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 LIBRARY OF 
 L. A. CO. MEDiCAt 
 , .6a4-SOUTHWESTUKEAYE. 
 
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 INTERCOLONIAL MEDICAL CONGRESS 
 OF AUSTRALASIA. 
 
 Xlcansactions 
 
 OF 
 
 SECOND SESSION, 
 
 HELD IN 
 
 MELBOURNE, VICTORIA, 
 
 JANUARY, 1889. 
 
 PUBLISHED UNDER THE DIRECTION OF THE LITERARY 
 
 COMMITTEE. 
 
 LIBRARY OTTRE 
 LOS AlWiELES COUNTY MEDICAL ASSOCIATION 
 
 634 SOUTH WEGTLAKE AVE, 
 
 MELBOURNE: 
 
 STILLWELL AND CO., PRINTERS, 195A COLLINS STREET. 
 
 1889. 
 
 %' 
 
 \^
 
 /j.S^-tQl : 
 
 ClUM
 
 ^ INTERCOLONIAL MEDICAL CONGRESS 
 
 OF AUSTRALASIA. 
 
 SECOND SESSION. 
 
 PATI^)N8. 
 
 His Excellenx'y !Sik Hexky Brougham Loch, G.C.M.G., K.C.E., 
 Governoi' of Victoi-ia. 
 
 His Exckllency the Kkuit Honorable Lord Carrington, G.C.M.U., 
 Governor of New 8outli Wales. 
 
 His Excellency Sir AV^illiam F. DrumiMond Jervois, G.C.M.G., 
 (xovernor of New Zealand. 
 
 His E.xcellency 8ir Anthony Musgrave, G.C.M.G., Governor of 
 Queensland (deceased). 
 
 His Excellency Sir William Cleaver F. Robinson, G.C.M.G., 
 Governor of South Australia. 
 
 His Excellency Sir Robert Claude Hamilton, K.C.R., (Governor 
 of Tasmania. 
 
 His Excellency Sir Frederick Napier Bijoome, K.C.M.G., 
 Governor of Western Australia. 
 
 His Excellency Sir John B. Thurston, K.C.M.G., Governor of 
 Fiji. 
 
 WITH THE SPECIAL COUNTENANCE AND SUPPORT OF 
 The Hon. Duncan Gillies, Premier of Victoria, and 
 Her Majesty's Ministers in Victoria.
 
 iv INTKKCOLONIAL MEDICAL CONGKKSS OF AUSTRALASIA. 
 
 PRESIDENT OF THE CONGRESS. 
 Thomas Nagiiten FitzGerald, F.?i. C.S.I. 
 
 VICE-PRESIDENTS OF THE CONGRESS: 
 
 CiiAKLES Morton Anderson, M.R.C.S. Eat;-., President of the 
 
 Canterbury Medical Association. 
 Thomas Chambers, F.R.C.P., F.R.C.S. Ed., &c., President of the New 
 
 South "Wales Branch of the British Medical Association. 
 William Edward Collins, M.B. Lond., M.R.C.S. Eng-., President of 
 
 the Wellington Medical Association. 
 Daniel Colquhoun, M.D. Lond., M.R.C.P. Lond., M.R.C.S. Eng., 
 
 President of the Otago Medical Association. 
 The Hon. John Mildred Creed, M.R.C.S. Eng., L.R.C.P. Ed., M.P. 
 
 (Sydney). 
 Frederick William Edmund Dawson, M.R.C.S. Eng., L.R.C.P. Ed., 
 
 President of the New Zealand Medical Association and of tlie 
 
 Auckland Medical Association. 
 Henry Croker Garde, F.R.C.S. Ed., Maryliorough (Queensland). 
 AVilliam Panton Grhjor, L.R.C.S. Ed., President of the Southland 
 
 Medical Association. 
 John Hugh Harricks, M.R.C.S. Eng., L. et L.M.K.Q.C.P.T., President 
 
 of the Maryborough (Queensland) Medical Societ}-. 
 Philip Sydney Jones, M.D. liond., F.R.C.S. Eng. (Sydney). 
 Samuel Thomas Knaggs, M.D., Ch. M. Aber., F.R.C.S. L, President 
 
 of tlie Medical Section of the Royal Society of New South Wales. 
 Joseph Henry Little, M.B. et CM. Edin., President of tlie Medical 
 
 Society of Queensland. 
 Cosby William Morgan, M.D. Brux., M.R.C.S. Eng., Newcastle 
 
 (N.S.AV.) 
 Henry Hayton Iiadcliffe, M.R.C.S. Eng., President of the Ballarat 
 
 District Medical Society. 
 Thomas Rowan, M.D. Sydney, F.R.C.S. Ed., President of the A^ictorian 
 
 I '.ranch f)f the Ih'itish Medical Association. 
 .Iames Pati;ick Ryan, M.K.Q.C.P.L, L.R.C.S.I., President of the 
 
 Medical Society of Victoria. 
 Tmomas Christie Smart,«F.R.C.S. Ed. (Hobart). 
 Edward Charles Stirling;, M.A., M.D. Cantab., F.R.C.S. Eng., 
 
 President of tlie Soutli Australian Branch of the Britisli Medical 
 
 Association. 
 Joseph Cooke Verco, M.D. Lond., F.R.C.S. Eng. (Adelaide), President 
 
 of tlie First Session of the Conajress.
 
 OFFICE-BKAHERS. 
 
 TREASURER. 
 
 George Ckaiiam, M.D. Melb., M.R.C.S. Eng., Riclnnoncl. 
 
 GENERAL SECRETARY. 
 Pkofessok H. B. Allex, M.D. et B.S. Melb., Melbourne University. 
 
 ASSOCIATE SECRETARIES. 
 J. W. Barrett, M.D. et M.S. Melb., F.R.C.S. Eng. 
 G. A. Syme, M.B. et M.S. Melb., F.R.C.S. Eng. 
 
 EXECUTIVE 
 
 T. (). F. Alsop, M.B. et CM. Edin., 
 M.R.C.S. Eng. 
 
 W. Balls-Headlev, M.D. et M.C. 
 Cantab., M.R.C.R Lond. 
 
 A. Bennett, M.D. et CM. Abeixl., 
 M.R.C.S. Eng. 
 
 F. D. Bird, M.B. et M.S. Melb., 
 
 M.R.C.S. Eng. 
 
 S. D. Bird, M.D. St. A., M.R.C.S. 
 
 Eng. 
 
 T. A. Bo WEN, M.R.C.S. Eng., 
 L.K.Q.C.P.I. 
 
 A. C Brownless, M.D. St. And., 
 F.R.C.S. Eng. 
 
 S. J. Burke, M.R.C.S. Eng., 
 
 L.K.Q.C.P.I. 
 J. G. Carstairs, M.D. Edin., 
 
 L.R.C.S. Ed. 
 A. CoLQUiiouN, M.B. Glas., 
 
 L.R.C.S. Ed. 
 J. Cooke, M.R.C.S. Eng. 
 W. H. Cutts, M.D. Edin. 
 R. B. Duncan, F.R.C.S. Ed. 
 C Duret, M.D. Paris. 
 W. H. Embling, L.R.C.P. Lond., 
 
 L.F.P.S.G. 
 
 G. H. Fetiierston, M.D. Melb., 
 
 L.F.P.S.G. 
 J. W. Y. FisiiBOURNE, M.B. et 
 
 Ch. M. Dub. 
 T. F. Fleetwood, M.B. Dub., 
 
 F.R.CS.I. 
 F T. West Ford, M.R.C.S. Eng. 
 
 COMMITTEE. 
 
 T. Foster, M.R.C.S. Eng. 
 
 T. M. GiRDLESTONE, F.R.C.S. Eng. 
 
 C E. GooDALL, M.B., B.S. Melb. 
 
 D. Grant, M.D. et CM. Edin. 
 A. S. Gray, M.R.C.S. Eng. 
 Professor G. B. Halford, 31. D. 
 
 St. A., M.R.C.S. Eng. 
 Colin Henderson, M.D. et CM. 
 
 Aberd. 
 L. Henry', M.D. Wurzbujg, 
 
 L.R.C.P. Lond. 
 T. Hewlett, M.R.C.S. Eng. 
 
 E. Hinciicliff, M.D. Edin., 
 M.R.C.S. Eng. 
 
 J. Jackson, M.D. Lond., M.R.C.S. 
 
 Eng. 
 E. M. James, M.R.C.S. Eng. 
 J. Jamieson, M.D. et CM. Glas. 
 H. JoNASSON, M.D. Wurzburg. 
 The Hon. G. LeFevre, M.D. et 
 
 CM. Edin., M.L.C. 
 A. J. R. Lewellin, M.B. et B.S. 
 
 Melb. 
 P. Moloney, M.B. Melb. 
 W. Moore, M.D. et M.S. Melb. 
 W. Morrison, M.D. et CM. Cilas. 
 J. V. McCreery, L.R.CS.I. 
 W. McCrea, M.B. Lend., M.R.C.S. 
 
 Eng. 
 P. H. MacGillivray, M.R.C.S. 
 
 Eng. 
 J. R. MacInerney, L.K.Q.CP.I., 
 
 L.R.CS.I.
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA 
 
 J. C. McKee, L.R.C.P. et S. Ed. 
 
 J. E. Neild, M.D. et B.S. Melb., 
 
 L.S.A. Loud. 
 J. Nicholson, M.D. Edin., 
 
 M.R.C.S. Eng. 
 H. M. O'Hara, L.K.Q.C.P.T., 
 
 L.R. C.S.I. 
 F. Peipers, M.D. Berlin. 
 O. Penfold, M.R.C.S. Eng. 
 A. J. W. PETTIC4REW, M.R.C.S. 
 
 Eng. 
 R. PiNCOTT, M.R.C.S. Eng. 
 R. D. PiNNOCK, M.B. et CM. Glas. 
 R. Power, L.R.C.P. Ed., L.R.C.S.I. 
 H. H. Radcliffe, M.R.C.S. Eng. 
 W. B. Rankin, F.R.C.S. Ed. 
 J. A. Reid, M.D. et CM. Aber. 
 James Robertson, M.D. Aber., 
 
 L.R.C.S. Ed. 
 T. Rowan, M.B. Melb., M.D. 
 
 Sydney, F.R.C.S. Ed. 
 J. T. RuDALL, F.R.C.S. Eng. 
 C S. Ryan, M.B. et CM. Edin. 
 J. P. Ryan, M.K.Q.C.P.I., 
 
 L.R.C.S.I. 
 A. Shields, M.D. Edin. 
 C Smith, M.D. Lond., M.R.C.S. 
 
 Ens. 
 
 D. Skinner, M.B. et CM. Aber. 
 S. Maberly Smith, M.R.C.S. Eng 
 
 L.R.C.P. Ed. 
 W. Beattie Smith, F.R.C.S. Ed., 
 
 L.R.C.P. Ed. 
 
 W. Snowball, M.B. Melb., L.R.C.S. 
 Ed. 
 
 J. W. Sprin(;thorpk, M.D. et B.S. 
 
 Melb., M.R.C.P. Lond. 
 W. H. Syme, L.R.C.P. Lend., 
 
 L.R.CS.L 
 M. B. Thomson, M.B. et CM. Edin. 
 J. Tremearne, M.R.C.S. Eng. 
 D. Turner, L.R.C.P. Lond., 
 
 L.R.C.S. Ed. 
 W. B. Walsh, M.D. Dub., 
 
 F.R.CS.L 
 J. H. Webb, M.R.C.S. Eng., 
 
 L.R.C.P. Lond. 
 W. P. Whitcombe, M.R.C.S. Eng. 
 H. C WiGG, M.D. Edin., F.R.C.S., 
 
 Eng. 
 J. Williams, M.D. Edin., M.R.C.S. 
 
 Eng. 
 J. J. E. WiLLMOTT, M.D. Aber., 
 
 M.R.C.S. Eng. 
 
 H. WOOLDRIDGE, F.R.C.S. Eng. 
 
 R. YouL, M.D. St. A., M.R.C.S. 
 Eno-. 
 
 ORGANISATION SUB-COMMITTEE. 
 
 The President. 
 
 A. C Brownless, M.D. 
 
 G. Graham, M.D. 
 
 E. M. James, M.R.C.S. 
 
 J. Jamieson, M.D. 
 
 P. Moloney, M.B. 
 
 W. McCrea, M.B. 
 J. E. Neild, M.D. 
 J. Robertson, M.D. 
 J. T. RuDALL, F.R.C.S. 
 J. Williams, M.D. 
 The Secretary. 
 
 RECEPTION 
 
 The President. 
 
 W. Balls-Headlky, M.D. 
 
 A. C Brownless, M.D. 
 
 F. T. West Ford, M.R.C.S. 
 
 COMMITTEE. 
 
 E. M. James, M.R.C.S. 
 P. Moloney, M.B. 
 C S. Ryan, M.B. 
 R. YouL, M.D. 
 
 TiiK Secretary,
 
 SECTIONAL OFFICERS. 
 
 LITERARY COMMITTEE. 
 
 The President. J. H. Webb, M.R.C.S. 
 
 J. Jamieson, M.D. The Secretary. 
 
 J. E. Neild, M.D. The Associate Secretaries. 
 
 The Secretaries of Sections and Sub-Sections. 
 
 vii 
 
 LOCAL SECRETARIES. 
 
 Nexo South Wales Philip Edward Muskktt, L.R.C.P. et S. Ed. 
 
 (Sydney.) 
 Queensland ... Francis Washington Everard Hare, M.B. 
 
 Durh., M.R.C.S. Eng. (Brisbane). 
 South Australia ... Ben.jamin Poulton, M.D. Melb., M.R.C.S. Eng. 
 
 (Adelaide). 
 Neio Zealand ... Joseph Osborne Closs, M.B., CM. Edin. 
 
 (Invercargill). 
 Western Australia John Rae Menzies Thomson, M.B., B.S. Melb. 
 
 (York). 
 Tasmania ... James M'Imery Pardey, M.B., B.S. Melb. 
 
 (Launceston). 
 
 LIST OF SECTIONS AND SECTIONAL 
 OFFICERS. 
 
 SECTION OF MEDICINE. 
 
 President ... The Hon. William Frederick Taylor, M.D., 
 
 Queen's College (Kingston, Canada), M.R.C.S. 
 
 Eng., M.P. (Brisbane). 
 Vice-Presidents ... Daniel Colquhoun, M.D. Lond,, M.R.C.P. 
 
 Lond., M.R.C.S. Eng. (Dunedin). 
 John Davies Thomas, M.D. Lond., F.R.C.S. 
 
 Eng., L.R.C.P. Lond. (Adelaide). 
 Secretary ... James .Jamieson, M.D. (Melbourne).
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 President 
 Vice-Presidents 
 
 Secretary 
 
 SECTION OF SURGERY. 
 
 Edward Charles Stirling, M.A., M.D. Cantab., 
 
 F.R.C.S. Eng. (Adelaide). 
 Charles Henry Haines, M.A., M.D. Queen's 
 
 Univ. Ii-el., F.R.C.S.I. (Auckland). 
 Henry Wideniiam Maunsell, M.B. Dub., 
 
 M.R.C.S. Eng. (Dunedin). 
 Richard Rendle, F.R.C.S. Eng. (Brisbane). 
 Frederick Dougan Bird, M.B., M.S. (Melbourne). 
 
 SECTION OF HYGIENE, FORENSIC AND STATE 
 MEDICINE. 
 
 President ... Henry Norman MacLaurin, M.A., M.D. Edin., 
 
 LL.D. St. A. (Sydney). 
 Vice-Presidents ... Alexander Johnston, M.D. St. A., M.R.C.S. 
 Eng. (Wellington). 
 Thomas Christie Smart, F.R.C.S. Ed. (Hobart). 
 Alfred Robert Waylen, M.D. St. A., M.R.C.S. 
 Eng. (Perth). 
 Secretary ... John William Springtiiorpe, M.D. (Melbourne). 
 
 SECTION OF ANATOMY AND PHYSIOLOGY. 
 
 President ... Professor T. P. Anderson Stuart, M.D., CM. 
 
 Edin. (Sydney). 
 Vice-President ... Professor Archibald AVatson, M.D. Pai-is and 
 
 Gottingen, F.R.C.S. Eng. (Adelaide). 
 Secretary ... James William Barrett, F.R.C.S. (Melbourne). 
 
 SECTION OF PATHOLOGY. 
 
 President ... William Camac Wilkinson, M.D. Lond., M.R.C.P. 
 
 Lond., M.R.C.S. Eng. (Sydney). 
 Secretary ... Henry Maudsley, M.D. (Melbourne). 
 
 SECTION OF OBSTETRICS AND GYNECOLOGY. 
 President ... Ferdinand Campion Batchelor, M.D. Durham, 
 
 F.R.C.P. Ed., M.R.C.S. Eng. (Dunedin). 
 Vice-Presidents ... Richard Stonehewer Bright, M.R.C.S. Eng. 
 (Hobart). 
 James Hill, M.D. Edin., F.R.C.S. Ed. (Brisbane). 
 Edward Willis Way, M.D. Edin., M.R.C.S. Eng. 
 (Adelaide). 
 Secretary ... Felix Meyer, M.B. (Carlton).
 
 SECTIONAL OFFICERS. IX 
 
 SECTION FOR DISEASES OF THE EYE, EAll AiNI) 
 THROAT. 
 
 President ... -Mai{K Johnston Symons, M.D., CM. Ediii. 
 
 (Adelaide). 
 Vice-Presidents ... Ciiakles Morton Anderson, M.R.C.S. Eiig. 
 (Cliristcluirch). 
 Andrew John Brady, L.K.Q.C.P.I. et L.R.C.S.I. 
 
 (Sydney). 
 Thomas Evans, M.R.C.S. Eng. (Sydney). 
 Secretarijfor Diseases of the Eye : 
 
 .James Jackson, M.D. (Melbourne). 
 
