropine, etc., to paralyse the accommodation of

the eye). The use of such drugs by any but a medical

practitioner was undesirable, and involved the risk of

serious inflammation of the eyes and loss of sight. This was admitted by the opticians, who said that it was their

intention to have a clause inserted in the Bill forbidding the use of drugs by opticians in accordance with the regulations made by the Worshipful Company of Spectacle Makers orT.ondon, and similar bodies in some other States,

where opticians register diplomas. l'he President, Mr. H.

H, Baker, also admitted, that, if drugs were not used, it

would be impossible to accurately test the refraction of

young people. The oculists contend that these qualifica-tions of the competence of the opticians as a sight-tester

are so sweeping that they completely cut away the justi-fication for Clause 8, and that any parliamentary sanction

to the practice of opticians as sight-testers would be con-trary to fact, and would he dangerous to the public.

2. The oculists urged that 'people asking for spectacles for the improvement of sight or relief of discomfort in

the use of their eyes often require treatment either local

or general. The opticians admitted this, and did not

claim any competence or any desire to afford relief in these directions. They claimed, however, that by acquiring

some knowledge of diseases of the eye they could dis-criminate between those who required, and those who did

not require, medical treatment, and that practically from

day to day the trained optician picked out, and sent on to

the oculist, the cases requiring his attention. The oculists pointed out, firstly, that only a thorough

training, first in general medicine and then in ophthal-mology, could qualify a man to diagnose correctly dis-eases of the eye, and to know when glasses were a suitable

and sufficient treatment for a case and when they were

not. Secondly, they draw attention to certain important

diseases of the eye, such as glaucoma, which might remain

latent though steadily progressing, and which only the skilled oculist could detect at the early stage, when treat-ment was most likely to be of use. It would be a serious

thing if Parliament, in effect, said to the public that they

might with safety consult opticians for defects of their sight. Tinder the provisions of this Bill they would have

no reason to suppose that in doing so they were making a

fatal error.

3. It was now generally known by the public that

August 23, 1913. AUSTRALIAN MEDICAL JOURNAL. 1183

headaches were often caused by errors of refraction, and might be relieved by the wearing of spectacles. Opticians every day advertised this fact, and invited sufferers to go to their "parlours" for relief. Once seated in the optic-ian's chair they never failed to buy a pair of spectacles, and if the first did not relieve, they purchased a second, or a third, in the vain attempt to cure a headache, which might be due to widely differing causes. It was quite impossible for the optician to diagnose the cause of the headache, and, therefore, he had no justification for pro-fessing to do so. Parliament at any rate would not be wise to authorise him to do anything involving the treat-ment o! disease. The eye, when its function for any rea-son was impaired, was a diseased eye, and the only person who should be authorised by Parliament to treat such an eye was a properly qualified and specially trained medical man.

4. By reason of its intimate association with every other part of the body, the eye frequently suffered in connection with general diseases. Often there was im-pairment of sight which might in many cases be so much improved by spectacles that the optician would not sus-pect the co-existence of disease. It is part of the experi-ence of all oculists how such persons are ignorantly treated by opticians, who were incapable of recognising the diseases from which they are truly suffering.

For these reasons the oculists maintained that opticians could not claim to be generally competent to test eyesight in the sense of determining the cause of defects of sight. Their training and methods could enable them only to measure refractive errors, and these only in certain groups of cases, while others were left completely outside their sphere. The sphere of treatment even by glasses was essentially that of the medical man, and was outside their competence.

This brought matters to an impasse, as the President of the V.O.A. stated, and the Conference was closed.

During the discussion reference was made to the sweep-ing exclusiveness of the provisions of Clauses 9 and 10, which went much further than anything in the Medical or Dental Acts. Under these clauses no one would be permitted to practice as a sight-testing optician unless registered in accordance with the Act. While medical men and dentists were registered, unqualified and unregistered persons were still permitted to treat disease by medicine or other means. The Legislature did not think it was in the interest of the public to restrict them from consulting whom they would when it gave them an indication whom they might safely consult. It was asked why the opticians desired such increased stringency in regula-tion. The answer given was that it was desirable to pre-vent the spectacle vendor fr•oni posing as a man competent to test sight. Several pointed out that the mechanical pro-cess of sight-testing could be quickly acquired and cor-rectly applied by a man of very humble attainments in scientific knowledge, and that such a man would be just as likely to test sight accurately as a highly trained scientist. There was no justification, therefore, for curtailing his liberty to practice if the public chose to employ him.

The Bill really proposed to create a close corporation of opticians who might keep to themselves a very lucrative trade under the specious plea that it was a highly skilled profession. Admission to this narrow corporation was to be granted by a Board consisting of the opticians them-selves, who would be in a position to exclude whom they could, and to keep their numbers within limits satisfac-tory to themselves. (See Constitution of Board—Clauses 11, 12 13.)

Any proposal to improve the training and education of opticians would meet with the ready support of the ocu-lists. It was held that it should be at once technical and scientific—should be directed not by the opticians alone, but by them with the assistance of men engaged in higher education at the University and Working Men's College, and that sight-testing should not be prescribed as an essential part of the course, although there could be no objection to its introduction as a part of the information which an optician might desire to possess.

SHOULD PUERPERAL FEVER RE NOTIFIED!

A writer in the "'Hospital" asks this question, and, while neither upholding nor rejecting his opinion, we reproduce it in the hope that some opinion may be forthcoming from correspondents:—

With the general policy of extending notification to every infective, and especially every epidemic, disease all modern expert opinion agrees. Thus measles is not yet notifiable in London, though public health au-thorities are practically unanimous in advocating that it should be; and it is probably only a matter of time before this desirable reform is instituted.

There is, however, one notifiable disease which might with advantage be deleted from the schedule, and that is "Puerperal fever," so called. Only .a couple of genera-tions ago this condition was regarded as an epidemic dis-ease of mysterious origin—or rather of disputed origin —

and compulsory notification was quite justi fiable in the light of what was then known about it. Nowadays it is universally admitted that puerperal fever, as a single de-finite disease, has no existence at all. Any sort of septic infection in any part of the genital tract may give rise to symptoms and signs of fever in a woman who has lately been through the ordeal of child-birth; and the treatment of this complication depends entirely on the situation of the infection and its character. Strictly speaking, any rise of temperature in a lying-in woman constitutes puerperal fever; but, of course, no one would apply this term to a temporary small rise above normal due, let us say, to constipation. The practical point is, however, that puer-peral fever is not a definite disease, such as scarlet fever or typhoid fever; but merely a symptom of many different conditions.

Furthermore, a considerable section of the intelligent public is now aware that rigid antisepsis in the conduct of labour is an almost absolute precaution against puper-peral fever; indeed, many of the public now believe that puerperal fever must necessarily be the result of negli-gence on the part of the obstetrician. It may be granted that puerperal sepsis diminishes in proportion as the strict observance of asepsis and antisepsis amongst obstetricians increases; but even the most expert and conscientious Listerian cannot guarantee complete im-munity from puerperal fever in his patients. Knowing, however, that in the public mind some degree of odium and loss of reputation attaches to anybody in whose prac-tice a case of puerperal fever occurs, doctors are ex-tremely unwilling to admit that this condition exists and to follow out the law of the lind by notifying it. The consequence is that the statistics dealing with the inci-dence of puerperal fever are misleading to a degree. As a rule only those cases get notified where the possibility of a fatal ending is by no means remote, or where admission to some public hospital is secured for the patient. The result is that the death-rate, as it appears from public health records, is somewhere in the neighbourhood of 40 to 50 per cent. of the cases; whereas if all cases were included it would probably not exceed 5 to 10 per cent., and might even be much less than that.

The present writer can call to mind a good many cases at least which were never notified as they should have been on a rigid interpretation of the law. Doubtless most practitioners could parallel these cases. A brief state-ment concerning four of them may be of use.

Some few years ago the writer admitted to hospital a woman desperately ill with acute septicaemia, two or three days only after her delivery. Despite all treatment she died in a few hours. He then learnt that another woman, delivered by the same practitioner, had died less than a week before with very 'similar symptoms; a death certificate was given to the relatives by this attending practitioner, stating that the cause of death was pneu-monia. There can be little doubt that this also was a case of acute puerperal septicaemia, and it went not merely unnotified, but also entirely unregistered. The next case was one which occurred in the private practice of a London consulting obstetrician of good reputation. Death was officially ascribed to typhoid fever, but it was admitted subsequently that the real cause was puerperal sepsis.

1184 AUSTRALIAN MEDICAL JOURNAL. August 23, 1913.

The other two cases illustrate an opposite difficulty—that of deciding whether a border-line case should or should not be regarded as "puerperal fever." The writer a few months ago encountered a case of mild cystitis during the puerperium, lasting about a week. The tem-perature ranged between normal and two degrees over normal, and there was absolutely no cause for it other than the cystitis; the symptoms yielded to simple drug treatment without any necessity for local measures. The case was not notified; and probably no one would con-tend that it ought to have been. Yet in absolute strict-ness it was a case of "puerperal fever," because there is no hard-and-fast line which defines what is and what is not a degree of fever which should be notifiable. Then, again, he lately saw with a colleague a case in which, after a fortnight of normal convalescence, a lying-in woman developed a temperature five degrees over normal, together with other somewhat alarming symptoms of sapraemic absorption. An intra-uterine douche brought away a small clot, the temperature fell rapidly to normal, and subsequent convalescence was uninterrupted. Here, again, the practitioner did not notify the case, though it was certainly one of "puerperal fever," nor does it appear that the advantage of doing so, from a public health stand-point, would have outweighed the obvious disadvantages attaching to such a course.

What then should be done? In the opinion of the writer, and of much higher authorities than he, puerperal fever should be struck off the list of notifiable diseases altogether. The arguments in favour of this course have been very ably marshalled by Dr. V. Bonney ("A System . of Treatment"; edited by Latham and English). He points out that "the object of notification is to facilitate the segregation of cases of disease infective to the com-munity at large; to enable the sanitary authorities to take steps to disinfect the dwellings of such patients; and to Permit of better investigation into the causes underlying the occurrence of epidemics. In all of these particulars notification fails in the case of puerperal sepsis; its only effect is to cast an often unmerited stigma on the obstet-rician, and to create a consequent disinclination to com-ply with the law, or even to recognise the disease unless it becomes extreme. In view of the bacteriology and pathology of child-bed fever, there is much less reason for its notification than in the case of wound sepsis after surgical operations, an occurrence far, more within the control of the medical man.