 Secretary for Diseases of the Ear and Throat: 
 
 Charles Lesin(;iiam Maynard Iredell, M.R.C.S. 
 (Melbourne). 
 
 SECTION OF PSYCHOLOGICAL MEDICINE. 
 
 President ... Frederick Norton Manning, M.D. St. A., 
 
 M.R.C.S. Eng. (Sydney). 
 Vice-Presidents ... Walter Edward Hacon, L.R.C.P. Lend., 
 M.R.C.S. Eng. (Christchurch). 
 Alexander Stewart Paterson, M.D. Edin., 
 
 L.R.C.S. Edin. (Adelaide). 
 Richard Battersby Scholes, M.B., CM. Edin. 
 (Brisbane). 
 Secretary ... William Beattie Smith, F.R.C.S. (Ararat). 
 
 SECTION OF PHARMACOLOGY. 
 
 President ... Baron Sir Ferdinand Von Mueller, M.D., 
 
 Ph. D., K.C.M.G., F.R.S. 
 Vice-President ... Thomas Dixson, M.B., CM. Edin. (Sydney), 
 Secretary ... David Grant, M.D. (Melbourne). 
 
 SECTION FOR DISEASES OF THE SKIN. 
 
 President ... James Patrick Ryan, M.K.Q.CP.L, L.R.C.S.I. 
 
 (Melbourne). 
 Secretary ... Robert Andrew Stirling, M.B. (Melbourne). 
 
 SECTION FOR DISEASES OF CHILDREN. 
 
 President ... William Snowball, M.B., B.S. Melb., L.R.C.S. 
 
 Ed. (Melbourne). 
 Secretary ... Arthur Jeffreys AVood, M.B. (Melbourne).
 
 ROLL OF MEMBERS OF CONGRESS. 
 
 Adam, G. Roth well .. 
 Adam, J. Basil 
 Agnew, The Hon. J. W 
 
 Aitchison, A. S. 
 Aitchison, E. 
 Allen, H. B. 
 Alsop, T. O. Fabian 
 
 Amess, James 
 Anderson, A. V. M. 
 Anderson, C. M. 
 Anderson, E. W. 
 
 Anderson, J. 
 Anderson, J. F. 
 Andrews, W. 
 Annand, G. 
 
 Appleyard, J. 
 Armstrong, G. A. 
 Ax'mstrong, \V. 
 Astles, H. E. 
 
 Backhouse, J. B. 
 Bage, Charles 
 Baird, J. C. 
 Balls-Headley, W. 
 
 Bancroft, J. 
 
 Bancroft, T. L. 
 Barker, W. 
 Barnard, C. E. 
 
 Barr, T. J. 
 Barrett, J. W. 
 
 M.B., CM. Edin. 
 M.B., Ch. M. Glas. 
 M.D. Glas., 
 
 M.R.C.S. Eng. 
 M.B., B.S. Melb. 
 M.B., B.S. Melb. 
 M.D., B.S. Melb. 
 M.B., CM. Edin., 
 
 M.R.C.S. Eng. 
 M.B., B.S. Melb. 
 M.B., B.S. Melb. 
 M.R.C.S. Eng. 
 M.D., B.S. Melb., 
 
 L.R.C.S. Ed. 
 L R.C.P. et. S. Ed. 
 L.R.C.P. et. S.Ed. 
 M D., B.S. Melb. 
 M.D., B.S. Melb., 
 
 M.R.C.S. Eng. 
 M.R.C.S. Eng. 
 L. R.C.P. et. S. Ed. 
 M.D., B.S. Melb. 
 M.D. St. A., 
 
 F.R.CP. Ed. 
 M.B., B.S. Melb. 
 M.D., B.S. Melb. 
 M.B., B.S. Melb. 
 M.D.,C.M.Cantab., 
 
 F.R.CP. Lond. 
 M.D. St. A., 
 
 M.R.C.S. Eng. 
 M.B., CM. Edin. 
 M.R.C.S. Eng. 
 M.D., Ch. M., Abei 
 
 M.R.C.S. Eng. 
 L.R.CP.et.S.Ed. . 
 M.D., M.S. Melb., . 
 
 F.R.C.S. Enff. 
 
 Melbourne, Vic. 
 Beaufoi't, Vic. 
 Hobart, Tas. 
 
 Albert Park, Vic 
 Albert Park, Vic. 
 Melb. Univ., Vic. 
 Hawthorn, Vic. 
 
 Tungamah, Vic. 
 Prahran, Vic. 
 Christchurch, N.Z. 
 Hawthorn, Vic. 
 
 Footscray, Vic. 
 Cootamundra,N.S.W. 
 Melbourne, Vic. 
 St. Kilda, Vic. 
 
 Longford, Tas. 
 East Melbourne, Vic. 
 Fitzroy, Vic. 
 Melbourne, Vic. 
 
 Brighton, Vic. 
 South Yarra, Vic. 
 Carlton, Vic. 
 Melbourne, Vic. 
 
 Brisbane, Q. 
 
 Brisbane, Q. 
 Albert Park, Vic. 
 Hobart, Tas. 
 
 Hawthorn, Vic 
 Melbourne, Vic
 
 UOLL OF MKMBERS. 
 
 Batchelor, F. C. 
 
 Bennett, A. 
 
 Bennett, F. A. 
 Bennie, P. B. 
 Bett, J. W. 
 Bickle, L. W. 
 
 Bii-ch, L. 
 Bird, E. J. 
 Bird, F. D. 
 
 Bird, 8. D. 
 
 Bird, W. J. 
 Black, A. G. 
 Blaxland, E. G. 
 
 Blaxland, H. 
 
 Bonnetin, F. H. 
 
 Borthwick, T. 
 Bowe, F. 
 
 Bowen, T. Aubrey 
 
 Bowman, R. 
 
 Boyd, Dr. 
 Brady, A. J. 
 
 Branson, G. B. 
 
 Brennan, J. M. 
 Brett, J. T. 
 Bright, R. S. 
 Brock, E. 
 Brown, H. R. 
 Brown, Valentine 
 Brown, W. 
 Ikown, W. H. 
 
 M.D. Durh., 
 
 F.R.C.P. Ed. 
 M.D., Ch. JNI. Aber., 
 
 L.R.C.P. Lond. 
 M.D., Ch. M. Aber. 
 M.D., B.H. Melb. . 
 M.B,,Cli. M. Aber.. 
 M.R.C.S. Eng., 
 
 L.R.C.P. Lond. 
 M.B., B.S. Melb. . 
 M.B., B.S. Melb. . 
 M.B., M.S. Melb., . 
 
 M.R.C.S. Eng. 
 M.D. St. A., 
 
 L.R.C.P. Lond. 
 M.B., B.S. Melb. . 
 M.B., Ch. M. Gla.s. . 
 M.R.C.S. Eng., 
 
 L.R.C.P. Lond. 
 M.R.C.S. Eng., 
 
 L.R.C.P. Lond. 
 M.R.C.S. Eng., 
 
 L.R.C.P. Lond. 
 M.B., CM. Edin. . 
 M.B. Lond., 
 
 M.R.C.S. Eng. 
 M.R.C.S. Eng., 
 
 L.K.Q.C.P.L 
 M.B., CM. Edin., . 
 
 M.R.C.S. Eno. 
 
 L.K.Q.C.P.L, 
 
 L.R.CS.L 
 M.R.C.S. Eng., 
 
 L.R.C.P. Ed. 
 L.F.P.S.G. 
 M.R.C.S. Eng. 
 M.R.C.S. Eng. 
 M.R.C.S. Eng. 
 L.R.C.P. et S. Ed. 
 M.B. Dub. 
 M.B., CM. Edin. 
 M.R.C.S. Entr. 
 
 Dunedin, K.Z. 
 
 Hamilton, \'ic. 
 
 Bairnsdale, \'ic. 
 Melbourne, Vic. 
 Richmond, Vic. 
 Adelaide, S.A. 
 
 Tarra\ ille, A'ic. 
 Northcote, Vic. 
 Melbourne, Vic. 
 
 Melbourne, \io. 
 
 Boort, ^'ic. 
 Carlton, Vic. 
 Sydney, N.S.W. 
 
 Sydney, N.S.W. 
 
 Stockton, New- 
 castle, N.S.W. 
 Kensington, S.A. 
 Maryborough, Q. 
 
 Melbourne, Vic. 
 
 Parramatta, N.S.W. 
 
 United States. 
 Sydney, N.S.AV. 
 
 Tungamah, Vic. 
 
 Corryong, Vic. 
 Melbourne, Vic. 
 Hobart, Tas. 
 Kilmore, Vic. 
 Snowtown, S.A. 
 Melbourne, Vic 
 Dunedin, N.Z. 
 Maffra, Vic.
 
 XU INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 Brownless, A. C. ... M.D. St. A., ... Melbourne, Vic. 
 
 Brummitt, R. 
 Bryant, H. W. 
 Burke, S. J. 
 
 Burton, J. 
 
 Biittner, A. 
 
 Byrne, W. S. 
 Campbell, W. B. 
 Carrutliers, C. U. 
 
 Carstairs, J. G. 
 
 Chambers, T. 
 
 Chapman, J. T. 
 Chisholm, E. 
 
 Cliishohn, ^Y. 
 
 Clarke, C. A. Dagnall 
 
 Clarke, H. St. John 
 Cleland, W. L. 
 Clenclinnen, F. J. 
 
 Clcss, J. (). 
 
 Clubbe, C. P. B. 
 
 Coane, J. 
 
 Cobb, F. 
 
 Cock burn, Hon. J. A. 
 
 Cohn, M. 
 Cole, F. H. 
 Collingwood, D. 
 
 Colquhoun, A. 
 
 M.D. St. A., 
 
 F.R.C.S. Eng. 
 M.R.C.S. Eng. 
 L.R.C.P. et S. Ed. 
 M.R.C.S. Eng. 
 
 L.K.Q.C.P.I. 
 M.D.Toronto, 
 
 M.R.C.S. Eng. 
 M.D. Berlin, 
 
 F.R.C.S. Ed. 
 M.B., Ch. M., T.C.D 
 
 L.K.Q.C.P.I., 
 
 L.R.C.S.I. 
 M.D. Edin., 
 
 L.R.C.S. Ed. 
 F.R.C.P., 
 
 F.R.C.S. Ed. 
 L.R.C.P. et S. Ed. 
 M.D. St. A., 
 
 M.R.C.S. Eng. 
 M.D. Lond., 
 
 M.R.C.S. Eng. 
 M.B. Lond. 
 
 F.R.C.S. Eng. 
 M.B., CM. Edin. 
 M.D., D. Ch. Brux 
 
 L.R.C.P. Lond. 
 M.B., CM. Edin. 
 M.R.C.S. Eng. 
 
 L.R.C.P. Lond. 
 L.R.C.P. Ed., 
 
 L.R.CS.L 
 M.R.C.S. Eng., 
 M.D. Lond., 
 
 M.R.C.S. Eng. 
 M.D. Copenhagen 
 M.B., B.S. Melb. 
 M.D. Lond., 
 
 F.R.C.S. Eng. 
 M.B. Glas., 
 
 L.R CS. Ed. 
 
 Kooringa, S.A. 
 Williamstown, Vic. 
 Melbourne, Vic. 
 
 Richmond, Vic. 
 
 Melbourne, Vic. 
 
 Brisbane, Q. 
 
 St. Arnaud, Vic. 
 Sydney, N.S.W. 
 
 Geelong, Vic. 
 
 Sydney, N.S.W. 
 
 Drysdale, Vic. 
 
 Ashfield, Sydney, 
 
 N.S.W. 
 Sydney, N.S.W. 
 
 St. Leonard's, Sydney, 
 
 N.S.W. 
 Richmond, Vic. 
 Adelaide, S.A. 
 Hawksburn, Vic. 
 
 Invercargill, N.Z. 
 Rand wick, N.S.W. 
 
 Brighton, Vic. 
 
 Fitzroy, Vic. 
 Adelaide, S.A. 
 
 Melbourne, Vic. 
 Carlton, Vic. 
 Sydney, N.S.W. 
 
 Sandhurst, Vic.
 
 UOLL OF MICMHRKS. 
 
 Colquhouu, A. G. 
 Colti[uhoun, P. 
 
 Connor, 8. 
 Cooke, J. 
 Cookson, J. 
 Corljin, T. W. 
 Courtenay, J. H. 
 Coutie, W. H. 
 Cox, J. 
 
 Crago, W. H. 
 
 Craig, W. J. 
 Crivelli, M. 
 Creed, Hon. J. M. 
 
 Cross, W. J. 
 
 Crossen, H. 
 Crowther, F. S. 
 Cunningham, P. H. 
 Curtis, H. C. 
 Cuscaden, G. 
 Cussen, G. E. 
 Cutts, W. H., sen. 
 Daisli, W. C. 
 Davenport, A. J. 
 
 Davies, T. S. 
 Dawes, R. St. M. 
 Dawson, F. W. E. 
 Dawson, — 
 DeZouche, I. 
 
 Dick, T. T. 
 
 Dickinson, G. W. 
 
 Dixson, T. 
 Dobbin, W. S. 
 
 Dowlinfj, F. 
 
 M.B., B.S. Melb. ., 
 M.D. Lond., 
 
 M.R.C.P. Lond. 
 M.D. Q.U.I. 
 M.R.C.S. Eng. 
 M.P,., B.S. Melb. ., 
 M.R.C.S. Eng. 
 L.R.C.P. Lond. .. 
 M.B., B.S. Melb. . 
 M.D. Melb., 
 
 M.R.C.S. Eng. 
 M.R.C.S. Eng., 
 
 L.R.C.P. Lond. 
 M.B., B.S. Melb. .. 
 M.D. Paris 
 M.R.C.S. Eng., 
 
 L.R.C.P. Ed. 
 M.B.Toronto, 
 
 L.R.C.P. et S. Ed. 
 L.F.P.S.G. 
 M.B., B.S. Melb. .. 
 M.B., Ch. M. Glas. 
 M.R.C.S. Eng. 
 L.R.C.P. etS. Ed. .. 
 M.B., B.S. Melb. .. 
 M.D. Edin. 
 M.D., B.S. Melb. .. 
 M.B. Lond., 
 
 M.R.C.S. Eng. 
 L.R.C.P. et S. Ed... 
 M.R.C.S. Eng. 
 M.R.C.S. Eng. 
 
 M.D.Q.U.L, 
 
 M.R.C.S. Eng. 
 M.D. Edin., 
 
 M.R.C.S. Eng. 
 M.B., CM. Edin., 
 
 M.R.C.S. Eng. 
 M.B., CM. Edin. . 
 M.B., Ch. B. Dul) 
 
 F.R.CS.L 
 M.Pk.CS. Enir. 
 
 Melbourne, A'ic. 
 Dunedin, N.Z. 
 
 Coleraine, Vie. 
 Prahran, Vic. 
 
 Adelaide, S.A. 
 Adelaide, S.A. 
 Melbourne, Vic. 
 Sydney, N.S.W. 
 Melljourne, Xk-. 
 
 Woollooniooloo, 
 
 N.S.W. 
 Melbourne, Xif. 
 Albert Park, Vic. 
 Woollahra, N.S.W. 
 
 Horsham, Vic. 
 
 Melbourne, Vic. 
 Melbourne, Vic. 
 Talbot, Vic. 
 Semaphore, S.A. 
 Port Melbourne, Vic. 
 Melbourne, Vic. 
 Hawthorn, Vic. 
 South Melbourne, Vic. 
 St. Kilda, Vic. 
 
 Benalla, Vic. 
 Gawler, S.A. 
 Auckland, N.Z. 
 s.s. " Massilia " 
 Dunedin, N.Z. 
 
 Melbourne, Vic. 
 
 INIoonee Ponds, Vic. 
 
 Sydney, N.S.W. 
 BruT\swick, Wc. 
 
 Riclimond, Vic.
 
 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 Doyle, Patrick 
 Drake, F. J. 
 Duigan, C. B. 
 Duncan, J. 
 Duncan, R. B. 
 Dyring, C. P. W. 
 Eastwood, F. 
 Eccles, J. V. 
 Elliott, C. B. 
 
 Ellis, H. H. 
 Embling, H. A. 
 
 Embling, W. H. 
 
 Erson, E. G. L. 
 Evans, J. H. 
 Evans, T. 
 Faithfull, R. L. 
 
 Faulkner, AV. J. 
 Fell, W. 
 Ferguson, H. L. 
 Fetherston, Gr. H. 
 
 Fetherston, R. H. 
 
 Fetherstonhaugh, C. 
 
 Fiaschi, T. 
 Fjeldstad, A. H. 
 
 Finlay, W. 
 
 Fischer, C. 
 
 Fishbourno, J. W. Y. 
 Fisher, A. 
 Fisher, T. C. 
 FitzGerald, T. N. 
 Fleetwood, T. F. 
 
 M.D., Ch. M. Q.U.T. 
 M.B. Melb. 
 L.R.C.P. et8. Ed. .. 
 M.B., CM. Aber. .. 
 F.R.C.S. Ed. 
 M.B., B.S. Melb. 
 M.B., B.S. Melb. 
 M.D. Michigan 
 L.R.C.P. Ed., 
 
 M.R.C.S. Eng. 
 M.B., Ch. B. Dub. ... 
 M.B., B.8. Melb., 
 
 L.R.C.P. Ed. 
 L.R.C.P. Lond., ... 
 
 L.F.P.S.G. 
 L.R.C.P. Ed. 
 M.B., B.S. Melb. ... 
 M.R.C.S. Eng. 
 M.D. Columbia 
 
 College, N.Y., 
 
 L.R.C.P. Lond. 
 M.D., Ch. M. Q.U.I. 
 M.B. Lond. 
 F.R.C.S.I. 
 M.D. Melb., 
 
 L.F.P.S.G. 
 M.D., CM. Ed., ... 
 