"Notification is, in fact, •a remnant from the days when the disease was held to be due to some mysterious con-tagion, the method of whose spread was unexplained and unpreventable." He suggests that compliance with this out-to-date regulation is only reasonable and necessary when by reason of the bacteriological examination and the clinical picture it is apparent that the patient is suffering from infection by a virulent organism. The conceivable objection to its abolition is that one great incentive to Obstetric carefulness and cleanliness might be abolished with it. But it has been shown, for one thing, that the vast majority of the cases, severe and trivial alike, are never notified as matters stand; and for another, we may remark that the worry and anxiety of having a case of puerperal sepsis on one's hands are a far greater incentive to per-fect Listerian technique than the comparatively minor detail of complying with the public health laws as regards notification.

Attu OOOttii. "Coprostasis: its Causes, Prevention and Treatment." By

Sir James Sawyer, M.D., T.ond., F.R.C.P. Birmingham: Cornish Bros., 1912.

Under this title Sir James Sawyer reprints six chapters from his "Contributions to Practical Medicine." The title is somewhat misleading as only three of the chapters deal with constipation from the physician's point of view, the other three treating of clinical observations on intestinal occlusions; lumbago coprostatica. the cause and treatment of a form of backache; and pilewort and piles. There is xio concerted scheme in the book, the chapters having evi-

dently been written as mere occasional papers. There is thus a great deal of overlapping and repetition. The writer formulates certain rules of practice in the treat-ment of habitual constipation, which his experience has abundantly confirmed: "(1) We should never leave the medicinal treatment of constipation of the bowels to our patients; (2) we should never prescribe drugs in the treatment of habitual constipation until we find that the constipation cannot be cured without the aid of such medicaments; (3) we should never prescribe drugs in the treatment of habitual constipation without the conjoined use at the same time of a well-selected and judicious combination of the numerous adjuvants of natural alvine relief which are at our disposal and which we should especially select by our experience in practice and dis-pose according to the individualities (sic) of the patient." The writer's style is usually quaint, often to pedantry, and frequently more rhetorical than the subject warrant "Many hearts throb to the fetich of a punctual faex," is one example. Many others could be quoted. The book is well printed. L.G.L.

"The Food Inspector's Handbook." Sixth edit., July, 1913. By Francis Vacher, late M.O.H. for Cheshire, vice-president of the Society of Medical Officers of Health. London: The Sanitary Publishing Co.

The book is a well printed, compact volume of 300 pages. It contains a hundred illustrations of pathological conditions occurring in animal and vegetable foodstuffs.

The qualifications of a "food inspector" are clearly set forth in the first chapter, and in the succeeding ones a concise statement is given of all the statutory powers conferred by the various public health acts and regulations at present in force throughout England. The remainder of the book is devoted to describing the physical signs by which unwholesome food intended for human consumption may be detected.

The fact that the book has passed through six editions is ample evidence of the practical value of the contents. The text has been revised and brought up to date, and seems to contain not only all that a food inspector re-quires to know, but much that is of service to a medical officer of health. W . S .

CURRENT LITERATURE.

The Small -pox in Sydney. Armstrong ("Aust. 'Ted. Gaz.," August 16th) says:— The special points of conformity for all practical pur-

poses between this epidemic and classical small-pox are two in number, namely, the invasion of the disease and the distribution of the rash. Ih individual cases even these identities may be wanting, more particularly when children are the subjects of attack, but in general they persist, and form a diagnostic barrier between this graded type of small-pox, and the other disease, which it most resembles—chicken-pox. The invasion period is well marked in almost every case in adults at all events. It is distinctive as compared with the invasion of varicella. Tt is usually rather gradual in its onset, and is marked by frontal headache (which, according to the statements of patients, is always the most prominent symptom), gene-ral febrile symptoms, backache (in about 20 per cent. of the cases), vague general pains, vertigo, rarely distinct rigors, and sometimes vomiting. Patients almost always liken the attack to one of influenza. The invasion period varies from one to eight days, and averages about 5 days, and during this time the toxaemic fever may run rather high. One has naturally very few opportunities of ob-serving the disease at this stage, but in two instances of the more severe cases which one has personally seen, and in two or three others upon which the testimony of other medical practitioners has been forthcoming, the tempera tore in the invasion stage has mounted well above 103deg. F.

All the symptoms of the period of invasion usually re-mit for a variable time before the rash appears, and the patient considers himself quite well and generally returns

AuguSt 23, IgI;. AUSTRALIAN MEDICAL JOURNAL. 1185

to work, if the illness has been sufficiently severe to com-pel him to cease work at all. For, in some of the milder cases the severity of the symptoms is not sufficient to cause cessation of ordinary occupation. In some cases the symptoms of the invasion period do not abate until the rash appears, but this seems to be unusual. Speaking generally, the period of invasion is longer than in the classical type of the disease.

Judging from the few cases in which young children have been affected up till now in this epidemic, the in-vasion period is much less marked in them than in adults in all its manifestations. In at least two instances one has been told by the mothers that the child suffered from drowsiness and restlessness for about a day before the rash appeared. It is also interesting to note that young children have suffered very slightly both as to numerical intensity of the focal rash and as to constitutional symgP-toms, as compared with adults.

The broad features of the distribution of the rash in the classical picture of small-pox are that the rash pre-fers the upper half of the body to the lower, that it is a rash of the face and arms rather than of the trunk and legs ; that it affects the distal rather than the proximal ends of the limbs, the back of the trunk rather than the fron the extensor surfaces rather than the flexor.

These broad features apply generally in this epidemic, but in individual cases the anomalies of distribution are great. For instance, in many cases there is a reversal of the order of incidence on the extensor and flexor surfaces of the arms. In many cases the density of the rash on the arms increases from below upwards as with chicken-pox, and we have seen it in cases more copious on the abdomen than on the chest, and even in some instances entirely absent from the face.

In many of the cases of this epidemic the numerical severity of the rash has been so low that all the pocks on the whole surface of the body numbered less than 20, and in some cases as few as three or four. In such cases it is impossible to expect the distribution of the rash to observe any law. Nevertheless, when taken broadly, the rash in this epidemic as a whole does follow the laws of distribu-tion observed by small-pox, and one of the most important of the diagnostic tests which are applied to it by the staff of this department in judging a case is the great and early predilection of the rash for the face as com-pared with the body and limbs. Usually in the milder cases the rash first appears as a pimple on the nose or forehead, and in the majority of the cases, particularly the later cases of the epidemic, the rash on the face continues to exhibit greater numerical intensity than on any other part of the surface.

It is in the characteristics of the eruption of this dis-order (_apart from the distribution) that some of the most marked differences are to be found from the classical conception of small-pox. The most striking of all these differences is the sparseness of the eruption. In a few of the cases which we have seen, it is true the rash has been fairly copious, even for an attack of the classical variety, and in one patient in which the pustules were counted, they numbered 4,000 upon the whole surface of the body, of which 362 were on the face. In another there were over 900 upon the face alone. But these cases have been quite the exception in this epidemic. The average number of lesions upon the face in the majority of cases has ranged from about 12 to, say, 30, while many cases have been observed in which the whole number of lesions uj)on all parts of the body could have been counted upon the fingers of the two hands.

Another direction in which the lesion has been usually aberrant has been in the course of its development. In the evolution of the typical lesion of small-pox the time occupied by the several stages is about two days for the papille, two days for the vesicle, and four days for the pustule until encrustation begins. The eruption usually appears also in a single crop; that upon the face being slightly in advance of the rest of the body. Here one finds the regular stages of the development of the lesions obliterated, or nearly so, in many of the cases. Often the first sign of the eruption is a pimple on the nose or fore-head, which acquires a pustular head in a few hours, and

sometimes so rapid is the change that the lesions seem almost to make their first appearance as pustules. They also appear in crops, and in many instances continue to come out from day to day throughout the whole period of efflorescence until most of the lesions have scabbed over. One of the most marked instances of this oc-curred in the case referred to as having over 900 lesions upon the face. Inthis case upon the tenth day of the rash 57 new pustules appeared upon the dorsum of one foot and 23 upon the other, and considerable numbers upon the hands and arms. [n most of the cases it has been observed that lesions in various stages of develop-ment have been present at the same time, and on the same part of the body, and in cases where the eruption has been at all copious the proportion of small and aborted lesions hasbeen very much greater than in strains of small-pox of the ordinary virulent type. In most cases of virulent small-pox a minority of the lesions are small or abortive, but in this forni of the disease such abortive lesions are frequently in the immense majority. Most of the variations from the ordinarytype appear to depend very largely upon the superficial character of the rash in this epidemic. This characteristic shows itself best in the absence of pitting of the skin observed in a number cf the patients who have already recovered and in the shallowness of the little ulcers which is seen when a pustule is accidentally ruptured. When the lesions are fairly large their superficial character is also shown by the appearance of the margin of the pustule. In chicken-pox the pustule or vesicle often appears to be lying upon the surface of the skin. In ordinary small-pox it j.tts through the skin, throwing the surrounding skin up in a slope round the base of the pustule. In this form of small-pox the appearance presented by a full-sized lesion is half-way between the two. It is less superficial than in chicken-pox, and more so than in ordinary small-pox. The same fact accounts for the sinuous jagged out-line and oval shape of the lesion which are often seen in the present epidemic, especially in those lesions situated on the trunk. The minor characteristids of the focal lesion, such as the umbilication and loculation of the vesicle, are in this epidemic equally anomalous. In the severer cases of the epidemic these are often present; but in the milder type of case they are often wholly wanting.

It is the relative or complete absence of the eruptive fever which accounts for the exceeding mildness of the present epidemic. Even in cases which pass as severe (and there have been one or two in which the rash upon the face was nearly confluent) the maturation of the pus-tules has been accompanied with very little elevation of temperature. In the case of the girl E.B., who was ad-mitted into the Sydney Hospital, and whose illness in many respects has been more typical of the ordinary form of small-pox than almost any other case seen in this epi-demic, she never had a temperature to speak of after the rash appeared. She was admitted into hospital on the 12th, and the rash first appeared on the 15th. Previous to the appearance of the rash she had a toxaemic fever run-ning very near 105 dng. F., but after the rash had once appeared her temperature only once touched 101 deg. F., and that was on June 20th, the day after her removal to the Coast Hospital. On the 21st it fell to 99 deg. F., and on the 22nd to normal, from which it never again rose. All through the stage of pustulation she stated that she felt perfectly well, and complained of not getting enough meat to eat.