 L.R.CS.I. 
 M.B., Ch. M. Dub., 
 
 L.R.CS.I. 
 M.D., Ch. ^l. Pisa... 
 Med. Cand. Univ. ... 
 
 Christiania 
 M.D. Cooper 
 
 Med. Coll. San 
 
 Francisco 
 M.D. Halle et Wur/., 
 
 M.R.C.S. Eng 
 M.B., M.Ch. Dub.... 
 M.R.C.S. Eng. 
 M.D., M. Ch., T.C.D. 
 F.R.CS.T. 
 M.B. Dub., F.R.C.S.I. 
 
 Hawthorn, Vic. 
 Kew, Vic. 
 Richmond, Vic. 
 Bairnsdale, Vic. 
 Kyneton, Vic. 
 Coburg, Vic. 
 Ballarat, Vic. 
 Melbourne, Vie. 
 Geraldton, W.A. 
 
 Double Bay, N.S.W. 
 Hawthorn, Vic. 
 
 St. Kilda, Vic. 
 
 Prahran, Vic. 
 Adelaide, S.A. 
 Sydney, N.S.W. 
 Sydney, N.S.W. 
 
 Kyneton, Vic. 
 Wellington, N.Z. 
 Dunedin, N.Z. 
 Prahran, Vic. 
 
 Carlton, Vic. 
 
 Nth. Melbourne, Vic. 
 
 Sydney, N.S.W. 
 Sydney, N.S.W. 
 
 Bathurst, N.S.W. 
 
 Sydney, N.S.W. 
 
 Moonee Ponds, Vic. 
 Melbourne, Vic. 
 Sydney, N.S.W. 
 Melbourne, Vic. 
 Warrnambool, Vic.
 
 ROLL OF MEMBERS. 
 
 Fleming, H. H. 
 Fletclier, A. A. 
 
 Fletcher, E. 
 Flett, W. S. 
 Flynn, J, J. 
 Ford, F. T. West 
 Foreman, J. 
 
 Foster, T. 
 Fox, G. 
 
 Fox, W. R. 
 Frizelle, T. 
 Fytie, B. 
 
 Fyffe, E. H. 
 Gamble, H. W. B. 
 Garde, H. C. 
 Gardner, W. 
 Garliek, T. A. 
 Gault, E. L. 
 Gibson, J. 
 Giles, W. A. 
 Girdlestone, T. M. 
 Goodall, C. E. 
 Graham, G. 
 
 Grant, D. 
 Gray, A. S. 
 Griffith, C. A. 
 Griffith, J. de B. 
 Grigor, W. P. 
 Gurdon, E. J. 
 
 Hacon, W. E. 
 
 Haig, W. 
 Haines, C. H. 
 
 Halford, G. B. 
 
 M.B., Ch. B. Dub. ... 
 M.D., B.S. Melb., ... 
 
 M.R.C.8. Eng. 
 .M.R.C.S. Eng. 
 M.D., CM. Edin. ... 
 M.B., Ch. M. R.U.I. 
 M.R.C.S. Eng. 
 L.R.C.P. Ed., 
 
 M.R.C.S. Eng. 
 M.R.C.S. Eng. ... 
 M.R.C.S. Eng., ... 
 
 L.R.C.P. Ed. 
 L.R.C.P. etS. Ed.... 
 M.D., M. Ch. Q.U.]. 
 M.R.C.S. Eng. 
 
 L.R.C.P. Lond. 
 M.B., Ch.M. Glas.... 
 L.R.C.S. Ed. 
 F.R.C.S. Ed. 
 M.D., Ch.M. Glas. ... 
 M.B., B.S. Melb. ... 
 M.B., B.S. Melb. ... 
 
 M.B., CM. Edin. ... 
 F.R.C.S. Eng. 
 M.B., B.S. Melb. ... 
 M.D. Melb., 
 
 M.R.C.S. Eng. 
 M.D., CM. Edin. ... 
 M.R.C.S. Eng. 
 M.R.C.S. Eng. 
 M.B., M.Ch. Dub.... 
 L.R.CS. Ed. 
 M.R.C.S. Eng., 
 
 L.R.C.P. Ed. 
 M.R.C.S. Eng. 
 
 L.R.C.P. Lond. 
 M.D. Maryland, U.S. 
 M.D. Q.U. L, 
 
 F.R.CS.I. 
 M.D. St. A., 
 
 M.R.C.P. Lond., 
 
 M.R.C.S. Eng. 
 
 Donald, Vic, 
 Carlton, Vic. 
 
 Carlton, Vic. 
 Fitzroy, Vic. 
 Bairnsdale, Vic. 
 Melbourne, Vic. 
 Sydney, N.S.W. 
 
 Colac, Vic. 
 Ruthergleii, Vic. 
 
 Fitzroy, Vic. 
 Roebourne, W.A. 
 Fitzroy, Vic. 
 
 Fitzroy, Vic. 
 Walhalla, Vic. 
 Maryborough, Q. 
 Adelaide, S.A. 
 Murtoa, Vic. 
 Alfred Hospital, Vic. 
 Windsor, N.S.W. 
 Adelaide, S.A. 
 Melbourne, Vic. 
 St. Kilda, Vic. 
 Richmond, Vic. 
 
 Melbourne, Vic. 
 Melbourne, Vic. 
 Elsternwick, Vic. 
 Balaclava, Vic. 
 Invercargill, X.Z. 
 Brighton, Vic. 
 
 Christchurch, N.Z. 
 
 Melbourne, Vic. 
 Auckland, N.Z. 
 
 Melbourne, Vic.
 
 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 Hamilton, A. A. 
 Hamilton, J. A. G. . 
 
 Hamilton, T. K. 
 
 Haiicock, R. 
 Hankins, G. T. 
 Hardy, C. H. W. 
 Hare, F. W. E. 
 
 Harkness, E 
 Harricks, F. M. 
 
 Harricks, J. H. 
 
 Harrison, W. A. 
 Harvey, R. R. 
 Hayman, F. D. 
 Hay ward, W. T. 
 
 Heffernan, E. B. 
 Hendei'son, A. V. 
 Henderson, C. 
 
 Henry, L. 
 
 Henry, T. J. 
 Hewlett, T. 
 Hill, J. 
 
 Hinchcliti; E. 
 
 Hocken, T. M. 
 Hodi^son, T. 
 Honman, A. 
 Hood, A. J. 
 
 Hooper, J. W. Dunbar 
 Hope, J. W. 
 Hope, T. C. 
 Home, G. 
 Howard, G. 
 Howitt, G. 
 
 M.B., Ch. B. Dub. .. 
 M.B. Dub., 
 
 L.R.C.S. Ed. 
 M.D. Dub., 
 
 F.R.C.S.I. 
 M.R.C.S. Eng. 
 M.R.C.S. Eng. 
 M.B., B.S. Melb. .. 
 M.B. Durh., 
 
 M.R.C.S. Eng. 
 L.R.C.R etS. Ed. .. 
 M.K.Q.C.P.I., 
 
 L.R.C.8.T. 
 M.R.G.S. Eng., 
 
 L.K.Q. C.P.I. 
 M.B., CM. Edin. .. 
 M.B., B.S. Melb. .. 
 M.R.C.S. Eng. 
 M.R.C.S. Eng., 
 
 L.K.Q.C.P.I. 
 M.D., B.S. Melb. .. 
 M.B., B.S. Melb. .. 
 M.D., Ch. M. Aber., 
 
 L.R.C.S. Ed. 
 M.D. Wjirz., 
 
 L.R.C.P. Lond. 
 L.R.C.P. et S. Ed.... 
 M.R.C.S. Eng. 
 M.D. Edin., 
 
 F.R.C.S. Ed. 
 M.D. Edin., 
 
 M.R.C.S. Eng. 
 M.R.C.S. Eng. 
 M.B., B.S. Melb. .. 
 M.R.C.S. Eng. 
 M.B., Ch. M. Glas.... 
 
 L.R.C.P. et S. Ed. 
 M.R.C.P. Ed. 
 M.B., Ch. M. Glas. 
 M.B., B.S. Melb. 
 M.D., B.S. Melb. 
 M.B., B.S. Melb. 
 
 Adelaide, S.A. 
 Kapunda, S.A. 
 
 Laura, S.A. 
 
 Brisbane, Q. 
 Sydney, N.S.W. 
 Ballarat, Vic. 
 Brisbane, Q. 
 
 Surrey Hills, Vic. 
 St. Kilda, Vie. 
 
 Maryborough, Q. 
 
 Hawthorn, Vic. 
 Creswick, Vic. 
 Harrow, Vic. 
 Norwood, S.A. 
 
 Fitzroy, Vic. 
 Camberwell, Vic. 
 Castlemaine, Vic. 
 
 Brunswick, Vic. 
 
 Sydney, N.S.W. 
 Fitzroy, Vic. 
 Brisbane, Q. 
 
 Sandhurst, Vic. 
 
 Dunedin, JST.Z. 
 Sunbury, Vic. 
 Williamstown, Vic. 
 Clarence River, 
 
 N.S.W. 
 Melbourne, Vic. 
 Fremantle, W.A. 
 Geelong, Vic. 
 Clifton Hill, Vic. 
 North Fitzroy, Vic. 
 Melbourne, Vic.
 
 KOLL OF MEMBERS. 
 
 Hudson, J. 
 
 M.I 5. Loud., 
 M.R.C.8. Eng. 
 
 Nelson, N.Z. 
 
 Hudson, R. F. 
 
 M.D. St. A., 
 L.F.P.S.a. 
 
 Ballarat, Vic. 
 
 Hull, W. 
 
 M.D. Loud., M.R.C.S. 
 
 Sydney, KS.W. 
 
 Hurst, G. 
 
 M.B. Lond., 
 
 M.B., CM. Edin. 
 
 Sydney, N.S.W. 
 
 Ick, T. E. 
 
 M.B., B.S. Melb. ... 
 
 Albert Park, Vic. 
 
 Inglis, E. M. 
 
 . M.B., CM. Edin., ... 
 L.R.CS. Ed. 
 
 Kew, Vic. 
 
 Iredell, C. L. M. 
 
 M.R.C8. Eng., 
 L.R.CP Ed. 
 
 Melbourne, Vic. 
 
 Irving, J. 
 
 M.D. Edin., 
 M.R.CS. Eng. 
 
 Christchurch, N.Z. 
 
 Irving, J. A. 
 
 L.R.CP. Ed., 
 L.R.CS.I. 
 
 Caulfield, Vic. 
 
 Jack, R. K 
 
 L.R.CP. etS. Ed. ... 
 
 Stawell, Vic. 
 
 Jackson, H. W. 
 
 M.R.CS. Eng., 
 L.R.CP. Ed. 
 
 Sydney, N.S.W. 
 
 Jackson, J. 
 
 M.D. Lond., 
 M.R.CS. Eng. 
 
 Melbourne, Vie. 
 
 Jakins, W. V. 
 
 M.R.CS. Eng., ... 
 L.R.CP. Ed. 
 
 Melbourne, Vic. 
 
 James, E. IVI. 
 
 M.R.CS. Eng. 
 
 Melbourne, Vic. 
 
 James, T. 
 
 M.R.CS. Eng. 
 
 Moonta, S.A. 
 
 Jamieson, J. 
 
 M.D., Ch. M. Glas. 
 
 Melbourne, Vic. 
 
 Jay, Melville R. H. ... 
 
 M.R.CS. Eng., ... 
 L.R.CP. Lond. 
 
 Adelaide, S.A. 
 
 Jee, H. C. 
 
 M.R.CS. Eng. 
 L.R.CP. Ed. 
 
 Alexandra, Vic. 
 
 Jenkins, E J. 
 
 M.D. Oxon., 
 
 M.R.CP. Lond., 
 M.R.CS. Eng. 
 
 Sydney, N S. W 
 
 Jermaine-Lulham, F. S. 
 
 M.R.CS. Eng 
 
 L.R.CP. Lond. 
 
 Melbourne, Vic 
 
 Johnston, A. 
 
 M.D. St. A., 
 M.R.CS. Eng 
 
 Wellington, N.Z 
 
 Johnston, A. A. 
 
 M.K.Q.CP.L, 
 LR.CS. Ed. 
 
 Moruya, N.S.W 
 
 Johnston, J. Couper ... 
 
 M.H., CM. Edin. ... 
 
 St. Kilda, Vic. 
 
 John.ston, J. 
 
 M.B., Cli. M. Glas. 
 
 Williamstown, Vic 
 
 Jonasson, H. 
 
 M.I). Wur/.. 
 
 Melbourne, Vic. 
 
 Jone.s, P. Sydney 
 
 M.D. Lond., 
 F.R.CS. Eng. 
 
 Sydney, N.S.W.
 
 XVUl 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Joske, A. 
 Joyce, J. F. 
 Keenan, A. J. W. 
 
 Kennedy, J. \V. 
 
 Kennedy, P. 
 
 Kenny, A. L. 
 Keogh, A. G. 
 Kerr, J. 
 Kilpatrick, W, 
 Kingsbury, J. 
 
 Kirtikar, K. R. 
 
 Knaggs, S. T. 
 
 Lalor, J. 
 
 Lane, C. T. 
 Lane, T. 
 
 Lawrence, Dr. 
 Le Fevre, Hon. G. 
 
 Lenipriere, C. L. 
 Lejidon, A. 
 
 Lethbridge, C. F. 
 Lewellin, A. J. R. 
 
 Liddle, P. H. 
 Lilie, H. 
 Lillies, H. 
 
 Little, J. H. 
 Lloyd, F. 
 Long, M. H. 
 
 Longden, F. R. 
 Loosli, R. J. 
 
 M.B., B.S. Melb. ... 
 L.R.C.P. etS. Ed. ... 
 M.D., Ch. D. Brux., 
 
 L.R.C.S. Ed. 
 F.R.C.S.L, 
 
 M.K.Q.C.P.I. 
 L.R.C.S.L, 
 
 L.K.Q.C.P.L 
 M.B., B.S. Melb. ... 
 M.B., Ch. M. Glas.... 
 M.B., Ch. M. Glas.... 
 M.B., B.S. Melb. ... 
 M.D. Univ. Pennsyl- 
 vania 
 M.R.C.S. Eng., 
 
 L.R.C.P. Lond. 
 M.D., Ch. M. Aber., 
 
 F.R.C.S.L 
 M.D.,Ch.D. Brux.,... 
 
 L.R.C.S.L 
 M.B., B.S. Melb. ... 
 L.R.C.S.L, 
 
 L.K.Q.C.P.I. 
 
 M.D., CM. Edin., 
 
 M.L.C. 
 M.B., CM. Edin. 
 M.D. Lond., 
 
 M.R.C.S. Eng. 
 M.R.C.S. Eng. 
 M.B., B.S. Melb., 
 
 L.K.Q.C.P.L 
 M.B., B.S. Melb. 
 M.D. Univ. Bonn. 
 M.R.C.S. Eng., 
 
 L.R.C.P. Ed. 
 M.B., CM. Edin. 
 M.D. Syd.,L.R. C.S.I 
 M.D. (Univ. City .. 
 
 of New York), 
 
 L.K.Q.C.P.I. 
 L.R.C.P. etS. Ed... 
 M.B., B.S. Melb. .. 
 
 Prahran, Vic. 
 Fitzroy, Vic. 
 "Windsor, Vic. 
 
 Hay, N.S.W. 
 
 Albury, N.S.W. 
 
 Melbourne, Vic. 
 St. Kilda, Vic. 
 Newcastle, N.S.W. 
 Yarra Glen, Vic. 
 Sydney, N.S.W. 
 
 Thana (Bombay), 
 India 
 
 Sydney, N.S.W. 
 
 Richmond, Vic. 
 
 Camberwell, Vic. 
 Inverell, N.S.W. 
 
 Malvern, Vic. 
 
 Melbourne, Vic. 
 
 South Yarra, Vic. 
 Adelaide, S.A. 
 
 Alexandra, Vic. 
 Melb. Hospital, Vic. 
 
 Beechworth, Vic. 
 Moree, N.S.W. 
 Armadale, Vic. 
 
 Brisbane, Q. 
 Melbourne, Vic. 
 Sydney, N.S.W. 
 
 Buninyong, Vic. 
 Camberwell, Vic.
 
 ROLL OP MEMBERS. 
 
 Lynch, p. 
 McAllister, J . F. 
 McCartliy, C. 
 
 McCartliy, C. L. 
 MacColl, D. S. 
 MjicCorniick, A. 
 
 McCrea, W. 
 
 McCreery, .J. V. 
 M'Culloch, S. H. 
 MacDoiiald, Archibald 
 
 MacDonald, il. Gordon 
 
 M'Donnell, E. P. 
 
 McFarlane, C. C. 
 MacFarlane, W. H. ... 
 MacGibbon, W. 
 
 MacGillivray, P. H. ... 
 MacGregor, 8ir W. 
 
 Maclnerney, J. R. 
 
 Maclntyre, J. M. 
 McKee, J. C. 
 MacKenzie, J. H. 
 M'Killop, H. 
 
 Mackintosli, J. S. 
 
 MacKnight, C. M. 
 MacLaiirin, H. N. 
 
 Maclean, H. K. 
 McMillan, T. L. 
 
 Maclellan, J. N. E. ... 
 McMullen, H. 
 
 L.R.C.P. etS. Ed. ... 
 M.B., B.S. Melb. ... 
 ]\l.D. Melb., 
 
 L.F.P.8.G. 
 M.B., B.S. Melb. ... 
 M.B., Ch. M. Glas. 
 M.B., CM. Edin., ... 
 
 M.R.C.8. Eng. 
 :M.B. Lond., 
 
 M.R.C.S. Eng. 
 L.R.C.S.I. 
 
 M.B., CM. Edin. ... 
 M.D. Med. Coll. ... 
 
 Pennsylvania 
 L.R.CR Ed., 
 
 L.F.P.S.G. 
 L.K.Q.CP.L, 
 
 L.R.CS.I. 
 L.R.CP. et S. Ed.... 
 M.B., B.S. Melb. ... 
 M.D. Brux., 
 
 L.R.CP. et S. Ed. 
 M.R.CS. Eng. 
 M.D. Aber., L.R.CP. 
 
 Ed., K.CM.G. 
 L.K.Q.CP.L, 
 
 L.R.CS.I. 
 L.R.CS. Ed. 
 L.R.CP. et8. Ed.... 
 F.R.CS. Ed. 
 F.R.CS. Ed., 
 
 L.R.CP. Ed. 
 M.D. Edin., 
 
 M.R.CS. Eng. 
 M.B., B.S. Mell). ... 
 M.D. Edin., 
 
 L.R.C.S. Ed. 
 M.B., CM. Edin. ... 
 M.D. St. A., 
 
 L.R.CP. et S. Ed. 
 M.B., Ch. M. Aber. 
 M.B. Dub., 
 
 L.R.CS.L 
 
 Carlton, Vic. 
 Sydney, N.S.W. 
 N^orthcote, Vic. 
 
 Footscray, Vic. 
 Richmond, Vic. 
 Sydney, N.S.W. 
 
 East Melbourne, Vic. 
 
 Kew Asylum, Vic. 
 Sydney, N.S.W. 
 Sale, Vic. 
 
 Dunedin, X.Z. 
 
 Forbes, N.S.W. 
 
 Mentone, Vic. 
 New Norfolk, Tas. 
 Fitzroy, Vic. 
 
 Sandhur.st, Vic. 
 New Guinea. 
 
 Fitzroy, Vic. 
 
 St. Kilda, Vic. 
 Eaglehawk, Vic. 
 Wodonga, Vic. 
 Goulburn, N.S.W. 
 
 Glanville, N.S.W. 
 
 Melbourne, Vic. 
 Sydney, N.S.W. 
 
 WilIiam.stown, Vic. 
 South Yarra, Vic. 
 
 Sydney, N.S.W. 
 Hawthorn, Vic.
 
 XX 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 JNIacMuUen, J. Carnegie 
 
 MacNaniara, P. J. 
 
 M'NisIi, J. 
 
 MacRoberts, W. K. ... 
 Macvean, P. 
 
 INIacan.sli, W. 
 
 Magill, M. 
 Malier, W. Odillo 
 
 Malioney, L. F. 
 
 Mailer, M. 
 
 Main, H. 
 
 M alone J, W. E. N. . . 
 
 Manning, Hon. F. N.... 
 
 Mansou, J. F. W. 
 Marano, G. Y. 
 Marten, Pv. H. 
 Martin, J. W. 
 Mason, J. B. 
 
 Massey, E. H. C. 
 Maudsley, H. 
 
 Maun.sell, H. W. 
 
 Menzies, E. 
 Meyer, F. 
 
 Milford, F. 
 
 Miller, J. J. 
 Mitchell, H. St. J. 
 
 Mitchell, J. 
 Mitcliell, J. T. 
 
 Mullisori, C. H. 
 
 L.K.Q.C.P.L, 
 
 L.R.aS.L 
 L.R.C.S.I. 
 M.D., T.C.D., 
 
 L.R. C.S.I. 
 M.B., L.K.Q.C.P.L... 
 M.D. Glas., 
 
 L.R.C.S. Ed. 
 M.B., CM. Edin., ... 
 
 L.E.C.P. et S. Ed. 
 M.B., B S. Melb. ... 
 M.D., Ch.M. Q.U.L, 
 
 M.R.C.S. Eng. 
 M.B. Durh., 
 
 M.R.C.S. Eng. 
 M.B., B.S. Melb. ... 
 M.B., B.S. Melb. ... 
 M.R.C.S. Eng. 
 M.D. St. A., 
 
 M.R.C.S. Eng. ... 
 M.B., B.S. Melb. ... 
 M.D. Nai>les 
 M.B. Cantab., M.R.C.S. 
 L.R.C.P. et S. Ed.... 
 M.R.C.S. Eng., 
 
 L.R.C.P. Ed. 
 L.R.C.P. et S. Ed. ... 
 M.D. Lond., 
 
 M.R.C.P. Lond., 
 
 M.R.C.S. Eng. 
 M.B. Dub., 
 
 M.R.C.S. Eng. 
 M.R.C.S. Eng. 
 M.B., B.S. Melb. ... 
 M.D. Heidelberg, ... 
 
 M.R.C.S. Eng. 
 M.B., B.S. Melb. ... 
 L.R.C.P. Ed., 
 
 L.F.P.S.G. 
 M.B., Ch. M. Aber. 
 M.D., Ch. M. Aber., 
 
 M.R.C.S. Eng. 
 M.B., B.S. Melb., ... 
 
 M.R.C.S. Enff. 
 
 Melbourne, Vic. 
 
 Warrnambool, Vic. 
 Myall River, N.S.W. 
 
 Newcastle, JS'.S.W. 
 Wedderljurn, Vic. 
 
 Brighton, Vic. 
 
 Thargomiiidah. Q. 
 Sydney, N.S.W. 
 
 St. Kilda, Vic. 
 
 Carlton, Vic. 
 Mabnsbury, A'ic. 
 Melbourne, Vic. 
 Sydney, N.S.W. 
 
 Mahasbury, Vic. 
 Sydney, N.S.W. 
 Adelaide, S.A. 
 Ci-eswick, Vic. 
 Longford, Tas. 
 
 Daylesford, Vic. 
 Melbourne, Vic. 
 
 Dunedin, N.Z. 
 
 Napier, N.Z. 
 Carlton, Vic. 
 
 Sydney, N.S.W. 
 
 Melbourne, Vic. 
 Kyneton, Vic. 
 
 Narandera, N.S.W. 
 Port Adelaide, S.A. 
 
 Malvern, Vic.
 
 ROLL OF MKMBEHS. 
 
 3Ionoy, C. H. 
 Moloney, P. 
 Molyneux, J. F. 
 
 Moore, G. 
 
 Morgan, Cosby W. 
 
 Moore, T. D. 
 Moore, W. 
 3Ioore, W. F. 
 Morgan, I). C. 
 
 Morrison, A. 
 Morrison, "W. 
 Morton, F. W. W. 
 Mueller, A. 
 Mueller, Baron Sir F. 
 
 von 
 Mullen, W. L. 
 Munro, A. Watson 
 Muskett, P. E. 
 Naylor, H. G. H. 
 Neild, J. E. 
 Nelly, F. J. 
 Newman, F. J. 
 New inarch, B. J. 
 
 Nickoll, J. S. 
 Nicoll, A. 
 Nolan, L. A. 
 
 Nonnan, W. 
 
 Noriie, A. 
 Noyes, A. W. F. 
 Nutting, P. 
 
 Nyulasy, F. A. 
 O'Brien, J. A. 
 O'Brien, J. W. 
 
 Ochiltree. E. G. 
 
 M.B., B.S. Melb. ... 
 M.B. Melb. 
 M.R.C.S. Eng., 
 
 L.K.C.P. Ed. 
 M.D. Syd., 
 
 M.R.C.S. Eng. 
 M.D. Brux., 
 
 M.R.C.S. Eng. 
 L.R.C.S.I. 
 
 M.D., M.S. Melb. ... 
 L.R.C.P. Ed. 
 M.R.C.S. Eng., 
 
 L.R.C.P. Ed. 
 L.R.C.P. et S. Ed.... 
 M.D., Ch.M. Glas.... 
 L.R.C.P. etS. Ed.... 
 M.D., Ch. D. Giessen 
 M.D., Ph. D., 
 
 F.R.S., K.C M.G. 
 M.B., B.S. Melb. ... 
 M.B., CM. Edin. ... 
 L.R.C.P. etS. Ed.... 
 L.R.C.P. et S.Ed. ... 
 M.D., B.S. Melb. ... 
 L.R.C.P. et S.Ed. ... 
 M.B., B.S. Melb. ... 
 M.R.C.S. Eng., 
 
 L.R.C.P. Lond. 
 M.R.C.S. Eng. 
 M.B., Ch.M. Aber.... 
 L.K.Q.C.P.I., 
 
 L.R.C.S.L 
 M.R.C.S. Eng., 
 
 L.R.C.P. Ed. 
 M.D., Ch.M. Aber. ... 
 M.R.C.S. Eng. 
 M.R.C.S. Eng., 
 
 L.R.C.P. Lond. 
 M.B., B.S. Melb. ... 
 M.B., Ch.M. Glas.... 
 M.B., Ch. B. Dub.,... 
 
 F.R.C.S.L 
 M.B., Ch.M. Glas., ... 
 
 M.R.C.S. Eng. 
 
 Prahran, Vic. 
 Melbourne, Vic. 
 Willianistown, Vic. 
 
 St. Kilda, A^ie. 
 
 Newcastle, N.S.W. 
 
 Queenscliff, Vic. 
 Melbourne, Vic. 
 Strathalbyn, S.A. 
 Bairnsdale, Vic. 
 
 Melbourne, Vic. 
 Ballarat, Vic. 
 Fitzroy, Vic. 
 Yackandandah, Vic. 
 South Yarra. Vic. 
 
 Kew, Vic. 
 Sydney, N.S.W. 
 Sydney, N.S.W. 
 Launceston, Tas. 
 Melbourne, Vic. 
 Fitzroy, Vic. 
 Geelong, Vic. 
 Sydney, N.S.W. 
 
 Hawthorn, Vic. 
 Tambo, Q. 
 Wari-agul, Vic. 
 
 Adelaide, S.A. 
 
 Sydney, N.S.W. 
 Deniliquin, N.S.W. 
 Caul field, Vic. 
 
 Toorak, Vic. 
 Sunbury, Vic. 
 Carlton, Vic. 
 
 Ballarat, Vic.
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 O'Connell, J. 
 O'Donnell, N. M. 
 O'Haia, H. M. 
 
 O'Neill, G. J. L. 
 Oram, A. Murray 
 O'Sullivan, M. U. 
 Owen, F. J. 
 Owen, W. H. ' 
 
 Palmer, G. 
 Pardey, J. M. 
 Park, J. H. 
 Parkinson, C. J. 
 
 Paterson, A. S. 
 
 Peipers, F. 
 Penfold, O. 
 Pentland, A. 
 Perceval, M. W. C. 
 Pestell, J. 
 
 Pettigrew, A. J. W 
 Phelps, W. 
 Pincott, R. 
 Pinnock, R. D. 
 Pockley, F. A. 
 
 Pollen, H. 
 Poulton, B. 
 
 Powell, J. J- 
 
 Power, R. 
 
 Praagst, L. F. 
 Prendergast, J. J. 
 
 Quaife, F. H. 
 Rabl, H. 
 Radclitfe, H. H. 
 Ralph, T. S. 
 Rankin. W. B. 
 
 L.R.C.P. et S. Ed. ... 
 M.B., B.S. Mell.. ... 
 L.R.C.S.I., 
 
 L.K.Q.C.P.I. 
 M.B., CM. Ediii. ... 
 M.D., CM. Edin. ... 
 L.R.C.P. et S. Ed. ... 
 M.D., B.S. Melb. ... 
 M.R.C.S. Eng., 
 
 L.K.Q.C.P.I. 
 M.B., B.S. Melb. ... 
 M.B., B.S. Melb. ... 
 L.R.C.P. Lond. ... 
 M.B. Lond., 
 
 M.R.C.S. Eng. 
 M.D. Edin., 
 
 L.R.C.S. Ed. 
 M.D. Berlin. 
 M.R.C.S. Eng. 
 M.B.Dub.,L.R.C.S.L 
 M.K.Q.C.P.L 
 M.R.C.S. Eng. 
 M.R.C.S. Eng. 
 M.R.C.S. Eng. 
 M.R.C.S. Eng. 
 M.B., Ch.M. Glas. ... 
 M.B., CM. Edin., ... 
 
 M.R.C.S. Eng. 
 M.D., M. Ch. Dub.... 
 M.D., B.S. Melb 
 
 M.R.C.S. Eng. 
 M.D. Lond., 
 
 M.R.C.S. Eng. 
 L.R.C.P. Ed., 
 
 L.R.CS.T. 
 M.B., B.S. Melb. ... 
 M.D. R.U.L, 
 
 M.R.C.S. Eng. 
 M.D., Ch.M. Glas.... 
 M.D.Munich 
 M.R.C.S. Eng. 
 M.R.C.S. Eng. 
 F.R.CS. Ed. 
 
 Adelaide, S.A. 
 Melbourne, Vic. 
 Melbourne, Vic. 
 
 Sydney, N.S.W. 
 Sydney, N.S.W. 
 Melbourne, Vic. 
 Fitzroy, Vic. 
 Melbourne, Vic. 
 
 Ararat, Vic. 
 Launceston, Tas. 
 St. Mary's, Tas. 
 Malvern, Vic. 
 
 Adelaide, S.A. 
 
 Hawthorn, Vic. 
 Sandhurst, Vic. 
 Jamestown, S.A. 
 Mt. Bischoft; Tas. 
 Kyneton, Vic. 
 Camperdown, Vic. 
 Melbourne, Vic. 
 Geelong, Vic. 
 Ballarat, Vic. 
 Sydney, N.S.W. 
 
 Gisborne, N.Z. 
 Adelaide, S.A. 
 
 England. 
 
 St. Kilda,, \^ic. 
 
 Melbourne, Vic. 
 Mel])ourne, Vic. 
 
 Sydney, K . S. W. 
 Murtoa, ^'ic. 
 Ballarat, ^'^ic. 
 Carlton, Vic. 
 St. Kilda, Vic
 
 ROLL OF MEMBERS. 
 
 XXIH 
 
 Ray, H. 
 
 .. M.B., Ch. M. (ilas. ... 
 L.R.C.S. Ed. 
 
 Carlton, Vic. 
 
 liees, J. 
 
 .. M.R.C.S. Eng., 
 L.R.C.R Ed. 
 
 Hindmarsh, S.A. 
 
 Reid, J. A. 
 
 .. M.D., Oh. M. Aber. 
 
 Sale, Vic. 
 
 Reid, J. 
 
 .. M.D., Ch. M. Aber. 
 
 Melbourne, Vic. 
 
 Reid, R. G. 
 
 .. L.R.C.P. etS. Ed. ... 
 
 Nagambie, Vic. 
 
 Rendle, R. 
 
 .. F.R.C.S. Eng. 
 
 Brisbane, Q. 
 
 Roberts, W. S. 
 
 .. M.R.C.S. Eng. 
 
 Dunedin, N.Z. 
 
 Robertson, J. 
 
 .. M.D. Aber., 
 
 L.R.C.S. Ed. 
 
 Melbourne, Vic. 
 
 Robertson, J. A. 
 
 .. M.B., Ch. M. Glas. 
 
 East Melboui-ue, Vic 
 
 Robertson, R. 
 
 .. F.F.RS.G. 
 
 Adelaide, S.A. 
 
 Robertson, R. 
 
 .. M.R.C.S. Eng. 
 
 St. Kilda, Vic. 
 
 Robertson, W. 
 
 .. M.B., B.S. Melb. .. 
 
 Adelaide, S.A. 
 
 Rooke, C. 
 
 .. F.R.C.S. Eng. 
 
 Germanton, N.S.W. 
 
 Rorke, C. 
 
 .. L.K.Q.C.P.I. 
 L.R.C.S.I. 
 
 Sydney, N.S.W. 
 
 Ross, C. 
 
 .. M.B., CM. Edin. .. 
 M.D. Syd. 
 
 Sydney, N.S.W. 
 
 Ross, E. F. 
 
 ... M.D. Brux. 
 
 M.R.C.S. Eng. 
 
 Sydney, N.S.W. 
 
 Ross, J. 
 
 ... M.D. Wurz. 
 
 Pyramid Hill, Vic. 
 
 Roth, R. E. 
 
 ... M.R.C.S. Eng. 
 
 Sydney, N.S.W 
 
 Rowan, T. 
 
 .. M.D. Syd., 
 
 F.R.C.S. Ed. 
 
 Melbourne, Vic. 
 
 Rudall, J. F. 
 
 ... M.B., B.S. Melb. .. 
 
 Melbourne, Vic. 
 
 Rndall, J. T. 
 
 ... F.R.C.S. Eng. 
 
 Melbourne, Vic. 
 
 Ruddle, R. G. 
 
 ... M.D., B.S. Melb. ... 
 
 Stawell, Vic. 
 
 Rundle, G. E. 
 
 ... F.R.C.S. Ed., 
 L.R.C.P. Ed. 
 
 Sydney, N.S.W 
 
 Ryan, C. S. 
 
 .. M.B., CM. Ed. 
 
 Melbourne, Vic. 
 
 Ryan, E. 
 
 ... M.B., B.S. Melb. .. 
 
 Nhill, Vic. 
 
 Ryan, J. P. 
 
 .. M.K.Q.C.P.I., 
 L.R.CS.I. 
 
 Melbourne, Vic. 
 
 Ryan, M. J. 
 
 ... M.B., B.S. Melb. .. 
 
 Kyneton, Vic. 
 
 Ryan, T. B. 
 
 ... M.B., B.S. Melb. .. 
 
 Clifton Hill, Vic. 
 
 Salmon, H. R. 
 
 ... M.B., B.S. Melh. ... 
 
 Ballarat, Vic. 
 
 Salter, A. E. 
 
 ... M.B., B.S. Melb. .. 
 
 Thursday Island, Q. 
 
 Scantlebury, G. J. 
 
 ... L.R.C.P. etS. Ed. .. 
 
 Linton, Vic. 
 
 Schleichei-, C. 
 
 ... M.D. Wurz. 
 
 Melbourne, Vic. 
 
 Schlesinger, R, E. 
 