In most of the cases sent to quarantine the temperature has continued normal throughout the eruptive stage, and the patients have not exhibited any symptoms of that pro-found illness which usually accompanies pustulation in t : ' unvaccinated. It is advisable at this point to repeat again that practically the whole of this epidemic has occurred among unvaccinated persons. Of the 450 per-sons who have so far been officially diagnosed as suffering from small-pox, only nine persons had ever previously been vaccinated, and they have been in all instances either old or elderly people who had been vaccinated in childhood, and whose immunity had had time to disappear. Sydney is probably the worst vac-cinated community in the whole civilised world, and it is this fact which makes the extreme mildness of the present outbreak so astounding.

1186 AUSTRALIAN MEDICAL JOURNAL. August 23, 1913.

CORRESPONDENCE.

Supply of Lymph.

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

Sir,—How is the following matter to be explained?

I am public vaccinator for this district. I have had no lymph officially sent me for more than a month. On my last application for some I was told that no lymph would be supplied outside the suburbs "till further notice." A week .ago a suburban practitioner applied for three tubes of lymph. Six were sent to him! And yet here am I as a public vaccinator supposed to be carrying out the law of compulsory vaccination for .infants, while righteously indignant mothers travel over miles of vile roads to keep

the law. On enquiry they find that the public vaccinator has no lymph, and no immediate hope of getting any.—Yours, etc, C.P.

18th August, 1913.

GENERAL.

The first completed report on the working of the na-tional insurance act in England forms a volume of 660 pages. It includes an account of the formation of an in-surance fund of nearly $100,000,000, the insuring of nearly fourteen million persons, the constitution and work of 236 insurance committees, and the making of regulation and special orders to meet unusual cases. During the first four months after the act came into force (July 15, 1912), 2,865 applicants received the sanatorium benefit for tuber-culosis in residential institutions, 507 in tuberculosis dis-pensaries, and 891 at home. By April 30th, 1913, the number in residential institutions had increased to 7,464, those treated in dispensaries to 2,167, and those treated It home to 4,993. At present there are in England over two hundred residential institutions which have accommoda-tion for eight thousand cases. The medical benefit agree-ments with physicians were first entered into for a period of only three months. It is claimed to be significant as an indication of the general attitude of the profession that on the expiration of this period the agreements were renewed by practically all the physicians. On January 15, 17,796 physicians were on the panels; on April 14 the number was 18,584, which forms between 80 and 90 per cent. of those engaged in industrial practice.

A curious feature of the vaccination figures compiled by . Mr. Knibbs appears to be that they were already •a topic of public discussion before they were published in the daily press.

The British Parliamientary party, which is to arrive, in-cludes several militant 'antivaccinationists.

The conference of hospital sta ffs as to the appointment of resident medical officcers at the three leading metro-politan general hospitals in Melbourne resulted in failure to arrive at any agreement.

In view of the complaint at the Port Melbourne council that the new measles hard established near the Infectious Diseases Hospital is not fit for reception of patients, Mr. J. Thomson, who is acting as Minister of Health in the ab-sence of Mr. Hagelthorn, conferred with Dr. Robertson and Mr. G. W. Watson, the Chief Architect of the Public Works department. The officers held that the statements made to the discredit of the work of the departments were not justifiable. When finally fitted up, they said, the build-ing would meet requirements. It was an improvement on the building originally expected by the Health department. Its 'purpose was for the reception of oversea cases, which can only be accommodated at Coode Island.

fßrítíob Alebícat 25gocíatíon.

VICTORIAN BRANCH.

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

Secretary.

NOTICES.

Warning Notices. Medical men, before applying for the position of medical

officer to lodges at Longreach, Central Queensland, are in-vited, before doing so, t0 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-tary, B.M.A., 429 Strand, London.

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.

VICTORIAN BRANCH.—Ordinary Meeting, 1st

in month. Clinical Meeting 3rd

in month. PEDIATRIC SOCIETY.—Second Wednesday in month.

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

MELBOURNE HOSPITAL CLINICAL SOCIETY.-4th Fri-day in the Month.

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.

Q^

//-.C)-(3°

^ Telephone 1434 Central.

701 1

.!s The treasurer in Victoria (Mr. R.

desires to acknowledge with thanks the butions:—

Amount previously acknowledged Dr. N. Crowley .. .. .. .. Dr. Stanley Argyle .. .. .. .. Dr. Reginald Morton .. .. , .. Dr. D. M. Officer .. .. .. .. ..

ttAill rs win,31"

.. £50 7 0 10 0 10 0 10

.. 1 1

ri-

6 6 6 6 0

Rev. H. S. Legge (Maldon) .. .. .. .. .. 1 i 0 Dr. J. L. Blakie .. .. .. .. . .. 1 1 0 Dr. W. P. Sweetnam .. .. , . , , . , 0 10 6 Dr. John H. C. Hicks .. .. .. .. .. .. .. 0 10 6 Dr. G. R. West .. .. .. , , 0 10 6 Dr. Mary A. Henderson .. 0 10 6 Dr. F. A. Newman .. .. . .. 1 1 0 Dr. A. Norman McArthur .. • .. .. 1 1 0 Dr. A. E. R. White .. .. .. . 1 1 0 Dr. John Murphy .. . 1 1 0 Dr. Edward Ryan .. .. .. .. .. 1 0 0 Dr. H. B. Devine .. .. .. .. .. .. .. .. 1 0 0 Dr. Herman Lawrence .. .. .. 1 1 0 Dr. D. .Murray Horton .. . . .. 1 1 0 Dr. Forbes Mackenzie .. .. .. .. 1 1 0 Dr. Rothwell Adam .. .. .. .. 1 1 0 Dr. J. E. Nihill .. .. .. .. .. .. .. 0 10 6 Mr, Paul H. Nihill .. .. .. .. ... .. 0 10 6 Dr. A. L. Kenny .. .. .. .. .. .. 1 1 0

Wednesday

Wednesday

LORD LlS'l'ER LATE RNA 'l'IONAI,' .Mi'

!•

1 tigus1 3o, 1913. AUSTRALIAN MEDICAL JOURNAL. 1187

- REFLECTIONS ON BACILLURIA.

JCI,l:A \ S:A1 l'l'H 11.D., M.S., B.Sc., _1lc1b. (Assistant Surgeon, St. Vincent's Hospital.)

It has apparently been evolved as part of the scheme of nature that colon bacilli shall inhabit in large numbers the intestinal tracts of birds, beasts and fishes, and no one wonders at

• it any more than at the sun's warmth. But it is conceivable that the gastric juice might always sterilise the ingesta and maintain them so throughout the tract. So, also, it has been evolved as part of Nature's design that the urinary tract shall as .a rule be devoid of bacterial inhabitants. I ut in the sane manner it is also conceivable that the bìoód might have been so -frequently infected by absorption from the bowel as to continuously requir e the kidneys to shower excretory infection on the urinary tract as to ren-der bacilluria universal. Even if it were so it is doubtful if there would be many very sick people because of the resistant nature of the urinary epithelium.

This resistant barrier is at times broken through in these infected cases and definite symptoms, gene-ral and local, supervene just as the barrier of the intestine is at tinges broken through, with resulting general symptoms. Nevertheless many of the people with bacilluria go on for a long time with just as good health as one sees in many not quite robust people whose urines are sterile. Medical opinion is now fully alive to the possibilities of these cases, and in no case the least obscure is the urine passed over without the most searching ex-amination, in which cultural tests play a prominent hart.

The following case, seen a few months ago, is very interesting in this respect. A man of 45 gave the history of having for some five years pre-viously attacks of high fever with severe headache and general pains accompanied by thirst, lasting as a rule, three or four days. These all recurred at inter-vals of from one to three months, and permitted him to resume his work within a day or two of cessation. Ile was seen at different times by his various doctors, some Of whom frankly admitted the obscurity of the trouble; whilst others thought it night be gall-bladder infection. 1 \hen seen in -11 elbourne, there was no evidence of lung involve-ment, nor of cardiac trouble, nor was the gall-bladder region at all suspicious. The right kidney, however, was distinctly moveable, appeared some-what enlarged, - and, was moderately tender. The specimen of urine passed was quite turbid, and on gentle agitation presented the typical shimmering, shot-silk effect by transmitted light.

Microscopic examination showed this to be due, as usual, to numerous bacilli. Dr. Brenan re-ported, after careful investigation, that the organ-ism was in pure culture as B. coli anaerogenes. The patient's serum agglutinated the bacilli in low dila-tions only, not more than t in to. He was given a 50-million dose of autogenous vaccine and examined 'three days later by the cystoscope, at to a.m.,

when he passed about 8 ounces of urine quite tur-bid from bacilli. The bladder had been emptied at 7 a.m. Beyond a reddened trigonum, the bladder showed only slight inflammation and the ureteric openings were normal and similar. Urine was drawn from each by catheter, and proved to be quite clear and sterile. Had 1 not done this I should have concluded from the rest of the inves-tigations that his right ureter and perhaps kidney were infected as well as the bladder. This is a clear example of the value of the cystoscope and catheter in the study of genito-urinary cases. One is more and more inclined to withhold full opinion about a case unless catheter specimens from each kidney can be obtained. 'l'he findings in this ex-amination forces to the conclusion that the bacilli adherent to the empty bladder multiplied at so rapid a rate in the sterile urine entering from the ureters as to render it quite turbid in three hours. Dr. Brenan found the same turbidity arising in vitro, using normal sterile urine inoculated with the culture in question. A very acid specimen de-layed the appearance very much, whilst in low degrees of acidity and in neutral and alkaline urines the growth was prompt and profuse. And all in vestigations, notably those of Dudgeon, seem to point to the fact that the urine possesses practically no antibacterial bodies, opsonic or otherwise. Very few of the pus cells in a urine loaded with bacilli have ingested any of the organisms, and this must be the explanation, in part at least, of the difficulty of management of these chronic cases. However much the antibacterial power of the blood and tis-sues be raised by 'appropriate vaccination, very little, if ally, effect is produced on the urine, the medium in which most of the organisms develop. When, however, they attempt to invade the tissues they meet an effective resistance by vaccine treat-ment. My experience is that the acute exacerba-tions, as marked by fever or accentuation of local symptoms, or both, are controlled and recurrences prevented by vaccines, by a few closes in some cases, but in others only by a prolonged course and perhaps by the preparation of fresh strains of vaccine several tinges. 'l'he ultimate banishment of the bacilli from the urine is another matter en-tirely and quite problematical in any one case.

Referring to the man just mentioned. one con-cludes that his attacks of high fever are due to the bacilluria,becaus e the use of the cystoscope with all care on him produced a slight similar attack which was prevented from being greater by the pre-ceding vaccine. It is well to remember that all these -cases are apt to be upset by instrumenta-tion. One case of a man comes vividly to mind. He had a bladder stone of the size of an ordinary marble. The urine contained colon bacilli. An ordinary lithotrity was performed and went un-eventfully. There was no haemorrhage nor appre-ciable injury to tissue. Yet he straightway de-veloped high fever and thirst with a continuous aching pain in the left loin, and was quite ill for several days. The urine contained an increased amount of bacilli, but very little pus or albumen. He ultimately quite recovered, but I cannot help thinking he would have had an easier time of it

1188 AUSTRALIAN MEDICAL JOURNAL. August 30, 1913.

with a suprapubic opening, where post-operative drainage would have been more thorough. And, generally speaking, it is quite a pertinent question whether drainage, or rather slightly imperfect drainage, may not be one constant factor in causa-tion of bacilluria. Of course the cases where there is gross cause, such as definite obstruction from prostate or stricture, or in cases of stone, tubercle and tumour, are not here referred to, but the other type of case, where the obstruction is so slight as to cause only diminished freedom of outlet. It has been suggested, for instance,, by one competent observer that the habitual holding of the urine too long, and consequent imperfect emptying, may be a cause. Then, again, kinks of ureter or slight obstructions from pressure on it by distended colon, by the results of appendicitis, and so on, are very suggestive. The very frequent colon cystitis in women, who, for one reason or another have to take to bed for a time, may also have part ex-planation in the imperfect emptying of the bladder as it undoubtedly also has in locomotor ataxia and other paralytic nervous diseases, and also in the aged, where muscle weakness results in the same imperfect emptying of the bladder. One helpful suggestion that emerges from these considerations is that the urine be volitionally passed more fre-quently than actually required by sensation in all affected cases.

Of course it is not here suggested that these mild partial obstructions are the sole cause of many cases of bacilluria, for there is the introduction of the organism necessary either from the meatus, or kidney or perhaps by direct transit through tissue from bowel to urinary tract, and, in all probability, an abnormally poor general resist-ance to the organism. As bearing some-what on this, I should like to recount a case of a young single woman which gave pause to several men, including myself. The essential point ill her case was the onset of attacks of severe illness resembling influenza. The temperature was soon 105, there was nausea and vomiting and ab-dominal pain not very definitely localised. Rigidity was inconspicuous, anorexia complete, and con-stipation marked. Judging by the scars on her abdomen and their order of sequence, the first diagnosis was gastric ulcer, though it does not appear that much was found. hater, after a year or two of varying success at work and further at-tacks in which the pains were more often on the right side of the abdomen, the appendix was ex-plored and removed, the finding 'being "slight in-flammation." Some few months after this she came under my care with her worst attack. She was restless, vomited frequently, had complete anorexia, vague abdominal pains, no rigidity, high, continuous fever, and was quite seriously ill.

It was only after a few days when she improved that a chance remark of hers about a hematuria occurring some months previously turned our at-tention fully to the urine. It must be admitted that colon bacilli could always be easily grown from the urine, though the turbidity was never marked. A few pus cells were present. Catheters

drew off sterile urine from the left kidney, but colon-infected urine from the right. There were no tubercle bacilli found after thorough search, and the von Pirquet reaction was negative. The patient now began more definitely to refer her pains to the right, over the course of the ureter, and, as re-covery was very slow, it was decided to explore the right kidney. A tough, moderately enlarged kidney was found with a double ureter. The union into a single one could not be seen, though it existed, as there was only one right meatus as seen by the cystoscope. The right ureters were largish and flabby but not distended. The con-clusion arrived at was that there was a partial obstruction at the ureteric union resulting in slight chronic pyelitis with exacerbations. It was decided to try further rest, vaccines and sup-porting treatment, but, despite all efforts, the pa-tient made no progress. There was persistent great weakness, much insomnia, recurrences of tem_ perature after hope had just begun to rise again, and the constant pain ultimately forced one's hand to a further operation, viz., of nephrectomy. The kidney was largish, with a very tough capsule, and showed microscopically the most intense universal round-celled infiltration with much obliteration of tubules and glomerali. After all these tribulations she slowly convalesced, and in three months was heavier than ever before, regained her colour and resumed normal activity.

In another case, a married woman with children, I expected from the symptoms to find a suppurating kidney—there being rigors, pain and swelling in

the loin and a colon bacilluria. Not much pus in urine, so it was thought to be pent-up. On ex-ploration one found a very large kidney with peri-renal thickening and a firm thickened ureter of finger thickness. As there seemed to be no finality about such a condition, and only ill-health without som,iething radical, I removed the kidney. The patient did very well and put on two stone weight and improved much in colour. The kidney showed the same sort of chronic inflammation. I am watching another case seen with Dr. Greig of a single woman, who gave the history of having passed objectionable urine since childhood. She sought urgent medical aid for an acute pain in the right side of abdomen, accompanied by vomiting and moderate temperature. The pulse was in-creasing and the right side of abdomen was tender and rigid, and enough doubt existed as to the na-ture of the case as to suggest an exploration for possible appendicitis. This was done, and an ap-pendix found in a very high, abnormal position with the tip close to the liver overlying the right kidney. It was not definitely inflamed;, though larger in diameter than normal. The real cause was seen to be a large right kidney elastic and non-cystic. There was a very well-marked colon bacil-luria, no tubercle bacilli and no stone. I consider this kidney another of the foregoing type. We treated her for some months with vaccines, using several fresh strains from time to time. The ten-derness has gradually disappeared and the kidney has reduced much in size, but it is still quite pal-

August 30, 1913. AUSTRALIAN MEDICAL JOURNAL. 1189

gable and aches occasionally. There has been some haernaturia on one or two occasions and bacilli are still copiously present, but she has been able to resume her work. At one time it looked as if a. nephrectomy would be the only remedy, but it is possible that the vigorous • vaccination averted this. It may, however, still be necessary. One wonders what the ultimate outcome of such a case in years will be in a young woman: a largish, tender kid-ney, very little pus or albumen in the urine, and a well-marked colon bacilluria.

This is one case beginning in early girlhood as an ordinary bacilluria. What becomes of most of them ? How many wind up with chronic inter-stitial nephritis? Probably most escape serious consequences by the pyelitis being one-sided, if pre-sent at all.

I have already referred to the mimicry of appen-dicitis by some forms of bacilluria; in sonic of these the urinary infection is not so obvious as in the above case. Some of the acute exacerbations with pain in the right side are misleading. With the present accepted . method of immediate opera-tion I shrewdly suspect that a normal appendix is removed late at night occasionally, and that soon afterwards cultures reveal at not very obvious bacil-luria as a probable cause of the symptoms.

Besides this, it must not be forgotten that a renal hamaturia may have its sole cause in bacilluria.

Hale White points out other cases of mimicry, one striking one being a suggested incipient phthisis, with mild, continuous temperature for months cleared up by vaccines. • He cites other cases strongly resembling renal calculus, and even biliary colic, they even conforming to the condition of sud-den onset of pain. There seemed to be no doubt that bacilluria was the sole abnormality in his cases.

The present attitude of mind one has towards the treatment of colon bacilluria may be summed up by saying that acute cases are approached hope-fully by rest, alkalies, hot baths and copious drinks, and, if they need the help, turn the corner towards cure with a dose or two of autogenous vaccine.

That any particular chronic case is approached with a perfectly open mind as to a possibility of permanent sterilisation of the urine, but that acute exacerbations and troublesome local symptoms may be prevented by the use of vaccines and the main-tenance of an acid urine; urotropin, perhaps, con-tributing in some. More or less occult and partial urinary stasis is sought for and remedied if possible.

In adults, irrigation is useful, though often only temporarily ; in young girls it is often very dis-turbing, and in some has given norelief. Whether constipation is a cause or not, the urine has been regularly worse when there have been indiscretions in diet and consequent bowel disturbances, and amelioration has resulted in righting this. I ap-proach instrumentation of any extent i n these cases with much care, including preliminary vaccination. i have not tried ureteral irrigation in any suitable cases, nor anti-colon serum. If no cause for urinary stasis can be discovered and remedied I do not think that sonic cases will ever be cured of their bacilluria.

SOME RECENT VIEWS ON TUBER- CULOSIS.

The present note in relation to the treatment of tuberculosis may be said to be one of disappoint-ment. The results of vaccine and sanatorium treatment on the large scale are beginning to come home, and the enthusiastic note of a few years back has become more sobered in tone. A recent special number of "Public Health" contained a symposium on the subject, and the key of the vari-ous authors is of singular agreement. Macalister ("Tuberculosis and the Tuberculins in Relation to Trim unity") says

A study of the pathology of tubercular disease shows that the action of the bacillus in producing characteristic lesions is partly toxic and partly me-chanical. An entering- bacillus coming to rest within the tissues may at first start local necrosis and the minute necrotic areas will be the point of origin of a typical tubercle. These initial stages have been accurately studied by Warthin in cases of tuberculosis of the placenta. In other cases the entering bacillus is taken up by a leucocyte and transported in the blood-vascular or lymphatic system to a remote part, there to initiate tuber-culous disease:

The active immunisation against tuberculosis depends upon the treatment of infected persons with bacillary products containing toxic sub-stances unmasked and freed from insoluble ma-terials, so as to stimulate the body to protect itself against further effusions of poisonous material.

The total number of varieties of tubercle bacil-lary products that have been recommended for the purpose of producing active immunisation amounts roughly to one hundred. A large number of these have not been deemed worthy of extensive trial, but have been placed rather in the category of his-torical curiosities. Others rest upon a restricted measure of clinical support; the evidence in favour of their efficacy is of a type difficult correctly to appreciate. Of the whole number less than ten have been used upon any extensive scale.

Tuberculins and allied preparations fall roughly into three classes. The first includes culture fluid products; the second, preparations from the bacil-lary bodies; the third,• preparations in which both culture fluid and bacillary bodies are employed. A small fourth group contains products which may be termed compound tuberculins, in which certain added drugs appear. 'ITese have no great practical importance.