 ... M.B., CM. Edin., .. 
 M.R.C.S. Eng. 
 
 St. Kilda, Vic.
 
 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 Scholes, R. B. 
 Scot-Skirving, R. 
 Scott, G. A. 
 Scott, J. H. 
 
 Scott, R. 
 Scott, T. 
 
 Scott, W. 
 Seal, C. 
 Service, J. 
 Shields, A. 
 Shewen, A. 
 
 Sliownian, L. F. 
 Shuter, C. Y. 
 
 Simmons, E. L. 
 Simons, C. W. 
 Simpson, D. 
 Sinclair, E. 
 Singleton, F. E. Corbet 
 Singleton, J. 
 Sisca, N. 
 Skinner, D. 
 Smart, T. C. 
 Smith, C. 
 
 Smith, J. Govett 
 Smith, P. 
 Smith, S. 
 Smith, S. Maberly 
 
 Smith, W. Beattie 
 
 Snowball, W. 
 
 Spoof, Axel R. 
 Springthorpe, J. W. 
 
 Stacpoole, A. R. 
 Siapleton, J. J. 
 
 M.B., CM. Edin. 
 M.B., CM. Edin. 
 M.B., CM. Edin. 
 M.D., CM. Edin., 
 
 M.R.CS. Eng. 
 M.B., Ch. M. Glas. 
 M.R.CS. Eng., 
 
 L.R.CP. Ed. 
 M.R.CS. Eng. 
 M.B. Melb. 
 L.R.CP. et S. Ed. 
 M.D. Edin. 
 M.D. Lond., 
 
 M.R.CS. Eng. 
 L.R.CP. et S. Ed. 
 M.B. Durh., 
 
 M.R.CS. Eng. 
 M.R.CS. Eng. 
 L.R.CS.I. 
 M.B., Ch. M. Glas. 
 M.D., Ch. M. Glas. 
 L.R.CP. et S. Ed. 
 M.D. Glas. 
 M.D. Naples 
 M.B., Ch.M. Aber. 
 F.R.CS. Ed. 
 M.D. Lond., 
 
 M.R.C.S. Eng. 
 M.R.C.S. Eng. 
 M.D. Syd. 
 M.R.CS. Eng. 
 M.R.CS. Eng., 
 
 L.R.C.P. Ed 
 F.R.CS. Ed., 
 
 L.R.CP. Ed. 
 M.B., B.S. Melb., 
 
 L.R.CS. Ed. 
 
 M.D., B.S. Melb., 
 M.R.CP. Lond. 
 
 L.R.C.P. et S. Ed. 
 
 M.B., CM. Edin., 
 M.R.CS. Encj. 
 
 Brisbane, Q. 
 Sydney, N.S.W. 
 Mai'yborough , Vic. 
 Dunedin, N.Z. 
 
 Ballarat, Vic. 
 Warrnambool, Vic. 
 
 Elsternwick, Vic. 
 Buninyong, Vic. 
 
 Sydney, N.S.W. 
 West Melbourne, Vic. 
 Sydney, N.S.W. 
 
 Ringwood, Vic. 
 Creswick, Vic. 
 
 St. Kilda, Vic. 
 Brighton, Vic. 
 Oakleigh, Vic. 
 Sydney, N.S W. 
 Melbourne, Vic. 
 Melbourne, Vic. 
 Hawthorn, Vic. 
 Beechworth, Vic. 
 Hobart, Tas. 
 Casterton, Vic. 
 
 Clarence R., X.S.W. 
 Brisbane, Q. 
 
 Kyneton, Vic. 
 Geelong, Vic. 
 
 Ararat, Vic. 
 
 Carlton, Vic. 
 
 Ab&, Finland 
 Melbourne, Vic. 
 
 Hawthorn, Vic. 
 Lambton, N.S.W.
 
 ROLL OF MEMBERS. 
 
 Stawell, R. R 
 
 Steel, T. H. 
 
 Steuhouse, W. M. 
 Steven, A. 
 
 Stewart, C. A. 
 Stewart, D. E. 
 Stewart, R. 
 Stirling, E. C. 
 
 Stirling, R. A. 
 
 Stoker, H. 
 
 Stuart, T. P. Anderson 
 Stuart, W. 
 Sweetnam, W. F. 
 Syme, G. A. 
 
 Syrae, W. H. 
 
 Symons, M. J. 
 Taaffe, O. G. 
 Tanant, H. J. 
 
 Taylor, Hon. W. F. . . . 
 
 Thane, E. 
 Thomas, J. Davies 
 
 Thompson, J. Ashburton 
 Thomson, J. R. M. ... 
 Thomson, M. Barclay... 
 Thwaites, J. S. 
 Tilley, W. J. 
 Toll, J. T. 
 
 Travers, G. F. 
 
 Tremearne, J. 
 Trood, C. J. 
 
 M.B., B.S. Melb. ... 
 M.D. Glas., 
 
 L.F.P.S.G. 
 M.D., Ch. M. Glas. 
 M.D., CM. Edin., ... 
 
 M.R.C.S. Eng. 
 L.R.C.P. etS. Ed.... 
 M.B., C.M. Edin. ... 
 M.D., B.S. Melb. ... 
 M.D. Cantab., 
 
 F.R.C.S. Eng. 
 M.B., B.S. Melb., ... 
 
 L.R.C.P. et S. Ed. 
 L.R.C.S.I., 
 
 L.K.Q.C.P.I. 
 M.D., CM. Edin. ... 
 M.D., Ch. M. Aber. 
 M.D., Ch. M. Q.U.I. 
 M.B., M.S. Melb., ... 
 
 F.R.C.S. Eng. 
 L.R.C.P. Lond., ... 
 
 L.R.CS.I. 
 M.D., C.M. Edin. 
 L.R.C.P. et S. Ed.... 
 L.R.CS.I., 
 
 L.R.C.P. Ed. 
 M.D. Qu. Coll. 
 
 Kingston, 
 
 M.R.C.S. Eng. 
 M.B. Lond., M.R.C.S. 
 M.D. Lond., 
 
 F.R.C.S. Eng. 
 ALR.C.S. Eng. 
 M.B., B.S. Melb. ... 
 M.D., CM. Edin. ... 
 M.B., B.S. Melb. ... 
 M.R.C.S. Eng. 
 M.R.C.S. Eng., 
 
 L.R.C.P. Ed. 
 M.R.CS. Eng., 
 
 L.R.CP. Lond. 
 M.R.CS. Eng. 
 M.B., B.S. Melb. ... 
 
 Melbourne, Yio. 
 Toorak, Vic. 
 
 Dunedin, N.Z. 
 Aulmrn, Vic. 
 
 Melbourne, Vic. 
 Brunswick, Vic. 
 Hindmarsh, S. A. 
 
 Adelaide, S.A. 
 
 Melbourne, Vic. 
 
 Wycheproof, Vic. 
 
 Sydney, N.S.W. 
 Brighton, Vic. 
 Mortlake, Vic. 
 Melbourne, Vic. 
 
 Stawell, Vic. 
 
 Adelaide, S.A. 
 Rochester, Vic. 
 Sydney, N.S.W. 
 
 Brisbane, Q. 
 
 Yass, N.S.W. 
 Adelaide, S.A. 
 
 Sydney, N.S.W. 
 York,\v.A. 
 South Yarra, Vic. 
 Tallangatta, Vic. 
 Warwick, Q. 
 Port Adelaide, S.A. 
 
 Hawksbuni, Vic. 
 
 Creswick, Vic. 
 Mooroopna, Vic.
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Turner, D. 
 
 Twynani, G. E. 
 
 Usher, J. E. 
 Vassie, R. 
 Vaughan, A. P. 
 Vause, A. J. 
 Verco, J. C. 
 
 Verity, H. W. 8. 
 
 Voss, F. H. V. 
 Wall, Max. 
 Walsh, W. B. 
 Walter, J. B. 
 Ward, R. D. 
 Warren, R. B. 
 
 Warren, W. E. 
 Watkins, S. C. 
 Watkins, W. L. 
 
 Way, E. W. 
 
 Waylen, A. R. 
 
 Webb, J. H. 
 
 Weber, J. A. 
 Weigall, R. E. 
 West, W. A. 
 
 Whitcombe, W. P. 
 Whittell, H. T. 
 
 Whitton, T. B. 
 
 Wigg, H. C. 
 
 Wight, J. c. 
 
 Wilkinson, A. M. 
 
 L.R.C.P. Lend., 
 L.R.aS. Ed. 
 
 M.R.C.S. Eng., 
 L.R.C.P. Lend. 
 
 L.R.CP. Lend. 
 
 Melbourne, Vic. 
 .. Darlingliurst, N.S W. 
 Toorak. Vic. 
 
 M.B., B.S. Melb. ... 
 M.B., CM. Edin. ... 
 M.D. Lond., 
 
 F.R.C.S. Eng. 
 M.R.C.S. Eng. 
 
 L.R.C.P. Ed. ... 
 F.R.C.8. Eng. 
 M.D. Munich 
 M.D.Dub.,F.R.C.S.L 
 M.D. Dub. 
 M.R.C.S. Eng. 
 F.R.C.S.L, 
 
 L.K.Q.C.P.L 
 M.D., Ch. M. Q.U.I. 
 M.R.C.S. Eng. 
 L.K.Q.C.P.L, 
 
 L.R.C.S.L 
 M.D. Edin., 
 
 M.R.C.S. Eng. 
 M.D. St. A., 
 
 M.R.C.S. Eng. 
 M.R.C.S. Eng.," ... 
 
 L.R.C.P. Lond. 
 M.D., Ch. D. Giessen. 
 M.B., B.S. Melb. 
 L.K.Q.C.P.L, 
 
 L.R.C.S.L 
 M.R.C.S. Eng. 
 M.D. Aber., 
 
 M.R.C.S. Eng. 
 M.D. Q.U.L, 
 
 L.R.C.S. Ed. 
 M.D. Edin., 
 
 F.R.C.S. Eng. 
 M.B., B.S. Melb., 
 
 M.R.C.S. Eng. 
 M.B. Melb. 
 
 Box Hill, Vic. 
 Teuipe, N.S. W. 
 Adelaide, S.A. 
 
 Cheltenham, Vic. 
 
 Rockhamj)ton, Q. 
 Colac, Vic. 
 Kew, Vic. 
 Chiltern, Vic. 
 
 Sydney, N.S.W. 
 Camden, N.S.W. 
 
 Sydney, N.S.W. 
 Manly, N.S.W. 
 Yarra Bend, Vic. 
 
 Adelaide, S.A. 
 
 Perth, W.A. 
 
 Melbourne, Vic. 
 
 Natimuk, Vic. 
 Elsternwick, Vic. 
 Sydney, N.S.W. 
 
 Ballarat, Vic. 
 Adelaide. S. A. 
 
 Reefton, N.Z. 
 
 Carlton, Vic. 
 
 Balaclava, Vic. 
 
 Mornington, Vic
 
 ROLL OF MRMBERS. 
 
 XKVU 
 
 Wilkinson, J. F. 
 Wilkinson, W. Camac . 
 
 Wilkinson, W. Clcland 
 Williams, D. J. 
 
 Williams, J. 
 
 Williamson, W. 
 
 Williamson, W. C. 
 Willis, T. R. H. 
 Willmott, J. J. E. 
 
 Wilson, J. S. 
 Wilson, J. T. 
 Wolfenden, J. H. 
 
 Wood, A. J. 
 Wood, P. U. 
 
 V^'ood, W. A. 
 Woodward, G. P. M. 
 
 Woinaiski, G. H. Zk- 
 Woinarski, S. E. A. 
 
 Zicliy 
 Wooldridge, H. 
 Woolley, G. T. 
 Won-all, R. 
 Wriglit, H. G. A. 
 Youl, H. 
 
 Young, J. 
 
 M.B., B.S. Melb. 
 M.D.Lond.,M.R.C.P 
 Lond.,M.R.C.S.Eng 
 M.B., Ch. B. Dub. .. 
 M.D. Ht. A., 
 
 F.R.C.S. Eng. 
 M.D. Edin., 
 
 M.R.C.S. Eng. 
 M.D. Edin., 
 
 L.R.C.8. Ed. 
 M.D.,M.Cli.Q.U.r... 
 M.B., B.S. Melb. .. 
 M.D.,Ch.M, Aber.,.. 
 
 M.R.C.S. Eng. 
 M.D.,Ch. M. Glas.,.. 
 M.B., CM. Edin. .. 
 L.R.C.S.r., 
 
 L.K.Q.C.P.I. 
 M.D., B.S. Melb. .. 
 M.R.C.S. Eng., 
 
 L.R.C.P. Lond. 
 M.B., B.S. Melb. .. 
 M.D. Brux., 
 
 F.R. C.S.I. 
 M.B., B.S. Melb. .. 
 M.B., B.S. Melb. .. 
 
 F.R.C.S. Eng. 
 M.R.C.S. Eng. 
 M.D., Ch. M. Q.U.I. 
 M.R.C.S. Eng. 
 M.D. St. A.,^ 
 
 M.R.C.S. Eng. 
 M.D., Ch. M. Q.U.I. 
 
 Bright, Vic. 
 Sydney, N.S.W. 
 
 Preston, X'u: 
 Queensclif}", Vic. 
 
 Melbourne, Yi(;. 
 
 Ararat, Vic 
 
 Parramatta, N.S.W. 
 Daylesford, Vic. 
 Melbourne, Vic. 
 
 Wilcannia, N.S.W. 
 
 Sydney, N.S.W. 
 Dunolly, A'ic. 
 
 Carlton, A'ic. 
 Palmerston, Northern 
 
 Territoiy. 
 Malvern, Vic. 
 
 Sydney, N.S.W. 
 
 West Melbourne, Vic. 
 Ballarat, Vic. 
 
 South Yaira, Vic. 
 Castlemaiiie, Vic. 
 Sydney, N.S.W. 
 
 Sydney, N.S.W^ 
 Melbournt% Vic. 
 
 Invercargill, N.Z. 
 
 HONORARY MEMBERS. 
 
 Blackett, C. R. ... Government ... Melbourne, Vic 
 
 Analytical Chemist 
 
 Bo.sisto, Hon. .). ... Chemist ... Richmond, Vic. 
 
 Candler, C. ... Melljourne Club ... Melbourne, Vic.
 
 XXVni INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Melbourne, Vic. 
 
 Ellery, R. L. J., F.R.S. Government 
 
 Astronomer 
 
 Hamlet, W. M. 
 
 Hector, Sir James 
 Hayter, H. H. 
 Kernot, W. C. 
 
 McCoy, R, F.R.8. 
 
 Masson, D. Orme 
 
 Newbery, Cosmo 
 
 Spencer-, W. B. 
 
 Government 
 
 Analytical Chemist 
 
 Government Statist 
 
 President of the Royal 
 Society of Victoria 
 
 Professor of Natural 
 Science 
 
 Professor of 
 Chemistry 
 
 Director of the Tech- 
 nological Museum 
 
 Professor of Biology 
 
 Sydney, N.S.W. 
 
 New Zealand 
 Melbourne, Vic. 
 Melboui'ne, Vic. 
 
 Melbourne, Vic. 
 
 Melbourne, Vic. 
 
 Melbourne, Vic. 
 
 Melbourne, Vic.
 
 PilEFACE. 
 
 The Literary Committee, in presenting to Members the 
 Transactions of the Second Session of the Intercolonial 
 Medical Congress of Australasia., regrets the delay that has 
 occurred in publication. 
 
 The success of the Session entailed difficulties through the 
 mass of Papers submitted, and the consequent necessity for 
 further financial arrangements. 
 
 The Government of Victoria, with great liberalit}', increased 
 the sum which had been granted to defray the cost of publica- 
 tion. 
 
 In view of the decision of the Committee to keep the 
 Transactions within a definite limit, it was unavoidable that 
 many Papers should be curtailed, and that others, to the regret 
 of the Committee, should be held back in their entirety. In 
 several instances, also, the rejiorts of discussions hav^e been 
 compressed, or even omitted. 
 
 In consequence of the great distances between the chief 
 centres of population in Australasia, small delays frequently 
 occurred while the requisite authors' corrections were being 
 obtained, and in some cases these corrections could be dealt witli 
 only in the column of errata. 
 
 With these explanations, the Committee submits the result 
 of its labours to the kindly judgment of the Members. 
 
 By order of the Literary Committee, 
 
 T. N. FITZCxERALD. 
 Melbourne, 1889. President.
 
 CONTENTS. 
 
 Inai GURAL Meeting 
 
 Pkesident's Address. T. N. FitzGerald 
 General Meetings, Keceptions, and Entertainments 
 Section op Medicine — 
 
 Puesident's Address. W. F. Taylor 
 
 Some Notes on Disease in British New Guinea. Sir W. McGregor 
 
 On Filaria. J. Bancroft . . 
 
 Beri-beri as seen in the Northern Territory of South Australia 
 
 P. M. Wood 
 Diseases of Polynesians, as seen in Queensland. F. Bowe 
 Malarial Fevers of Tropical Queensland. T. S. Dyson 
 The Hepatic Element in Disease. J. W. Springthorpe 
 Notes on Seven Cases of Typhlitis. A. S. Joske 
 The Importance of the Constitutional Factor in Disease. J. Kobertson 
 Phthisis in New Zealand. D- Colquhoun .. 
 Treatment of Phthisis by Climate. D. Turner 
 The Open-air Treatment of Phthisis. J. P. Ryan . . 
 On Pneumatic Therapeutics, by means of the Portable Apparatus 
 
 V. Marauo . . 
 On the Immediate Treatment of Pleurisy with Eli'usion. S. D. Bird 
 The Nervous Substratum of Influenza. J. W. Springthorpe . . 
 On Want of Proportion in the Signs and Symptoms of Diseases of the 
 
 Heart and Great Vessels. J. Jamieson .. .. 
 