The same writer gives a useful summary of the tuberculin reaction theories as follows:—

There are, broadly speaking, four different schools of thought, which afford different explana-tions of the tuberculin reaction. The schools of Koch, Wassermann and Ehrlich consider that the action is due to the working of a primary toxin. That this toxic antigen reacts with the antibody present in the focus of disease and with the floating antibody present in the circulation. The inter-

1190 AUSTRALIAN MEDICAL JOURNAL. August 30, 1913.

mediate zone of a tuberculous lesion, where there is a derangement of cell metabolism, is rich in anti-tuberculin, and the introduiction of fresh tuber-culin induces a coalescence of antigen, antibody and complement with consequent cell destruction and liberation of toxic products. Citron and others are of opinion that tuberculous infection causes a mul-tiplication of sensitive cell receptors at the focus of disease and throughout the body, and attribute the reaction to their excitation.

Wolff-Eissner also hypothecates an amboceptor action, but regards the reaction body as possessed of lytic properties. These lysins or bactericidal bodies possess the power not only of killing and disintegrating the bacteria to which they are antagonistic, but also of attacking and breaking up introduced tuberculin in a manner analogous to that in which albuminolysins decompose introduced albumin. The degradation products of tuberculin are the toxic bodies which produce the character-istic reaction. This hypothesis thus attributes the phenomenon to formation of a secondary toxin.

The same view, that degradation products of tuberculin are responsible for these effects, domin-ates the work of Friedberger and of Vaughan and their co-workers, who would homologate the re-action to a true anaphylactic manifestation. Von Pirquet makes use of the term allergia and draws an analogy with the observations of v. Behring upon cellular hypersensitiveness in tetanus.

It has hcen suggested that the reaction is not specific but is a toxic effect, due to the albumoses contained in tuberculin. This may, however, be at once negatived, as albumose free tuberculins are capable of producing reactions.

As to the results of treatment with tuberculin Cecil Wall ("The Therapeutic Use of Tuberculin") is not very optimistic:—

The selection of cases for treatment by tuber-culin requires great care. If we assume, as seems justifiable, that many, if not most, of the symptoms of pulmonary tuberculosis are due to the absorption of autogenous tuberculo-toxins, we must exercise great caution in the injection of old tuberculin, or tuberculins somewhat similarly prepared, to pa-tients suffering from such symptoms. This consti-tutes one of the great difficulties in the ambulant treatment of pulmonary tuberculosis by tuberculin. Unless the patient is under 'close observation, it is impossible to arrive at any estimate of the amount of auto-inoculation occurring, and the injection of tuberculin may at times produce unexpected and dangerous reactions. The thermometer is usually employed as the simplest indicator of auto-inocula-tion, and it is a sound rule that injections of tuber-culin should be given with the very greatest cau-tion if the temperature within the previous twenty-four hours has exceeded 99. The cases which are Most favourable for ambulant treatment are those in which the temperature never exceeds normal, and in which the extent and symptoms of the disease are slight.

It is extremely difficult to estimate the value of tuberculin treatment: the type of case from which

the bc,l results are claimed is that in which a cer-tain number of recoveries may be expected with other it wins of treatment. Evidence is accumulating that patients, at all events in the earlier stages of the disease, do better if they receive tuberculin as well as hygienic treatment, but it does not seem probable that tuberculin alone will give satisfactory results without adequate attention to hygiene, or that it can be expected to lead to the arrest of the disease in advanced cases. On the other hand, there is no doubt that unless it is used with extreme caution tuberculin may lead to disastrous results.

Shrubsall ("The Selection of Patients for Sana-torium Treatment ") gives a crisp little bit of his-tory :-

'IThe modern sanatorium was inaugurated in 1840 by I,oddington at Sutton Coldfield. He realised the necessity for constant supervision, and therefore for collecting patients together in one community. and drew attention to the disadvantages of an in-door life, saying that the equable temperature at that time demanded for treatment should be that of the outer air. He also recommended that provision should be made for the employment of convalescent patients who ought not to return to their previous occupations. Unfortunately 13oddington's ideas were ridiculed and only bore fruit after trans-plantation to German soil.

In 1859 Brehmer opened the pioneer sanatorium at Gorbersdorf in Silesia. His central aim was to strengthen the heart. He had noted that while most consumptives had small hearts, the inhabi-tants of mountainous areas in which tuberculosis was very rare, had large hearts, and concluded therefrom that the larger heart had conferred the immunity. The general features of his treatment were:—

Life in the open. Freedom from debilitating surroundings. Methodical hill climbing. An abundant fatty dietary. Various hydrotherapeutic measures. Constant medical supervision. Somewhat later I)ettweiler, a patient and later

an assistant of Brehmer, introduced the liegekur system in his sanatorium at Falkenstein. He made less use of graduated exercise, but directed his patients to lie for hours together in open shelters, the liegehallen. He made a great point of feeding, proclaiming the kitchen to be the true - pharmacy of the sanatorium. His methods, though modified to some extent 'in the direction of increased exercise, are those now adopted at the majority of Continen-tal sanatoria for paying patients.

Walther of Nordrach, from attracting many Eng-lish patients, was the reintroduces of the sana-, torium to this country. He abandoned the liege- hallen, which he is said to have called quarrelling halls, as giving insufficient rest, and kept his pa-tients in their own rooms or on balconies during the rest periods. He advocated progressive and extensive walking exercise, and a stuffing dietary. The majority of the private sanatoria in this coun-try have been modelled on his system. From this

sr

August 30, 1913. AUSTRALIAN MEDICAL JOURNAL.

arose the use of sleeping chalets, yvhich have been found adapted to home use and have spread ex-tensively in connection with the dispensary system brought to the front by Sir Robert Philip.

This writer strikes a dubious note in relation to one point upon which great stress has been laid:—

It is difficult to estimate the educational value of sanatorium treatment, and while many ex-patients serve admirably to spread the tenets of personal hygiene, others show no signs of improvement or conviction and remain as careless as ever. I am more hopeful of the educative effect of the health visitor or the dispensary nurse influencing the homes directly.

Perhaps the most recent of new procedures in the treatment of advanced phthisis is still the pro- duction of an artificial pneumo-thorax. Leonard Colebrook ("Medical Magazine," May) gives a very good description of the technique of this pro- ceeding and its dangers and difficulty. His own results are not very encouraging to others:—

Briefly to consider now what results have been achieved, and what may be hoped for from the up- plication of this procedure in practice. To this end 1 might refer you to the published reports of very many Continental workers, embracing in their pur- view probably not less than 700 cases, and to the records of 17 cases treated in this country by Dr. 1)e V. Pearson, but in the short _ time available I propose rather to submit to you only a summary of my own small experience and such findings as I have been able to adduce from it. Seventeen pa- tients have been submitted to treatment within the past two years, most of them in-patients at St. Mary's lIospit+.1, under the care of Sir Almroth Wright, to whose helpful counsel and interest throughout their treatment I am largely indebted. Almost without exception they have been very grave cases, holding out but little hope from any programm e of treatment—th us time of them had previously been subject to long periods of sana- torium treatment, while two were recruited from the wards of a Home for the Dying. of these 17 cases, three may with propriety be excluded from a survey of results since the attempt to induce pneumothorax was early abandoned—in two them on account of adhesion of the pleural su faces, and in the third on account of a supervenin melancholia. Fourteen cases remain for considers tioll, of tivhoau four are dead, two who showed no improvement under the treatment (one of them, be it said, vvas a native of India, who came to us from the Home . for the Dying, and 'never took kindly to the operation), and two who fell victims to the fortuitous risks attendant upon the operation, each (levcloping too rapidly a complete nneumothorax in consequence of a slight injury to the lung. Ten patients are still under observation, of whom each and every one has, in•-my opinion, given unmis- takable evidence of the value of the procedure in question. • Happily we have, in the temperature record, an objective criterion for judgment, since all these patients, save one, were chosen primarily on account of fever which had failed to

yield -satis- factorily to the patent e.xploitation of more con- servative measures, rest, tuberculin, therapy, etc.

Infantile blurt hum.

Clock ("Journ. A.M.A.," July 19th) gives 117 cases treated by "intestinal implantation" of B. Lactis Bui- garicus:—

Method.—The treatment consisted of the administration of a pure culture of the true Bacillus lactis 'bulgaricus— the Type A. organism, which was isolated from Bulgarian soured milk (yoghurt) and first described by Grigoroff of Massol's laboratory at Geneva. This culture was im- ported through the Johns Hopkins Hospital and elaborated in tablet form in the Hynson Wes :tcott Laboratories at Baltimore. One or two tablets were usually given every two or three hours; but, in severe cases, two or even three tablets were given every two or three hours before and after each feeding—making a total, in some cases, of forty-two tablets in twenty-four hours.

Diets During Treatment.—Seventy-four babies were continued on their respective milk diets; among this num- ber were four breast-fed babies, ranging in age from 12 to 15 months, who were removed from the breast and placed on bottle-feeding composed of equal parts of whole milk and water; and •twenty-three babies between 15 months and 2 1/2 years of age who were continued on their mixed dietaries of milk, cereals, soups, etc. This number also includes twelve babies who were continued on breast- feedings, and thirty-.five babies who were continued on their regular milk mixtures or on their regular mixtures slightly diluted with water.

The remaining forty-three patients were placed on a starvation diet. of barley water for twenty-four to forty- eight hours, after which small quantities of boiled, skim- med or whole milk were usually added to the diet.

Conclusions.--T.he most impressive facts, which stand out boldly as the result of this method of treatment, are:

1. The gain in weight, in spite of the number of stools. 2. The rapid change in colour of the stools to yellow. 3. The rapid subsidence of fever. 4. Absence of mucus and blood from the stools at the

end of forty-eight hours. 5. The fact that the hygienic surroundings of the pa-

tientsand the degree of intelligence of the mothers had no influence on the results.

6. A starvation diet, accompanied by purgation, is pro- ductive of loss of weight and strength, and serves to pro- long the course of the disease; and further, such a pro- cedure can no longer be advanced as a rational method of treating infantile diarrhoea.

a 7. The digestive powers in infantile intestinal condi-

tions, even when associated with fever, are not so im - o f paired as to prevent the digestion and assimilation of a r- milk diet. This fact is corroborated in typhoid fever, where the "high calorie diet, in contrast to the starvation diet, has reduced the mortality to a remarkable degree \lnrenvar

, t e cases herein recorded prove the value and rationale of continuing a milk diet in infantile intestinal conditions, as illustrated and emphasised in the diagram of the weights.