 A Case of Cerebellar Disease, in which an Exploratory Trepliining and 
 
 Removal of Diseased Brain-substance was followed by Good Results 
 
 H. Maudsley 
 Cerebellar Disease. J. C. Verco . . 
 
 A Case of Injury to the Frontal Region of the Brain. D. Colquhoun 
 A Series of Cases Illustrating Localisation in Nervous Diseases 
 
 J. W. Springthorpe . . . . . . . . . . 
 
 A Case of Raynaud's Disease. D. Grant .. 
 Aortic Incompetence and Locomotor Ataxia. D. Colquhoun .. 
 Chnical Notes on some Cases of Cerebro-spinal Fever. W. Finlay 
 On some Forms of Sunstroke Observed in Children. W. K. MacRoberts 
 Typhoid Fever, General Meeting Concerning 
 
 History of Typhoid Fever in Victoria, and Its Etiology. J. Robertson 
 
 The Etiology of Typhoid. J. G. Carstairs . . 
 
 Typhoid Fever Connected with Milk Supply. H. B. Allen 
 
 Typhoid Fever, History of an Epidemic. A. V. Henderson .. 
 
 A Note on the Incubation Period of Enteric Fever. J. C. Verco 
 
 Notes on Typhoid Fever. J. W. Springthorpe 
 
 Notes on Variations in the Pathological Process in Typhoil Ftver 
 
 H.B.Allen 
 The Cold Bath Treatment of Typhoid Fever. F. E. Hare 
 Notes on Typhoid and its Treatment. F. H. Bonnefin 
 Discussion on Typhoid .. .. .. .. .. 
 
 1 
 
 !) 
 21 
 
 3.5 
 46 
 49 
 
 54 
 
 59 
 64 
 67 
 71 
 73 
 79 
 87 
 90 
 
 93 
 
 99 
 
 101 
 
 106 
 
 113 
 117 
 117 
 
 121 
 129 
 135 
 139 
 144 
 149 
 149 
 155 
 159 
 169 
 172 
 173 
 
 175 
 179 
 185 
 188
 
 I'AriE 
 
 XXXU INTERCOLONIAL MEDICAL COXGUESS OF AUSTRALASIA. 
 
 Section of Surgery — 
 
 President's Address — Is Surgery a Science ? E. C. Stirling . . 197 
 Laparotomy, with Remarks on some of the Injuries and Diseases which 
 
 may Render the Operation Necessary. Sydney Jones .. .. 216 
 
 Upon the Treatment of tlie so-called Tropical Abscess of the Liver, by 
 
 Free Incision and Stitching of tlie Abscess-wall to the Lips of the 
 
 Parietal Wound. J. Davies Thomas . . . . . . . . 230 
 
 Congenital Phimosis and Adherent Prepuce. Gr. T. Woolley . . . . 234 
 
 Resection of the Intestine by a New Method. H. W. Maunsell . . 236 
 
 Critical Review of the Results of Excision of Hard Chancre. M. Crivelli 241 
 Observations on the Practice of Cystotomy. A. MacCormick . . 246 
 
 Supra-pubic Lithotomy. J. Tremearne . . . . . . . . 257 
 
 Twenty Successful Cases of Supra-pubic Lithotomy. H. O'Hara . . 260 
 
 Notes on Lateral Spinal Curvature, with Special Reference to Treatment. 
 
 G. A. Scott . . . . . . . . . . . . . . 264 
 
 The Management of Traumatic Head Cases, with a view to the 
 
 Prophylaxis of Immediate and Remote Morbid Sequela?. A. J. W. 
 
 Pettigrew . . . , . . . . . . . . . . 269 
 
 The Treatment of the Sac in Herniotomy. K. R. Kirtikar . . . . 271 
 
 A Case of Diffuse Suppurative Periostitis of the Tibia, terminating in 
 
 Recovery almost without Necrosis. J. C. Verco .. .. 277 
 
 Abscess in the Left Middle Cerebral Lobe — Evacuation by Operation — 
 
 Temporary Improvement — Death. J. C. Verco and E. C. Stirling 280 
 
 A Few Observations on some Cases of Cancer of the Breast, with a 
 
 Table of Forty-seven Cases. F. Milford . . . . . . 288 
 
 On the Use of Special Exercises and of Active and Passive Movements, 
 
 as an Aid to Surgical Treatment. R. E. Roth . . . . . . 298 
 
 An Instrument for Accurately Recording Lateral Curvature of the Spine. 
 
 R. E. Roth .. .. .. .. .. .. .. 299 
 
 Case of Compound Dislocation of tlie Ankle-joint, with Fracture of 
 
 Astragalus j;c/- ae and Resection of Same. H. C. Garde . . . . 300 
 
 A Case of Loreta's Operation for Dilatation of the Pyloric Orifice of the 
 
 Stomach. W.Gardner .. .. .. .. .. 301 
 
 The Surgery of the Kidney, W. Gardner , . . . . . . . 305 
 
 A New Procedure for the Cure of Congenital Talipes Varus and Equino- 
 
 varus. T. N. FitzGerald .. .. .. .. ..316 
 
 Subcutaneous Drilling in the Treatment of Bone Inflammation. T, N. 
 
 FitzGerald . . . . . . . . . . . . . . 321 
 
 A Case of Cleft Palate. T. N. FitzGerald . . . . . . , . 326 
 
 Hydatid Disease, General Meeting Concerning .. .. .. 328 
 
 The Geographical Distribution of Echinococcus Disease. .). Davies 
 
 Thomas .. .. .. .. .. .. ..328 
 
 Age in Relation to Hydatid Disease. J. Davies Thomas . . . . 342 
 
 Sex in Relation to Hydatid Disease. J. Davies Thomas . . . . 343 
 
 The Surgical Treatment of Hydatid Disease, W. Gardner . . . . ♦ 345 
 
 The Operative Treatment of Echinococcus Disease. J. Davies Thomas 352 
 Hydatid of the Brain — Removal by Operation — Death after Four Days. 
 
 J. C. Verco . . . . . . . . . . . . . . 377 
 
 Notes of a Case of Hydatid Cyst of the Zygomatic Fossa. J. R. M. 
 
 Thomson .. .. .. .. .. .. ..385 
 
 Case of Multiple Hydatid Cysts Treated by Thoracic Incisions — Recovery. 
 
 J. C. Verco and A. A. Lendon . . . . . . . . 388
 
 CONTENTS. XXXlll 
 
 Hydatid Disease (Continued) — pack 
 
 Treatment of Hydatid Disease by Injection of Permanganate of Potass. 
 
 W. P. Whitcombe . . . . . . . . . . . . 389 
 
 Upon tbe occasional presence of Bilirubin in Hydatid Cysts. J. Davies 
 
 Thomas .. .. .. .. .. .. ..390 
 
 Discussion on Hydatid Disease . . . . . . . . 392 
 
 Section oe Hygiene, Forensic and State Medicine — 
 
 President's Address — Comparative View of the Mortality of the 
 
 Different Colonies from Certain Diseases. H. N. MacLattrin 401 
 A Record of the Present Sanitary State of New South Wales. 
 
 J. Ashburton Thompson . . . . . . . . . . 434 
 
 State Medicine in New South Wales, with some Remarks on the Medical 
 
 Acts of the Colony. C.W.Morgan .. .. .. . . 45& 
 
 Hygienic Conditions in Victoria. J. W. Springthorpe . . . . 465 
 
 The Sanitary Condition of New Zealand. Leger Erson . . . . 485 
 
 State Medicine in Western Australia. J. R. M. Thomson . . . . 489 
 
 Sewage Disposal. W. F. Taylor . . . . . . . . . . 490 
 
 Leprosy in its Relation to the European Population of Australia. 
 
 J. M. Creed . . . . . . . . . . . . 499 
 
 Short Account of the Climatology of Nelson, New Zealand, and the 
 
 diseases for which it is most suited. J. Hudson . . . . 504 
 
 The Colonies as a Health Resort for Consumptives. J. Carnegie 
 
 MacMullen .. .. .. .. .. ..509 
 
 Some Observations on the Westerly Winds of Winter in their influence 
 
 on disease. F. Milford . . . . . . . . . . 512 
 
 Should the Medical Practitioner be an Officer of the State ? .J. T. Mitchell 515 
 Anthrax in Australia, with some Account of Pasteur's Method of 
 
 Vaccination — Demonstration at Junee, N.S.W. W.M.Hamlet .. 522 
 A Note on Pasteur's Methods. M. Crivelli . . . . . . . . 535 
 
 Is Cholera Quarantine Scientifically Sanctioned ? K. R. Kirtikar . . 539 
 The Necessity of Federal Inspection of Foreign-going Ships Arriving at 
 
 Australian Ports, coupled with Isolating and Federal Quarantine 
 
 Laws. A.E.Salter .. .. .. .. .. 545 
 
 The Evils of Specialism. D. Turner . . . . . . . . 551 
 
 Hygienic Conditions of Abo, Finland. Axel R. Spoof . . . . 554 
 
 Some Remarks on the principles and practice of Ventilation for Cold 
 
 and Warm Climates. W. V. Jakins . . . . . . . . 558 
 
 What becomes of the Typhoid Germ in Sewage Farms ? A. Shields . . 562 
 Sectional Meetings and Abstract of Discussions . . . . 565 
 
 Section of Anatomy and Physiology — 
 
 President's Address. T. P. Anderson Stuart . . . . . . 569 
 
 Demonstrations and Exhibits. T. P. Anderson Stuart . . . . 585 
 
 The Nature of Vision in Animals. J. W. Barrett . . . . . . 588 
 
 Section of Pathology — 
 
 President's Address. W. C.\mac Wilkinson . . . . . . 591 
 
 The Pathology and Clinical Significance of an Excess of Indican in the 
 
 Urine. R. H. Marten .. .. .. .. ..611 
 
 Unilateral Renal Atrophy, with Cases. T.C.Fisher -.. .. 615 
 
 The Microbe of Gonorrhcea. M. Crivelli . . . . . . . . 620 
 
 Section of Obstetrics and Gyn.sicology — 
 
 President's Address. F. C. Batchelor . . . . . . . . 625
 
 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 Section of Obsteteics and Gyn.5;cology (Contimwd) — 
 
 Pregnancy in its Various Stages, complicated by or associated with 
 
 Ovarian Disease. T. Rowan . . 
 Pifty Cases of Abdominal Section. F. C. Batchelor 
 Two Cases of Extra-uterine Pregnancy, successfully treated by 
 
 Abdominal Section. E. Worrall 
 Conditions Warranting the Removal of the Ovaries and Tubes 
 
 W. Balls-Headley 
 Twisting of Pedicle in Ovarian Tumours. W. Gardner 
 Puerperal Hysterectomy, or Porro's Operation by a New Method 
 
 H. W. Maunsell 
 Discussion 
 Should a Medical Man Practise Midwifery, while in charge of a case of 
 
 Puerperal Fever. J. C. Verco 
 Some Remarks on the Administration of Ana?sthetics during Labour' 
 
 S. Maberly Smith 
 Discussion 
 A Case of Uterine Pregnancy Supervening on Ectopic Gestation, which 
 
 had Persisted Four Years. T. Chambers 
 A Modification of Marion Sims' Operation for Metrotomy. G. R. Adam 
 The Menstrual Function, its Inception, Duration and Cessation, 
 
 Comparatively Considered. E. W. Anderson 
 Pilocarpine in Puerperal Eclampsia. R. H. J. Fetherston 
 The Obligations of Gynecology to Obstetrics. Felix Meyer . . 
 Electricity in Diseases of Women. J. Foreman 
 Section fob Diseases of the Eye, Eae and Throat — 
 President's Address. M. J. Symons 
 On Convergence. M. J. Symons . . 
 A series of cases of Resection of the Optic and Ciliary Nerves. H. Lindo 
 
 Ferguson 
 Sandy Blight and Granular Ophthalmia. T. Aubrey Bowen . . 
 Granular Conjunctivitis. R. B. Duncan 
 A case of Sarcoma of the Eyelids. W. OdUlo Maher 
 Remarks on Ojihthalmic Work in Western Australia. J. W. Hope 
 The treatment of Chronic Catarrh of the Middle Ear. .J. W. Barrett 
 Notes on a case of Optic Neuritis, following exposure to heat. H. Lindo 
 
 Ferguson 
 A case of Cerebellar Abscess, unsuccessfully treated by trephining. H 
 
 Lindo Ferguson 
 A case of Congenital Cyst of the Lower Lid, with Microphthalmos. W 
 
 Odillo Maher 
 A case of Glaucoma, in which Iridectomy appeared to be hurtful. J. T 
 
 Rudall 
 Death from Septic Meningitis, following excision of a suppurating eyeball 
 
 J. T. ilutiall 
 The Ocuiar Manifestations of late Hereditary Syphilis. G. Adliugton 
 
 Sym.. 
 
 On the 1 1 alment of Inlierited Specific Keratitis. J. Jackson . . 
 
 On the liaii^'tr of operating on Eyes in which Mucoceles co-exist. J. W 
 
 Bant; 
 Ocular •• |)tnms due to Diseases of the Nasal Cavities. T. K. Hamilton
 
 I 
 
 CONTENTS. XXXV 
 
 Skotion ¥Qii Diseases of the Eye, Eak and Throat C Conthnted) — rAt:e 
 
 A case of Double Glaucoma Fiilminans. Guido Thon .. .. 781 
 
 Post-nasal Growths. T. K. Hamilton . . . . . . . . 782 
 
 Aural Disease and Epilepsy. C. L. M. Iredell . . . . . . 789 
 
 The value of Redness of the Handle of the Malleus as a symptom in 
 
 diseases of the Middle Ear. J. W. Barrett . . . . . . 704 
 
 Phlyctenular Conjunctivitis in Erythema Nodosum. L. W. Bickle . . 79() 
 
 Exhibits. H. Lindo Ferguson .. .. .. .. .. 797 
 
 Nasal Calculus from a girl aged ten years. C. Morton Anderson . . 797 
 
 Microscopic Specimens of Glioma of the Retina. C Morton Anderson 798 
 Diphtheria — 
 
 On the Nature and Causes of Diphtheria, and its Pielation to Croup. J. 
 
 Jamieson . . . . . . . . . . . . . . SOU 
 
 Notes on Diphtheria. A. Jarvie Hood . . . . . . . . 807 
 
 Discussion on Diphtheria . . . . , . . . . . 814 
 
 Section of Psychology — 
 
 President's Address. F. N. Manning . . . . . . . . 816 
 
 A case of Sporadic Cretinism, with remarks. F. N. Manning . . . . 834 
 
 A contribution to the Study of Sporadic Cretinism — Six cases occurring 
 
 in South Australia. E. C. Stirling .. .. .. .. 840 
 
 Race and Insanity in New South Wales. Chisholm Ross . . . . 849 
 
 Insanity in Australian Aborigines, with a brief analysis of thirty-two 
 
 cases. F. N. Manning .. .. .. .. .. 857 
 
 Inebriety — its Etiology and Treatment. Patrick Smith . . . . 860 
 
 A Contribution to the Study of Inebriety. C. McCarthy . . . . 867 
 
 Australian Lunatic Asylums — Remarks on their Economic Management 
 
 in the future. W. L. Cleland . . . . . . . . . . 870 
 
 Lunacj' Legislation in the Australian Colonies. W. Armstrong . . 877 
 The Training of Nurses and Attendants in Hospitals for the Insane. 
 
 W. C. Williamson . . . . . . , , . . . . 887 
 
 The Extension of Hospital Methods to Asylum Practice. Eric Sinclair 895 
 The Housing of the Insane in Victoria, with special relation to the 
 
 boarding-out system of treatment W. Beattie Smith .. .. 898 
 Section of Pharmacology — 
 
 President's Address. Baron Sir F. von Mueller . . . . 909 
 On the Materia Medica and Pharmacology of Queensland Plants. T. L. 
 
 Bancroft .. .. .. .. .. .. ..927 
 
 Notes on the Poisonous Action of Species of Gastrolobium and Oxylobium. 
 
 J. C. Rosselloty . . . . . . . . . . . . 931 
 
 Bismuth : A Consideration of its probable Therapeutic Position. T. 
 
 Dixson .. .. .. .. .. ,. ..933 
 
 A Note on Drumine : Is there such a body '? T. Dixson . . . . 937 
 
 On the Dosage of Iodide of Potassium, with especial reference to the 
 
 treatment of psoriasis. W. M. Steuhouse . . . , . . 938 
 Some Evidence on the Efficacy of Chiau Turpentine in Cancer. H. E. 
 
 Astles .. . .. .. .. .. ..941 
 
 Notes on the External Use of Sulphate of Iron. Colin Henderson . . 943 
 
 Notes on two cases of Snake-bite. J. S. Thwaites . . . . . . 945 
 
 Notes on some Indian Drugs, with Exhibits. K. R. Kirtikar . . . . 946 
 
 Notes on an Exhibit of Indian Remedies. R. Temple Wright.. .. 956 
 
 On a New Mode of Administering the Protoxide of Iron. T. S. Ralph 958
 
 XXXvi INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Section for Diseases of the Skin — 
 President's Address. J. P. Kyan 
 Notes on the Treatment of some of the more frequently met with Sk: 
 
 Diseases. E. L. Faithfiill 
 Kotes of a fatal case of Pemphigus. A. A. Lendon . . 
 A note on the New Zealand Birch Itch. D. Colquliouu 
 On some cases of Alopecia Areata and its probable causes. D. Colquhouii 
 Notes on some Skin Affections complicating Urethritis. E. A. Stirling 
 Notes on a Case of Leprosy. F. Peipers 
 A case of Ichthyosis. J. P. Eyan . . 
 Section for Diseases of Children — 
 
 President's Address — On Intestinal Troubles in Children. W. 
 
 Snowball . . 
 Gastro-enteritis in Children — some points in Pathology and Therapeutics. 
 