8. In severe cases, best results are obtained by ad-ministering a large number of the tablets during the first two or three days of the treatment. As many as forty-two bulgara tablets in twenty-four hours have been given to very young babies without untoward effects.

9. The implantation method of treatment has pro-gressed beyond the experimental stage, and the results of its use can no longer be questioned or disputed. This treatment has been proved of practical, clinical and scien- tific value; and its simplicity should appeal to every prac-titioner.

10. In order to secure the best results, in using the im-plantation treatment, a pure culture of the true B. lactis bulgaricus must be employed; otherwise disappointment will follow.

atStrattau fliebtcat journal 3oth AUGUST, 1913.

PUERPERAL ECLAMPSIA.

Probably no topic in the realm of obstetrics has had more careful attention than the treatment of eclampsia, and yet there is no complication of pregnancy about which there is a greater uncer-tainty as to the underlying causation and in Which more varied lines of treatment have been advo-cated. Apart from the vexed question of the man-agement of labour in such cases, there have been from time to time a host of drugs hailed as specific which a more extended experience has cast aside as useless. At the present time the most general concensus of opinion would be as to the efficacy of intestinal lavage with or without the hypodermic administration of morphia. Dr. F. W. N. Haultain, of Edinburgh, recently communicated to the Edin-burgh Obstetrical Society an account of seven cases of eclampsia treated by the intramuscular injection of veratrone, which _furnishes a new set-ting of an old tale.

Veratrum viride is a drug which has been almost forgotten, although it once had a reputation as a vascular depressant and spinal sedative. Vera-trone is a combination for hypodermic use of vari-ous alkaloids contained in the older preparations of green hellebore, and has been introduced by a well-known American firm of inanufacturing chemists. Its action, as detailed in Dr. Haultain's cases, appears to have been striking. Within an hour of administration the blood-pressure fell in a marked degree and the pulse was notably slowed in frequency. In two patients no fits occurred after the first dose. Dr. Haultain states the depressant action may be evanescent, and in one instance the blood-pressure rose again after three hours and three fits occurred, but after a second dose no fur-ther trouble was encountered. The only subsi-diary measures employed were a hot pack and washing out the stomach. All the patients recovered.

This communication was of course not put for-ward as an epoch-marking discovery. Although veratrum is not official in the British pharma-copoeia, it is included in that of the United States, and it has been used and recommended for puer-peral eclampsia for many years and has been also frequently condemned as useless. Hirst ("Obstet-rics") refers to it as the American treatment of eclampsia. The difficulty has been that the tincture is apt to disagree and produce irritant symptoms. The new form of administration appears to consti-tute a distinct advance, and it remains to be seen whether other observers can obtain any results similar to those recorded by Dr. Haultain. The series of seven cases is, of course, much too in-significant a number on which to base more than a presumption, but such a consecutive series, how-

1192 AUSTRALIAN MEDICAL JOURNAL. August 30, 1913.

ever, if small, responding with equal readiness to the same drug is certainly encouraging. The use of a powerful depressant like veratrum is not free from dangers of its own, and the slowing of the pulse-rate is probably at present the best guide as to its margin of safety. It may he that disappoint-ment will again result, but any suggestion for the treatment of puerperal eclampsia which offers rea-sonable prospect of proving effectual is at least worthy of mention and trial, and further informa-tion will, no doubt, very soon he accumulated.

Poto aub ttCommeut5. The B.M.A The National Insurance Act in Great

Annual Britain does not seem to be working Meeting quite so smoothly as some enthusiasts

would wish it to appear. The recent an-nual meeting of the B.M.A. at Brighton has been the scene of animated discussions and has really seen the first battle between the socialistic and conservative ele-ments in the medical profession. As to the Insurance Act, resolutions were passed as to the need for amend-ment in the following amongst other directions:—

To authorise a charge to the insured person for night calls.

That an insured person shall not be entitled to re-quire medical attendance from any medical •practi-tioner other than the practitioner on whose list he is. as, for instance, in respect of the administration of a .

genes al anaesthetic or assistance at an operation. That an insured person shall not be entitled to

medical attendance or treatment for any disease or dis-ablement caused by his own misconduct other than venereal diseases.

That the term "income from all sources" shall include sums received by way of allowance, annuity, or other-wise, as, for instance, by the son of a wealthy father. A motion to insist on the exclusion of venereal diseases

from medical benefit produced a lively debate, but this was defeated.

The radical spirits proposed to frankly declare the B.M.A. a trade union, and more is likely to be heard of this movement which may be an augury of future dis-sensions. The "Lancet" says:—

"The main topic before the representative body on Monday was a proposal, vigorously supported by certain members, inviting the meeting to declare itself favour-able to the formation of a union, registered under the Trade Union Acts, of such medical practitioners as might desire to join together in this wal for the defence of their interests. As was to be expected, this suggestion of a medical trade union, under the aegis of the British Medi-cal Association, aroused keen opposition, although a num-ber of members supported it with equal zeal. After both sides had been given a full hearing the debate was closured at 6 p.m., and a Cara vote was demanded and taken. As a result the proposal was defeated by 11,408 votes to 5,259. Had the voting been taken by roll call the motion would have been rejected by a rather smaller though sufficient majority."

•

The The annual figures for the Rotunda Hos- Rotunda pital for 1911-12 are contained in July Hospital number of the "Dublin Journal of Medical

Sciences." In the extern department 2,339 deliveries were effected with a maternal mortality of 10. Forceps were used in 54 cases and version employed in 8. The placenta required manual removal in 18. Four of the deaths were from ante-partum haemorrhage, 2 being unavoidable and 2 accidental. Inside the hospital 2,136 deliveries occurred with a mortality of 11. Forceps

Expenditure.— The total expenditure for the year 1912 was high, and showed an increase of more than 25,000 over that for 1911. The prices of various articles had increased, making the cost of living higher. The daily average cost of each patient during 1912 was 1/11, or 3d. per head more than during 1911. The daily average cost of each patient after deducting fees paid for maintenance was 1/6, making a reduction of 5d. per head on each patient. In 1911 the reduction was not more than 4d. per head.

W. L. CLELAND, Head of Department.

gCb, Ji300k5.

August 3o, 1913. AUSTRALIAN MEDICAL JOURNAL. 1193

were applied 79 times and version employed in 22 in-stances. Manual removal of placenta was required in 22. Of the total 2,030 were normal vertex presentation. Fourteen cases of eclam:psia were met with and these were all treated on the plan advocated by Tweedy of lavage and morphia. Laceration of the perineum is re-corded in 546 cases, and there were two cases of cervical laceration which required suturing. There was complete rupture of the uterus in two cases, but the report does not state whether this occurred in the hospital. Dr. Jel-lett states he has continued the practice of allowing patients to get up after confinement at a much earlier date than usual, and he has no reason to alter the plan. Patients who are well after 48 hours are made to leave bed to pass water at least twice in 24 hours, and after 72 hours are encouraged to walk a few steps. Thereafter the time they sit up is gradually increased. The master also states that he has abandoned argyrol for the prophylaxis of ophthalmia and returned to nitrate of silver.

Health of The estimated population on December

South 31st, 1912, was 430,090, viz., 218,613 males

Australia and 211,477 females. This showed an ad- vance of 11.918' on the estimated popula-

tion at the beginning of the year, made up of 7,743 by excess of births over deaths, and 4,175 by excess of im-migration over emigration. The births registered num-bered 12,079, being more by 1,022 or 9.24 per cent. than tl- Ne recorded in 1911, and being the highest number registered in any year. The birth-rate per 1,000 of the population was 28.65, against 26.89 in the previous year, and was the :most satisfactory since the year 1896. The birth-rate reached its lowest point (23.84) in 1903, since which year a gradual improvement has taken place. The rate for 1912 is exactly the same as that of the Common-wealth. Of the total births registered in 1912, 6,168 were male births and 5,911 female, the proportion of the former to 100 of the latter being 104.35. In England, according to recent returns, the proportion for the five years ended with 1910 was 103.9. The Commonwealth ratio for 1911 was 104.73. The births entered in 1912 as illegitimate numbered 569 (311 males and 258 females), against 464 in the previous year. The percentage of illegitimate births to the total births registered during the year was 4.71. The deaths registered in 1912 numbered 4,336, being more by 298 than those of the previous year, and the highest number recorded since 1899, being above the decennial average by 440. The increase in the number of deaths over those for 1911 was shown in every age group, but was highest amongst infants and old people. Seven hun-dred and forty-four children under one year died in 1912, against 669 in 1911, and 1,493 persons of 65 years and up-wards in 1912, against 1,386 in 1911. The deaths of infants under 1 year of age numbered 744 (429 males and 315 females), against 669 in 1911, and were in the proportion of 6.16 to 100 births registered. The rate for 1912 is some-what higher than that for 1911, which was the lowest recorded. That a notable reduction has taken place in recent years is manifest, if the two decennial periods ending with 1902 and 1912 be compared; the average rate for the first is 10.61, and for the second 7.04, a decrease of 34 per cent.

The marriages registered in 1912 numbered 4,056, not only being more by 20 than those celebrated in 1911, but also being the highest number ever recorded in any one year. Since 1903 every year has shown a satisfactory advance in marriages, and the number in 1912 is 79 per cent. higher than that for 1903. The marriage rate (that is, the rate of marriages, not of persons married) per 1,000 of the mean population was 9.62, against 9.81 in the previous year, and was the second highest rate ever re-corded.

L 1CY IN SOUTH AL?STR III I.

The total cases under care during the year was 1,317, whereas for the year 1911 it was 1,328. The number of male cases for 1912 was 12 more, whereas the number of female cases for the same year was 19 less. The :total number of patients who were discharged or died was 235 for 1912, as compared with 244 for 1911. The average number of patients resident during the year 1912 was 1,067, or 2 more than for 1911. The number of patients who have been admitted during the past 67 years is 9,942, made up of 5,835 males and 4,107 females. The ratio of lunatics, idiots, and persons Of unsound mind to the population con-tinues to keep about the same, and is markedly lower than in any of the other four Australian States, being 2.51. The male ratio is a good deal higher than the female one, being 2.81 males to 2.21 females. The reverse is the case in an old established country like England. In newer populated States, such as Western Australia and Queensland, the male ratio is very markedly larger than the female one, whereas in Victoria the female ratio is rather larger than the male, in this way resembling England. The ratio of admissions to every 10,000 of the population is 5.42, which is the lowest on record, with the exception of the years 1896 and 1898. The female ratio has not been so low before, ex-cept on two occassions, namely in the years 1888 and 1896. It is one of the saddest points in this form of illness that the home surroundings and the attention of relatives have, as a rule, a bad influence in tending to retard recovery. Sending the early cases to a general hospital is also not specially favorable, as it is difficult to give the patients sufficient treatment in the sun and open air without con-stant supervision. This latter is very irritating to a mind affected. The ages of the patients admitted were dis-tributed much as usual, the senile cases not being as numer-ous as in 1911. In the latter year there were 46 cases, whilst in 1912 there were only 28 cases. The other forms of mental disorderr were distributed amongst the admis-sions very much the same as In 1911, and showed a great similarity. There was nothing in the mtiological factors and associated conditions in the admissions that was un-usual or calls for any special report.

Deaths.— During 1912 there were 122 deaths, namely 78 males and 44 females. This was a large number, being 11.4 per cent. on the average number of patients resident, being 12.9 per cent for males and 9.6 per cent. for females. The male percentage is almost the highest on record. The per-centage of deaths on the total number of admissions during the past 67 years is 32 per cent., being 33.1 per cent. for males and 30.3 per cent. for females. Of admissions during 1912, 23 died during the year. The chief causes of death were::Cerebro-spinal diseases, 21 cases; cardiac disease, 36 cases; and diarrhoea, 32 cases. The cardiac disease and diarrhoea were chiefly contributing causes. Nearly half the

cases were over 60 years of age, namely, 53, and of these, 29 were over 70

"The Bradshaw Lecture on the Diagnosis and Treatment of Incipient Pulmonary Tuberculosis." By D. B. Lees, M.D., F.R.C.P.; pp. 116, demy 8vo. London: H. K. Lewis.

In this lecture the author makes three principal claims: (1) That the existence of an incipient pulmonary tuber-culosis can be easily demonstrated by careful percussion (provided that during the examination of the front of the

Years of age.

1194 AUSTRALIAN MEDICAL JOURNAL. August 3o, 1913.

chest the patient is in the recumbent position with re-laxed muscles) long before any bacteriological evidence is obtainable and while the auscultatory evidence is still insufficient for a diagnosis. (2) That a negative bac-teriological report is often fatally deceptive, and that to wait for the demonstration of bacilli in the sputum is like postponing the diagnosis of cancer until the glands are involved. (3) That in the earliest stage of a pulmonary tuberculosis it is always possible, and in a somewhat later stage usually possible to obtain prompt and perma-nent arrest of the disease by the employment of the method of continuous antiseptic inhalation. The evidence on which this statement is based is given in the table of seventy cases, the clinical facts of which are stated in the papers reprinted as appendices to the lecture. The lecture embodies the results of .much careful observations, espec-ially in regard to the practice of percussion. Dr. Lees considers that certain "dull areas" are always to be demonstrated and their increase or diminution with the deterioration or improvement on the case can be made out by careful measurement. He states that after a little practice it is possible to estimate the size of a dull area to one-sixth or even one-eighth of a fingerbreadth, ap-proximately equivalent to one-third and one-quarter of a centimetre. The most characteristic sites of these areas are described. In urging the utility of treatment by con-tinuous inhalation of antiseptic vapours, Dr. Lees states that "If a patient inhales a combination of antiseptic vapours persistently, day and night (except when actually taking food), by the principle of diffusion of gases the antiseptics must make their way into the pulmonary alveoli, if the inhaler be worn for a sufficient length of time. And if antiseptic drugs like creosote, carbolic acid and iodine are dissolved in alcohol, ether and chloroform, there must be a gradual absorption of these anaesthetic agents into the blood, for this is an A.C.E. mixture and we know that if used in greater strength it would prove the absorption by producing general anaesthesia. The slow absorption of these agents in a very dilute condition must carry with them into the blood the antiseptics dis-solved in them. How far these may be transformed in the blood is for physiological chemistry to determine, but it seems likely that some antiseptic influences will thus be carried by the blood stream to the tuberculous foci, which will then be attached both from without the lungs and from within." The seventy-case histories in the appen-dices are well worthy of study. Their inclusion greatly increases the value of the book, which may be recom-mended to those interested in the diagnosis and treatment of tuberculous disease. L.S.L.

CURRENT LITERATURE. ^ .+..+-+

Pituitary Extract in Uterine Inertia.

Edgar ("Amer. Journ. Obstet.," July) concludes:- 1. Ampoules or vaporoles of the drug should alone b e

employed, as in our experience, constant results failed

when the pituitary extract in bulk solution was used. 2. There are three reliable proprietary preparations of

the drug now on the market; all of these were used at

different periods in our cases. 3. For decided action, 0.4 gram of the drug is usually

called for, although in ordinary cases, with little obstruc-tion, half that dose we found sufficient.

4. As the effect of the drug lasts but thirty minutes,

repetition of the dose is often called for. 5. Intramiuscular injection is usually satisfactory; caus-

ing no local reaction or pain. Further, no toxic symptoms

were observed from the use of the drug even in maximum

doses. 6. Pituitary extract may be combined with ergot when

the action of the former fails, and with heart stimulants

in shock cases, without compromising the actions of these

drugs. 7. Pituitary extract has no place In normal labour, the

administration should be confined in obstetrics to instances

of primary and secondary inertia, to post-partum haemor-

rhage and Caesarean section, in the last as a substitute

for ergot. 8. The, drug produces strong intermittent uterine con-

tractions often prolonged for several minutes. We have

never observed true continuous tetanic uterine contrac-tions (tetanus uteri).

9. Although theoretically the uterine contractions are

intermittent, practically in the face of resistance, the

contractions approach to the continuous in character and

clinically must be so reckoned with. 10. Full and even small doses of the drug in the first

stage of labour, have caused in our cases fatal compres-sion of the fetus, premature separation of the placenta,

and deep rupture of the cervix. 11. In the first stage or where decided obstruction

exists in the second stage, I give small tentative doses of pituitary extract, not with complete delivery by means of

the drug in view, but to bring the head in easy reach

of a simple forceps operation. ,Seven of our thirty-nine cases were thus treated.

12. Pituitary extract acted promptly and efficiently in

most of our thirty-nine cases of inertia in the first and

second stages. Its action was more positive in multiparae then in primiparae; it acted better at full term than in premature cases; also better in the second than first stage of labour when administered shortly after the spon-taneous artificial rupture of the membranes.

In the nineteen cases in which the drug was used im-mediately after the third 'Stage for post -partum haemor-rhage due to inertia, our results were disappointing. So much so that we consider its action here most unreliable and not as positive as the ergot preparations.

In our eighteen post-partum cases, we found no effete of the drug in two cases; it was necessary to use ergot

in two instances; a hot acetic acid douche in two more;

to pack the uterus in seven cases, and in the remaining

six cases only were good uterine contractions observed.

13. In Caesarean section we could not observe any ad-vantage of pituitary extract over ergot, aside from the

observation that the former acted more promptly and hence need not be administered so early in the operation. 14. In induction of labour the drug failed to initiate

contractions, but apparently initiated them after the use of gauze, the bougie or hydrostatic bag. Our belief is

that the drug strengthened already existing contrac-tions not yet apparent to patient or physician.

15. For primary inertia in abortion cases, our results

with the drug were disappointing. 16. For atony of the bowel and bladder and as a galac-

togogue our results were frankly negative. 17. The dangers to mother and child in the indiscrim-

inate administration of this drug for primary or secondary inertia of the first or second stages of labour must be reckoned with. Only a few of our thirty-nine cases of inertia were

frankly in the first stage of labour and these were our

earlier cases. The remainder were in the second stage or 'border line cases just merging into the second stage.

We consider the use of the drug in the first stage a dangerous practice, liable to cause death or deep asphyxia of the fetus, separation of the placenta, uncalled-for lacera-

tion of the cervix and possible uterine rupture.

18. We have to report, of our thirty-nine cases of inertia

in the first and second stages, two and probably four

still-born children due, in our opinion. to the use of pitui-tary extract, before full dilatation, and three instances of

deep laceration of the cervix requiring suture to control the bleeding.

19. We look upon the cause of pituitary extract before full dilatation or dilatability of the cervix as equivalent to the use of ergot at this time. In fact it is probably

more harmful than ergot, by reason of the more powerful contractions produced and the uncertainty of its action.

20. We have repea.edly observed prolonged tempestuous

contractions, when the drug was given in the face of too

much resistance, closely simulating tetanic contractions of the uterus (tetanus uteri).

21. The action of the drug is most uncertain. One can never predict in a given case, either from the amount of the drug administered, or from the character of inertia and the obstruction to be overcome how powerfully the drug will act upon the uterus.

August 30, 1913. AUSTRALIAN MEDICAL JOURNAL. 1195

22. We have repeatedly observed both in private and hospital practice that 0.2 gram of pituitary extract, half the usual dose commonly employed, produced such pro-longed and powerful uterine contractions that uterine rup-ture was imminent and anaesthesia was required to con-trol the action of the drug on the uterus.

23. In our opinion the drug should never be employed for inertia in any stage of labour, unless anaesthesia is at hand for immediate use, and preparations complete for immediate operative delivery, if necessary, to avoid uterine rupture.

24. Finally, with due regard to its action, and passible dangers, pituitary extract is a most valuable addition to our resources for the treatment of primary and secondary inertia.

Tuberculosis front Ritual Circumcision.

Emmett Holt ("Journ. A.M.A.," July 12) publishes a case and bibliography:

Of the forty-one patients, including my own, sixteen are known to have died; seven are reported as having partially recovered or being scrofulous; in twelve the final results were not given; and only six are stated in the histories to have recovered. The youngest fatal case is that of the patient whose history I have reported. In several instances death has occurred as late as 11 months from tuberculous meningitis. The usual cause of death has been general tuberculosis. In many of the reports several children have been infected by a single operator, Thus, in Lehmann's cases, all ten of the children were thus infected; Gescheit reports four infants infected by the same operator; Lindmann, two patients; Debrovitz, four patients. In nearly all of the reports the fact is stated that the families were free from tuberculosis. As a rule the earliest symptoms of infection have been ob-served in about a week after the operation. The wound does not heal, but suppuration occurs and ulceration soon follows. The early ulcer may be anywhere on the pre-puce but is often on the frenum. It may remain as a localised process or be general. At the end of a second or third week inguinal adenitis develops. In a very con-siderable number of cases it is reported that the lymph-nodes broke down and abscess formed, usually in two or three months after the initial infection. The cases in which early suppuration of the inguinal lymph-nodes took place and which were operated on, either by removal or curetting, were among those in which the results were the best. The symptoms of a widespread general infec-tion rarely occurred earlier than the third or fourth month.