 D. Collingwood 
 Discussion on Gastro-enteritis 
 
 An anomalous case of Acquired Infantile Syj^hilis. E. A. Stirling 
 On a case of Syphilitic Dactyhtis in a Child. E. A. Stirling . . 
 On a ease of Acquired Syphilis in a Child three years old. J. P. Eyan. . 
 The Correlation of Follicular Tonsillitis in Children with other Zymotic 
 
 Diseases. A. Honman 
 Pathological Museum — 
 
 Catalogue of Specimens submitted by Professor Allen 
 Specimens of Hydatid Disease 
 Appendix — Antiseptic Surgery and some of its results. E. B. Duncan 
 
 PAGE 
 961 
 
 965 
 967 
 
 970 
 972 
 974 
 976 
 977 
 
 981 
 
 984 
 990 
 991 
 
 992 
 994 
 
 995 
 
 999 
 1004 
 1009' 
 
 CORRIGENDA ET ADDENDA. 
 
 Page xiii. After " Dawson," insert " Eankine, M.D." 
 „ XV. After '• Gibson," insert " M.D., CM. Edin. ; Windsor, N.S.W." 
 ,, xvii. For " Irving, J. A.," read " Irwin, J. A." 
 „ xviii. After "Lawrence," insert " M.E.C.S. Eng., L.E.C.P. Lond." 
 ,, xix. In the eleventh line from the bottom, read " Glanville, S.A." 
 ,, xxiv. " Simons, C. W.," should read " Simons, C. N." 
 ,, xxvi. " West, R. A.," should read " West, W. A." 
 ,, 78. In the lifth line from the bottom, read " is said." 
 ,, 193. In lines 32 and 35, for " Chamberlain," read " Chamberland." 
 ,, 435. In line 26, for " suburban," read " urban." 
 
 ,, 437. In the fifth line from the bottom, omit the words "on the Health Officer." 
 „ 440. In the last column of both tables, after " Total," read " at all ages." 
 „ 441. Line 24, after the words "and five miles long," insert " and by a 6 ft. 
 
 wrought-iron pipe, a further distance of five miles." 
 ,, 442. Line 25, for " a rate which is 8d. in the £," read " a sliding scale, the 
 
 maximum charge being 6d. in the £." 
 ,, 449. In the eleventh line from the bottom, for " coroner's," read " coroners." 
 ,, 455. In column 2, line 1, for " 423,403," read " 423,493 ; " and in line 3, for 
 
 " 952,524," read " 452,524." 
 ,, 497. In line 32, for " Croyden," read " Croydon." 
 ,, 503. Line 7, for " Hawaia," read " Hawaii." 
 ,, 589. In line 21, for " 3-58," read " 4-54 ; " and in line 23, for " 4-54," read 
 
 "5-85." 
 „ 636. In the third line from the bottom, for " symtoms," read " symptoms." 
 „ 776. Inlinel6, for " V12,"read" VR."
 
 INTERCOLONIAL MEDICAL CONGRESS 
 
 OF AUSTRALASIA. 
 
 SIECOI^ID SESSIOIT. 
 
 INAUGURAL MEETING. 
 MONDAY, JANUARY 7, 1889. 
 
 The Second Session of the Intei'colonial Medical Congi'ess of 
 Australasia was inaugurated in the Wilson Hall, University of 
 IMelbourne, on Monday, January 7, 1889. His Excellency Sir Henry 
 Brougham Loch, G.C.M.G., K.C.B., Governor of the Colony of Victoria, 
 with Lady Loch and suite, arrived at 11.30 a.m., and was received 
 and escorted to the dais by the President and the Members of the 
 Reception and Organisation Committees. On the dais, which was 
 decorated with plants from the Botanic Gardens, and flowers from the 
 gardens of the Parliament Houses, were seated the Honourable Duncan 
 Gillies (Premier of Victoria), Sir Henry Parkes (Premier of New South 
 Wales) and the Misses Parkes, Mrs. T. N. FitzGerald, the Bishop of 
 iMelbourne and Mrs. Goe, His Honour the Chief Justice and Mrs. 
 Higinbotham, Sir James MacBain (President of the Legislative Council) 
 and Lady MacBain, Mr. M. H. Davies (Speaker of the Legislative 
 Assembly) and Mrs. Davies, the Chancellor of the University of 
 Melbourne and Mrs. Bi'ownless, Colonel Sargood (Executive Vice- 
 President of the Centennial International Exhibition) and IMrs. Sargood, 
 Dr. Verco (President of the First Session of the Congress), Colonel 
 Brownrrgg (Commandant of the Victorian Military Forces) and Mrs. 
 Brownrigg, the Right Worshipful the Mayor of Melbourne (Alderman 
 B. Benjamin) and Mrs. Benjamin, Sir H. Wrenfordsley, Q.C., Dr. 
 Kirtikar (of Bombay), Baron F. von Mueller, K.C.M.G., Professor 
 McCoy, F.R.S., Professor Kernot (President of tlie Royal Society of 
 Victoria), the AVarden of the Senate of the University and Mrs. Topp, 
 and other distinguished guests. The Members of Congress were seated 
 in front of the dais, and the I'emainder of the hall was well filled with 
 visitors. 
 
 The President (Mr. T. N. FitzGerald) took the chair, and invited 
 His Excellency the Governor to formally open the Congress.
 
 I INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 THE GOVERNOR'S ADDRESS. 
 
 His Excellency the Governor was enthusiastically received. He 
 said : — 
 
 Mr. President and Gentlemen, — Your meeting here in Congress is 
 one of the most important of the many very interesting events that 
 will make this period memorable in the history of Austi'alasia. The 
 result of this Congress will be, I venture to believe, as greatly to the 
 advantage of medical science throughout Europe and America, as it 
 will be productive of great good in the country in which it has 
 assembled. Eminent medical gentlemen have come from India and 
 distant countries, as well as from all parts of Australia, to take pai't in 
 the deliberations of this meeting ; men whose reputation as medical 
 scientists will give to the papers which they will submit to the 
 Congress a position of commanding influence upon some of the greatest 
 medical questions of the day. 
 
 The range of work that comes within the compass of medical science 
 is so vast that no one mind can grasp and treat in an exhaustive 
 manner the several branches in all their varied bearings ; while, in the 
 busy walk of practical life, few medical men can aftbrd the time 
 requisite for a close examination of more than one or two subjects of 
 special study. These meetings are therefore of untold value, where 
 the mental wealth acquired by individual scientists is collectively 
 submitted to the critical analysis of their fellow workers, whose 
 education, experienced observation and general knowledge properly 
 fit them to discuss, consider, and estimate at their proper value the 
 deductions that may with safety be drawn from the careful investiga- 
 tion of the specialist. 
 
 The amount of woi'k which the preparation for a meeting of this 
 character entails can only be adequately appreciated when we reflect 
 that the papers to be read are the outcome of years of unremitting 
 study and obsei'vation, devoted to the successful attainment of the 
 noblest end to which the greatest intellects can be applied — the 
 amelioration of huiiian suffering in all its varieties and forms of miseiy 
 — and tlius indirectly, to the strengthening and development of the 
 brain power of the world, on which the ever-growing requirements of 
 the day make an ever-increasing demand. 
 
 It is perhaps a fitting close to the rejoicings with which the com- 
 pletion of the Centennial of Australasia lias been commemorated, that 
 this Congress should be now assembled in Melbourne. The past 
 hundred years are replete with liistoric events which have created a 
 British empire in the southern hemispliere ; but marvellous as has been 
 the progress which has led to this develoj^ment, it is not so marvellous
 
 fiOVKRNOR S ADDRESS. 3 
 
 ns tlie advance that has been made during tlie same period in tlie 
 knowledge and application of inedical science ; and if the experience of 
 the past hundred years may be accepted as being any guide as to what 
 the discoveries may be in the future, then those who may hope to live 
 for the next thirty or forty years may revel in intellectual anticipations 
 as to what they may then know and witness. 
 
 "While the principal objects for which the Medical Congress has 
 assembled will, without doubt, receive every consideration and be kept 
 carefully in view, I trust the members of the Congress will likewise 
 accept my assurance that it is our anxious desire to ofter to all our 
 most cordial welcome, whether they come from distant lands, from the 
 sister colonies, or from our own country districts, as also to those whose 
 familiar faces we gladly recognise as belonging to our own immediate 
 neighbourhood ; and I venture to submit as my personal medical 
 contribution for the consideration of this great Congress, the pro- 
 position, which I trust may be carried without a dissentient voice, that 
 health is largely promoted by a well-projoortioned amount of relaxation 
 and enjoyment of this world's pleasures, and I ain not sure whether the 
 rule advocated in this colony, eight hours' work, eight hours' sleep, 
 eight hours' play, should not be adopted by this Congress as the great 
 panacea against all ills. 
 
 I trust I may be permitted to congratulate Mr. FitzGerald, whose 
 untiring efforts have in so large a measure contributed to bringing 
 together so many eminent gentlemen, upon what I may safely, in 
 anticipation, call this very sviccessful meeting of the Medical Congress ; 
 and I congratulate myself upon its being one of the happy incidents 
 connected with the ]30sition I have the honour to occupy in this colony, 
 that I am permitted to be so far connected with this great and 
 important meeting as to have been requested to perform the duty of 
 declaring the Medical Congress open — a duty which I have now the 
 honour to fulfil, with the most sincere and heartfelt good wishes that 
 the result of its deliberations may tend to the advancement of science 
 and to the benetit of mankind. 
 
 The President then called upon the General Secretary, Professor 
 Allen, to read the Report of the Executive Committee. 
 
 Professor Allen accordingly read the following report : — 
 
 REPORT OF THE EXECUTIVE COMMITTEE. 
 
 May it please Your Excellency, Mr. President, Members of 
 
 THE Congress, Ladies and Gentlemen, — 
 
 At the close of the First Session of tlie Intercolonial Medical Congress 
 
 of Australasia, held in Adelaide in August and September 1887, it was 
 
 unanimously resolved that the Second Session should be held in 
 
 B 2
 
 4: INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Melbourne in 1890, or at such earlier time as the Medical Societies 
 of Victoria might determine, and Mr. T. K. FitzGerald was elected 
 President of the Session. Professor Allen undertook to bring the 
 question of date and other necessary inatter.s before the IMedical 
 Associations of Victoria. Accordingly, he submitted tlie following 
 l>roposition to the four Associations : — " That the Medical Societie.s of 
 Victoria empower a Provisional Committee to fix the date of the next 
 Session of the Intercolonial Medical Congress of Australasia, and to 
 make all iieedful arrangements for such Session until a general meeting 
 of enrolled members can be held, at which a Progress Report shall be 
 submitted, such Provisional Committee to consist of tlie President-Elect, 
 six representatives chosen by the Medical Society of Victoria, six by the 
 Victorian Branch of the British Medical Association, three by the 
 Ballarat District Medical Society, and three by the Bendigo Medical 
 Society, the Committee having power to add to its numbei', five members 
 forming a quorum." The Associations approved this proposal, and 
 representatives were appointed as follow : — By the Medical Society of 
 Victoria — Professor Allen, Dr. J. Jackson, JNIr. E. M. James, Dr. 
 Jamieson, Dr. Neild, and Dr. J. Williams ; by the A^ictorian Branch of 
 the British Medical Association — Dr. Cutts, Dr. Graham, Dr. Henry, 
 Dr. Ptowan, Mr. Rudall, and Dr. Springthorpe ; by the Ballarat District 
 IMedical Society — Mr. Radcliffe, Mr. Tremearne, and Mr. Whitcombe ; 
 by the Bendigo Medical Society — Dr. Hincheliff', Mr. MacGillivray, 
 and Mr. Penfold. 
 
 The Provisional Committee, thus constituted, met for the first time on 
 December 6, 1887, when Dr. Graham w^as elected Honorary Treasurer, 
 and Professor Allen Honorary Secretary ; Dr. J. W. Barrett and Mr. 
 G. A, Syme Avere afterwards appointed Associate Secretaries. The 
 terms of membership were defined, and a guarantee fund was created to 
 cover any possible re.sidual liabilities. Rules of procedure were 
 adopted, and it was determined to exercise largely the power given to 
 the Committee of adding to its number. In this way the Committee 
 came to consist of 87 members, representing very fully, not only the 
 Societies, but also the whole profession throughout Victoria. It was 
 finally resolved that the Congress should assemble on Monday, January 
 7, 1889, and should rise on Saturday, January 12. 
 
 On April 5, 1888, a circular was address(Kl to members of the 
 profession throughout Australasia. Over two thousand copies were 
 despatched. The response was so satisfactory that on May 10 it was 
 j)ossible to hold the first meeting of enrolled members. The Provisional 
 Committee was then converted into the General Executive of the 
 Conr^ress. A Special Organisation Committee was created, with power 
 to determine the division of the Congress into Sections, to appoint the
 
 REPORT OF THE EXECUTIVE COMMITTEE. 5 
 
 officers of the Sections, and to perforoi all other acts necessary for the 
 organisation of the Congress, reporting from time to time to the General 
 Executive. This Organisation Committee consisted of tlie President, 
 Dr. A. C. Brownless, Dr. Graham, Mr. E. M. James, Dr. Jamieson, 
 Dr. Moloney, Dr. McCrea, Dr. Neild, Dr. James Robertson, Mr. 
 Rudall, Dr. J. Williams, and the Secretary. 
 
 A Eecei)tion Committee was then appointed to make provision for 
 the housing of the Congress and its Sections, and for the reception and 
 entertainment of visitors. This Committee consisted of the President, 
 Dr. Balls-Headley, Dr. Brownless, Mr. F. T. West Ford, Mr. E. 
 M. James, Dr. Moloney, Dr. C. S. Eyan, Dr. You), and the Secre- 
 tary. 
 
 Their Excellencies the Governors of all the Colonies kindly consented 
 to act as Patrons of the Congress, and expressed their interest in its 
 l)roceedings. His Excellency Sir Henry Loch, Governor of Victoria, 
 graciously promised to render his invaluable assistance in promoting the 
 success of the Congress, and in giving honourable reception to the 
 members. The Executive Committee deplores the subsequent removal 
 by death of Sir Anthony Musgrave, the late Governor of Queensland, 
 who had wi-itteu in the kindest manner about the prospects and work 
 of the Congress. 
 
 The Honourable Duncan Gillies, Premier of the Colony of Victoria, 
 kindly stated that the Government would do everything in its power to 
 aid the Congress and to assist in the entertainment of members, and at 
 his instance the Parliament voted a sum of money to cover the cost of 
 printing the Transactions. 
 
 The Presidents of all the Medical Associations of Australasia accepted 
 office as Vice-Presidents of the Congress ; and with them were associated 
 Di'. Verco, who so honourably discharged the office of President in the 
 First Session ; Dr. Sydney Jones and Dr. Creed, of Sydney ; Dr. Cosby 
 Morgan, of Newcastle ; Dr. Garde, of Maryborough, Queensland ; and 
 Dr. Smart, of Hobart. 
 
 The University buildings, including the Wilson Hall, were offered 
 for the meetings of the Congress, at the instance of the Chancellor, 
 Dr. Brownless, and this ofier was gratefully accepted. 
 
 After much consideration, it was determined that the Congress should 
 be divided into nine Sections, namely : — (1) Medicine, (2) Surgery, 
 (3) Hygiene, Forensic and State Medicine, (4) Anatomy and Physiology, 
 (5) Pathology, (6) Obstetrics and Gynaecology, (7) Diseases of the Eye, 
 Ear, and Throat, (8) Psychological Medicine, (9) Pharmacology. Two 
 sub-sections were provisionall}" constituted for Diseases of the Skin and 
 Diseases of Children. These were subsequently converted into 
 Sections. A President, Vice-Presidents, and a Secretary Avere
 
 b INTERCOLONIAL MEDICAL COXORESS OF AUSTRALASIA. 
 
 appointed for each Section, The Presidents and Vice-Presidents 
 were chosen from among the most eminent members of the Profession 
 outside Victoria, the only exception being that Baron F. von Mueller, 
 K.C.M.G.,at the repeated request of the Organisation Committee, accepted 
 the Presidency of the Section of Pharmacology. The Secretaries of Sec- 
 tions, for reasons which are obvious, were selected from among the members 
 of the Profession in Victoria. Local Secretaries were appointed for the 
 sevei'al Colonies, as follow : — for New South Wales, Dr. Muskett ; for 
 Queensland, Dr. Hare ; for South Australia, Dr. Poulton ; for New 
 Zealand, Dr. Closs ; for Tasmania, Dr. Pardey ; for Western Australia, 
 Dr. Thomson. The Executive Committee desires to acknowledge how 
 much the exertions of the Local Secretaries have contributed to the 
 success of the Congress. 
 
 Progress having thus been made, a final circular was issued to 
 members of the Profession on July 8tli, showing in detail the 
 organisation of the sections. Of this circular, two thousand two 
 hundred and fifty copies were distributed. Communications were 
 addressed to the leading Medical Journals throughout the United 
 Kingdom, France, Germany, the United States, and Canada ; and 
 through the kindness of the Surgeon-General at Calcutta, Sir 
 Benjamin Simpson, and his Secretary, Dr. Bomford, circulars were 
 distributed among members of the Medical Staff in the Presidencies 
 of India. The Executive Committee desires to acknowledge the kind 
 spirit which has characterised the notices of the Congress that :)ppeared 
 in the British and Foreign Medical Press. 
 
 At the instance of the Honourable the Premier of Victoria, the 
 railway departments of various Colonies undertook to grant tickets at 
 special rates to members of Congress travelling to Melboui-ne. The 
 principal shipping companies also agreed to make concessions in favour 
 of members en route to the Congress. For all these acts of courtesy, 
 the Executive Committee now return its grateful thanks. 
 