The diagnosis has been made in many of the cases by the clinical symptoms and history alone. Some of these were reported before systematic search for the tubercle bacillus in wounds was practiced or modern tuberculin tests were employed. In nearly all of the latter cases reported, the diagnosis has been established by the dis-covery of the bacilli in the inguinal abscesses, sometimes from the preputial ulcers. In the latter situation they must be carefully differentiated from smegma bacilli. That the infection spreads through the lymphatic system seems certain and early removal of the inguinal lymph-nodes would therefore appear to be the most important measure to be employed in checking the extension of the infection. To be successful this must of course be done early.

In a very large proportion of the cases reported the first diagnosis made was syphilis, and the patients were treated for weeks and months by antisyphilitic meas- ures without benefit and with loss of valuable time. It is my own belief that syphilis is less frequently acquired in this manner than is tuberculosis and that the latter disease should be first suspected. With the modern means of diagnosis in tuberculosis the early recognition of these cases ought not to be difficult. While the number of re- ported instances of tuberculosis acquired through cir- cumcision is considerable there must be a very much larger number that have never found their way into "erature. Tt is certain also that syphilis has been spread

n'snner. These facts lead me to emphasise the L :... c 11 -. , the late T'rofesso* Maas, the German

surgeon, that "it is the duty of the physician to raise his protest against the perfornrance of ritualistic circum-cision in every case."

CORRESPONDENCE.

Spinal Nerve Lesions. (To the Editor of "The Australian Medical Journal.") Sir,—Dr. Sewell's useful and very suggestive, if some-

what condensed, article on the phenomenon of spinal transverse lesions, which appeared in your issue of August 23rd, touches upon many points both in clinical work and in physiology—at least 1 can vouch for the latter. On the purely academic side one is reminded of the pro-nounced difference between man and the lower animals in the greater need and use of skilled movements of the limbs and in the many changes which have been produced by the assumption of the erect posture. Both factors have combined to pull the original spinal arcs headwards, to make new afferent epicritic "private paths" and to ob-literate most, though not all, of the original arcs sub-serving progression. My chief purpose in writing is, how-ever, to fasten upon our detail and draw attention to the great difficulty which besets anyone who is dealing with either the physiology or the pathology of micturition. That difficulty is centred round the question, To what ex-tent is the trigónal musculature, innervated by the hypo-gastrics, developed in the human bladder? To this ques-tion physiology, which experiments only with the lower animals, cannot of necessity give an answer; it can only claim to have narrowed clown the problem and set the question in its - present simple form. No information has as yet been supplied by either anatomy or pathology. Yet until this question is set at rest we can have but a very defective physiology of the human bladder and most cer-tainly a very defective pathology of the same. It is surely from the clinical side that the desired data will eventually come. Illustration cases must be sought for and studied, such, for instance, as that outlined by Dr. Sewell, where there is a lesion in the lumbar autonomic gap producing dissociation between the hypogastric and sacral nerve mechanisms. The pity of it is that so vast an amount of clinical material, bearing on this problem, is put to no use, and particularly so in countries outside the British Empire, and solely through lack of that knowledge of the structure of the cord and peripheral nervous system which is so manifest in Dr. Sewell's article.—Yours, etc.,

W. A. OSBORNE.

Paralysis—Blind—Deaf and Dumb. Recovery after 28 Years. (To the Editor of "The Australian Medical Journal.") Dr. Butchart sends the following note of a case which

has lately been exciting public interest:— William Ilton was admitted to the Austin Hospital on

4th October, 1887. At that time he was 44 years of age. single, and a butcher by trade. He resided in the Kyneton district, and his illness began in 1885, when he was found by his neighbours in an unconscious condition. He was removed to the Kyneton Hospital, where he remained for a period of two years and two months. He was then transferred to the Austin Hospital, and was admitted as "Paralysis, as well as Deaf, Dumb, Blind." In this con-dition he remained till October, 1912, when it was found that he was recovering his sight. This was quite restored to him, but his other senses apparently remained dormant until June, 1913, when he commenced to talk, and a little later surprised everyone by announcing that he could "hear the train whistle."

Between October and June his conversation was limited to the use of the Card Alphabet. Now, however, he has dispensed with that.

It must, however, be pointed out that at long intervals during the past four years other patients in the same ward have on two or three occasions declared that they heard Ilton speak a few words.

During this long time, Ilton's health has required very little medical attention beyond, of recent years at least, a few minor ailments, chiefly abdominal and one attack of influenza about three years ago.

Austin Hospital, Heidelberg, 14th July, 1913.

1196 AUSTRALIAN MEDICAL JOURNAL. August 3o, 1913.

Medical Graduates' Photo. Fund. To the Editor of "The Australian Medical Journal.")

Sir,—The Committee of the Melbourne Medical Associa-tion are anxious to proceed with the erection of the cases to contain the photographs of the Melbourne Medical Graduates. It is desired that the work should be com-pleted in time for the Jubilee celebrations of the Melbourne Medical School, It may be as well to remind our graduates that the Medical Students' Society has recently presented to the University all the photographs of the Fifth Year's Students of Medicine. The collection dates back to 1883, and we have ascertained that we shall be able to provide a complete portrait gallery of the Melbourne Medical Graduates from the date of the. foundation of the Uni-versity. The collection is so unique and valuable that we are desirous of providing adequate accommodation for it, to protect it against the ravages of time. It has been estimated that at least £ 100 will be required.

Thanks to those who have already contributed, a sum of £ 70 is available, so that the work may be commenced without delay. Before closing the fund, however, the Committee feel that there are many sympathisers able and willing to contribute who only require to be reminded. It is hoped that they will forward their subscriptions to Dr. S. Argyle, 91 Collins-street, without delay. All subscriptions will be acknowledged in the columns of "The Australian Medical Journal."—Yours; etc.,

H. DOUGLAS STEPHENS, KONRAD HILLER,

Hon. Secs.

GENERAL.

LORD LISTER INTERNATIONAL MEMORIAL.

The treasurer in Victoria (Mr. R. Hamilton Russell) desires to acknowledge with thanks the following contri-butions:—

Amount previously acknowledged .. £69 14 0 Dr. Colin Gray .. .. 1 1 0 Dr. E. Alan Mackay .. .. . . 1 1 0 Dr. F. H. Cole .. .. .. .. 1 1 0 Dr. R. L. Forsyth .. .. .. .. 0 5 0 Dr. L. Balfour .. .. .. .. 0 5 0 Dr. M. D. Silbenberg .. .. .. 0 5 0 Dr. W. G. D. Upjohn .. .. .. 0 5 0 Dr. Percy Brett .. .. .. .. .. .. .. 0 5 0 Dr. J. D. King Scott .. .. 0 5 0 Dr. Rupert Downes .. .. .. 0 5 0 Dr. D. M. Embleton .. .. 0 5 0 Dr. S. F. Macdonald .. .. . 0 5 0 Dr. W. S. Garnett .. .. .. .. 0 5 0 Dr. C. Roache .. .. .. .. .. 0 5 0 Dr. C. McLane .. .. .. 0 5 0 Dr. Herbert Weigall .. .. .. .. .. .. 0 5 0 Dr. A. H. Sturdee .. . 0 10 6

According to the St. Helena Blue-book for the year 1912, just received at the Colonial Office, the estimated civil population on 31st December amounted to 3,519. To this must be added the Royal Marine detachment and crews of shipping in the port, bringing up the total to 3,772. The birth-rate for the year in the civil population worked out at 28.4 per 1,000, and the death-rate at 12.5 per 1,000 (as against 10.9 in 1911). Of the 44 deaths 20 were those of persons over the age of 70, one of whom had reached the age of 98. The general health of the island during the year was good. The increased death-rate was mainly due to deaths from old age. On the other hand, the infant mortality rate was only 9.61 per 1,000, calculated on the n•uniber of registered births—a marked decrease on the previous year. There were no deaths from zymotic disease. An outbreak of scarlet fever occurred in the latter part of the year. The disease first appeared in August, and, owing to the prompt and stringent measures taken to prevent dissemination, was for a long time confined to Jamestown. All cases were isolated in the military hos-

TOrítí5fj fifiebícar a55oríatíoit. VICTORIAN BRANCH.

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

NOTICES.

Warning Notices. 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-tary, B.M.A., 429 Strand, London.

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.

VICTORIAN BRANCH.—Ordinary Meeting, 1st Wednesday in month.

„ „ Clinical Meeting 3rd Wednesday In month.

PEDIATRIC SOCIETY.—Second Wednesday in month. EYE & EAR SECTION.-4th Tuesday in Month. MELBOURNE HOSPITAL CLINICAL SOCIETY.-4th Fri-

day in the Month.

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.

pital, which was specially set apart for the purpose, and all infected material and bulidings were thoroughly dis-infected. Latterly, however, one or two cases appeared in the western country districts. Up to the end of the year the total number of cases amounted to 31. Most of these were of a mild type, and no deaths occurred. It has been impassible to trace the origin of the outbreak, the last instance having occurred in 1903.

PERSONAL.

Dr. G. C. Mathison, formerly of Melbourne, has been awarded the D.Sc. degree in the University of London for his thesis on The Action of Asphyxia on Nerve Centres and other papers.

Dr. Forbes Winslow, the Well-known alienist physician, who died recently in London, left an estate sworn for probate at £27, according to the "Evening Standard."

Dr. Jamieson was present at the annual meeting of B.M.A. held at Brighton.

Dr. Gordon Craig, of Sydney, is leaving on a trip to America.

Dr. W. Anstey Giles, of Adelaide, is on a visit to Mel-bourne to follow the golf championship contests.

Library Digitised Collections

Title:

Australian Medical Journal 1913

Date:

1913

Persistent Link:

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

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Australian Medical Journal, August 1913

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