 Concernijig the work of the Congress, it was at an early stage 
 determined that the President of each Section should deliver an Address, 
 and that such arrangements should be made as to permit all members 
 of Congress to listen to these Addresses. The Executive Committee 
 believes that these Addresses alone would be ample justification for the 
 assemljling of members. But, in addition, two important General 
 Meetings will be held, one for the discussion of Hydatid Disease, the 
 other for the consideration of the varied questions relating to Typhoid 
 Fever. Three afterno(ms will be devoted wholly to Sectional Meetings; 
 and the Executive Committee de.sires to express its regret that com- 
 paratively little time is available in which to submit so many valuable 
 papers.
 
 REPORT OF THE EXECUTIVE COMMITTEE. 7 
 
 A full pio^ramnie of the Pfoceedings of the Congress has been 
 printed, in which will also he found a sketch of the University 
 Buildings, showing the rooms iu which the Sections will meet. Con- 
 venient passes for members' use have been })re[)are(l. The Secretary 
 will be glad to sup[)ly programmes and passes to an}' members who have 
 not yet received them. 
 
 Special Demonstrations will be given in the various Hospitals, and in 
 the Pathological ^luseum at the Medical School. 
 
 For the accomplishment of the work of the Congress, it is essential 
 that meetings should be held both in the mornings and the afternoons. 
 In order to avoid inconvenience, one of the large rooms of the 
 University has been set apart in which lunch will be provided 
 on Tuesday, Wednesday, Thursday and Friday. The Executive 
 Connnittee trusts that as many members as possible will avail themselves 
 of the opportunity so afforded for social intercourse. 
 
 For the full recording of the proceedings at the general meetings of 
 the Congress, the Honourable the Premier has kindly arranged that 
 Government Shorthand Writers shall be in attendance ; and the 
 Executive Committee gratefully acknowledges the assistance thus given. 
 
 It was resolved by the Executive that medical students in academic 
 dress should be admitted to the meetings of the Congress. 
 
 The Executive Committee recognises with heartfelt thanks the 
 assistance given by the leailers of social life in Melbourne, in fitly 
 entertaining the Members of the Congress. At tlie close of this meeting, 
 the Right Worshipful the Mayor of Melbourne, Alderman Benjamin, 
 will receive Members at the Town Hall, and will entertain them at 
 luncheon. On Tuesday evening, the President of the Congress reqitests the 
 honour of the company of Members at dinner at the Town Hall. On 
 Wednesday evening. His Excellency the Governor and Lady Loch will 
 receive the Members of Congress at Government House. On Thursday 
 evening, the Honourable the Speaker of the Legislative Assembly, 
 Mr. M. H. Davies, has invited the Members of Congress to meet 
 the Members of Parliament at dinner in the Town Hall. On 
 Friday evening, the President of the International Exhibition, Sir 
 Jameis MacBain, and the Executive Commissioners, have invited 
 ^lembers to attend a Special Concert at the Exhibition. (.»n Saturday, 
 Sir William and Lady Clarke will entertain Members at a Garden 
 Party at Ptupertswood. On the following Monday, the Honourable the 
 Premier, Mr. Gillies, and the Government of Victoria, have invited 
 ^Members to an excursion by sea to Port Phillip Heads. The Metropolitan 
 Liedertafel has resolved to invite the members of Congress to a smoke- 
 night concert in the upper hall of the Athemeum, on Monday evening, 
 the Uth inst.
 
 8 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 The Yorick Club has, with great courtesy, adniitted the Members of 
 the Congress to the privileges of Honorary Membership. 
 
 The Eight Worshipful the Mayor of Melbourne has placed at the 
 disposal of members a room in the Town Hall, namely room five on the 
 second floor, where one of the Congress attendants will at all times be 
 on duty. Letters and parcels may be sent to this room. 
 
 For the decoration of the Wilson Hall at this Inaugural Meeting, 
 the Congress is in large part indebted to the Hon. the Minister of 
 Lands, and under his instructions to Mr. Guilfoyle, the Curator of the 
 Botanic Gardens. 
 
 The Executive Committee desires to acknowledge the assistance which 
 it has received from the Clerk of the Legislative Assembly, G. H. 
 Jenkins, Esq. ; the Town Clerk of the City of Melliourne, E. G. Fitz- 
 gibbon, Esq. ; and from the Registrar of the Melbourne University, 
 E. F. A'Beckett, Esq., and the members of his staff". 
 
 It remains only to record that the total number of members of tlie 
 Congress is 653, of whom 13 are honorary members. Of the ordinary 
 members 339 come from Victoria, 95 from New South Wales, 40 from 
 South Australia, 24 from New Zealand, 16 from Queensland, 11 from 
 Tasmania, 5 from Western Australia, 1 from the Northern Territory, 
 1 from New Guinea, 5 from England, 1 from India, 1 fi'om the Dutch 
 Indies, and 1 from Finland. 
 
 Dr. Yerco (Adelaide) moved the adoption of the report. The 
 Executive Committee was to be congratulated on having brought the 
 preliminary arrangements in connection with the Congress to such a 
 satisfactory issue. The Programme of the Proceedings indicated the 
 amount of work members of the Congi'ess had been stimulated to do, 
 and the formidable list of socialities which it included showed the 
 interest that had been excited in the non-professional section of the 
 community. The inauguration of the Second Session gave hope of the 
 firm establishment of the Intercolonial Medical Congress as a permanent 
 institution. 
 
 Dr. Batch ELOR (Dunedin) seconded the motion. The work of 
 organising the proceedings was entrusted to good hands when it was 
 given to Professor Allen. From the programme which had been 
 prepared, and the enthusiastic reception which had been given to 
 members, he judged that the Second Session of the Congress would 
 prove a thorough success. 
 
 The motion was carried by acclamation. 
 
 The President then invited the Hon. Duncan Gillies, Premier of 
 Yictoi-ia, to welcome the visiting members.
 
 THE president's INAUGURAL ADDRESS. 9 
 
 THE PREMIER'S ADDRESS OF WELCOME. 
 
 The Premier (Mr. Gillies), who was received with cheers, spoke as 
 follows : — 
 
 Your Excellency, Mr. President, Ladies and Gentlemen, — I 
 have been requested to offer a cordial and hearty welcome on behalf of 
 the Government of the Colony of Victoria, to those gentlemen who have 
 come from the other colonies and elsewhere, for the purpose of attending 
 this Congress. It must have been to them no small sacrifice to leave 
 their homes, when they were engaged in important work, to attend the 
 conference, but they have the satisfaction of knowing that they will 
 probably be engaged in still more important work. I venture to think 
 that no higher duty could be performed by medical gentlemen, than to 
 attend a Congress where matters of the greatest moment will be 
 discussed. The work of medical men is all important, for what better 
 office can there be than the amelioration of suffering humanity ? I feel 
 quite confident that the labours of this Congress will be commenced in 
 a desire to ascertain the truths of medical science, and to obtain 
 more information than members possibly have at present with reference 
 to the difficult questions that will be brought up for discussion. The 
 labours of the members ought to do good, and I am quite sure that 
 they will. I trust that members generally will be animated by a desire 
 to help forward the greatest mission that any body of men can possibly 
 be engaged in, and that is, the promulgation of sound laws for the 
 protection of health and the removal of disease. 
 
 THE PRESIDENT'S INAUGURAL ADDRESS. 
 
 The President (Mr. T. N. FitzGerald) then delivered the following 
 Inaugural Address : — 
 
 Your Excellency, Members op the Congress, Ladies and 
 Gentlemen, — When last year, at the first Medical Congress ever held in 
 the Australasian Colonies, I was chosen President-elect of the next 
 similar gathering, I was very proud to have obtained such an honour. I 
 received with feelings of ]irofound gratitude the expression of confidence 
 and regard that my fellow-workers, in the noblest of all vocations, were 
 so good as to convey to me. And now as I stand before you, who have 
 come hither from ever}'' part of Australasia to take counsel together on 
 matters of grave import, I feel that I have reached the crowning point 
 of my ambition ; for I need hardly say, that although material success 
 is very ])roperly an object we may all laudably strive to win, if only we 
 strive fairly and honorably, a still higher {)rize is that which is conveyed 
 in the willing trust of a whole brotherhood. I wish, therefore, here to 
 declare how deeply sensible I am of tlie honour of which I was then 
 made the recipient, and how pioud I am to occupy the place that now I
 
 10 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 fill. Let me, however, sincerely assure you, that I feel conscious of 
 considerable diffidence in having so closely to follow the late President, 
 whose eloquent address in Adelaide won from us such enthusiastic and 
 well-merited recognition. 
 
 And now let me offer you all a cordial welcome to Melbourne, which 
 some of you, I dare say, behold for the first time. Our city has been 
 called " Marvellous Melbourne," and no doubt for some reasons it 
 deserves the title. It is very far from perfect, as we who have lived in 
 it so long very well know. To it, then, such as it is, I bid you welcome! 
 We will endeavour to make your stay in it as agreeable as we can, 
 so that when you leave us, you may carry away hot unpleasant 
 reminiscences of your vi.sit. 
 
 Gentlemen, before proceeding further, pei'mit me to offer a few words 
 of explanation. You are no doubt aware, before we left Adelaide, it 
 was agreed that the Congress should be convened in 1890, and this 
 resolution would doubtless have been adhered to, had not the political 
 authorities of the day suddenly decided to hold the Centennial Exhibition 
 and invite all nations. When the Commissioners were debating their 
 preliminaries, a [(reposition was started that this would be a very favourable 
 opportunity for holding the next session of the Congi'ess. The suggestion 
 at first encountered serious opposition from many who are generally fore- 
 most in support of any movement that tends to the advance of medicine, 
 and whose ojjinions deserved most attentive consideration. The change 
 contemplated was no doubtanimpoi-tant one, more especially as it involved 
 a direct departure from the resolution tacitly agreed upon in Adelaide; 
 but it was urged that, although a year's time was a very shore interval 
 between the two meetings, and allowed but a brief space to collect fi'esli 
 facts and arrange material, yet the chance Avas too opportune to l)e 
 missed. At another time, the means of travelling from distant parts 
 would not be so easy, and assistance from other sources might not be so 
 readily attainable. Consequently it was determined, oh a full vote of 
 the profession, to alter the Adelaide programme, and to convene our 
 gathering this year. The date being fixed, those who had opposed the 
 alteration the most strongly, veiy generously consented to act with the 
 lai'ger section, so that we have since worked together in pei'fect 
 harmony in making the preliminary arrangements. I am delighted to 
 say that the fear expressed by the opponents to the change, that the 
 time would be too short to collect sufficient material, has not been 
 justified by results, and that we have experienced from all quarters a 
 most gratifying readiness to co-operate with us in making the Congi-ess 
 an unqualiHed success. 
 
 It has been asked, what are the especial advantages to be looked for 
 from an Australian Medical Congress 1 What practical good is likely
 
 THE president's IXAUGURAL ADDRESS. 11 
 
 to come from the gathering together of medical men in these southern 
 hands? Are there, it is demanded, any diseases peculiar to Australia, 
 or affections which have not been investigated exhaustively liy the 
 higliest authorities in Europe ? Do the conditions of climate and the 
 social habits of the people modify diseases ? Or do certain affections, 
 which are common to all hititudes, assume here particular characters 
 that difierentiate them from tlie aspect they present under other 
 geographical circumstances 1 
 
 AVell, I do not forget that, on the other side of the world, and especially 
 in those large centres of human life where the perils of existence 
 and the factors of disease are so many and so constant, the finest 
 intellects are contimially engaged, investigating in every branch and 
 every branchlet of the com[)ound science of medicine. They have 
 abundant means, elaborate appliances, the fullest opportunity and 
 uninterrupted leisure at their command, to work out the problems 
 "which continually are spread before them. The microscope enables them 
 to make additions every day to the sum of that division of the medical 
 sciences, which half a century ago, or even less, may be said to have 
 had no existence. Histology is thus always revealing to them, and 
 through them to the whole medical world, something new. The chemist 
 in like manner is for ever throwing light upon etiology, pathology, and, 
 especially in its larger significance, therapeutics. There are very many 
 highly accomplished men content in their enthusiasm to spend the 
 spring-time and early summer of their lives in the exhausting work of 
 hospital duty, happy and well enough rewarded in their own esteem, 
 if they but do now and then, amid the thousands of routine cases they 
 have to treat, light upon some new clinical fact, or discover some hitherto 
 un)-ecognised action of a drug. Surely, asks the ])essimist querist, your 
 local medical societies suffice for the re[>ort of unusual cases, and the 
 exhibition of anatomical peculiarities or rare distortions; why then, with 
 puny strength, endeavour to emulate the mighty efforts of the northern 
 hemispheres, having in remembrance that some of their endeavours 
 have not been crowned with perfect success 1 
 
 We do not, we cannot hope to bear comparison with the great medical 
 gathei-ings of the congresses or associations in Europe. But with all 
 becoming humility, and with the admission that we cannot hope for some 
 years successfully to rival our l)rethren in the healing ciaft in the old 
 world, I have yet to say that we have here three thousand medical men, 
 educated and trained in the same way, and qualified \\\) to the same 
 limits, as are those at home. We have amongst us representatives of 
 nearly every medical school or college in Europe, who have opportunities 
 of studying and treating disease and of maturing their knowledge, both 
 in private and hospital practice. Then again, as we all well know, in
 
 12 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 many medical and surgical affections, the practice adopted by some of 
 the leading men in the different colonies is decidedly at variance 
 (whether rightly or wrongly) with the views held by home authorities. 
 Surely therefore we are able to add something to the sum of that 
 knowledge which we have as a kind of joint-stock, and to the en- 
 largement of which it should be both our duty and pleasure to 
 contribute. 
 
 To reply further, it should be remembered that though the habits and 
 conditions under which we live bear a social similitude, yet they are by 
 no means identical with those existing in Europe. In the older 
 civilizations and in America, we see the working population of 
 the cities crowded together in a manner utterly unknown to us. The 
 facts lately published by the Special Sanitary Commissioners of the 
 Lancet, on the sweating system among tailors in Liverpool and 
 Manchester, must be an incomprehensible revelation to the native born 
 of these colonies. In the rural districts of the old country, the labourers 
 are ill and insufficiently fed, ill-clothed, over-worked, and everywhere 
 subjected to the extremes of cold or heat in their seasons. The wealthy, 
 for the most part, especially the females, are fashion worshippers, self- 
 indulgent, and almost entirely unemployed, the more active alone finding 
 vent for their energies in eleemosynary efforts. 
 
 With us, on the other hand, the cities are wide spread (too much so 
 if anything), each man, even to the poorest, lives in his own house, 
 animal food is plentiful and cheap, the hours of labour are short, and 
 summer and winter are much the same, except that in their seasons 
 occasionally the hot days are hotter, and the cold days are colder. 
 Such weather as is implietl by the terms zero, blizzard, continuous rain, 
 ice-storms, &c., we are unacquainted with, unless through newspaper 
 description. On certain days it is true the heat is apt to be opi)ressive, 
 especially to the inactive, and trying to the aged and sick, yet it can 
 never be said to be unbearable or inimical to life. Then again, 
 the difficulty and often impossibility of ensuring constant domestic 
 service, com])el even the most opulent of this connnunity to do for them- 
 selves what they would be glad to pay others to do for them ; and thus, 
 in the performance of household work, our gentlewomen procure for 
 themselves an amount of bodilv exercise, which, although unsought and 
 sometimes unwelcome, is a distinct benefit to them, and there can be no 
 question that it saves them from many ills to which they would 
 otherwise be subjected. Thus then, in this continent we find men of 
 all classes living under the most favourable circumstances, climate 
 nearly all that can be wished for, healthy inheritance, both mentally 
 and physically, ample space for every one, and well requited industry 
 prevailing everywhere.
 
 I 
 
 THE president's ixaugural addhes.s. 13 
 
 Surely witli these ha})!)}' surrouudiugs, which exist, as far as I am 
 aware, to such an extent in no other place, we have a spacious field, 
 es[)ecially our own property, for investigating disease as it occurs 
 uninfluenced by the many causes which excite and maintain it at home. 
 For instance, we have long been taught, rightly or wrongly, that scrofula 
 and tubercle are affected by squalor and dirt ; that phthisis is favoured 
 by close vitiated atmosphere and cold night air. These causes are 
 present but to a slight extent with us, yet occasionally we find scrofulous 
 impregnations excessively virulent; while phthisis is as common with us 
 as it is in England, and decidedly more so than in Canada and Scotland. 
 
 Again, here in this land, certain acquired constitutional diseases in 
 the tertiary ulcerative forms, such as rupia, are comparatively mild 
 affections, and seldom present that grave character which is such a 
 continual source of anxiety to the European practitioner. As a 
 corollary to the limited intensity of such affections, we would expect to 
 find skin diseases rare and mild in character. Is this the case 1 We 
 are a busy people, yet melancholia is a common form of insanity to be 
 met with in our asylums. Then again, do we enjoy an immunity from 
 the nervous diseases so frequently to be met with in the great 
 manufacturing and mercantile centres of Great Britain 1 And if we 
 do not, what is the explanation 1 It is not difficult to discover, 
 therefore, that the field for observation is here veiy wide, and that 
 in whatever direction of special knowledge we may look, there is an 
 abundance of matter to intei-est and occupy us, without at all travelling 
 over trodden paths, or turning over ground which has yielded up all its 
 nutrient elements to the cultivator. 
 
 There are a number of similar questions in which our peculiarly 
 happy circumstances will perhaps allow us, by a process of 
 elimination, to throw a light on obscurities, and to regard causes 
 from a point of view from which, without these advantages, they 
 cannot be seen by the profession at home. So too, should we ask 
 ourselves, cannot advantage be taken of our almost unlimited space to 
 bfing under control such distressing social maladies as habitual 
 drunkenness? Then again, is not this the opportunity to come to 
 .some agreement as to where a suitable mountain x'esidence can be found 
 for the delicate and consumptive 1 Whether a better treatment may 
 not be advised in counselling protracted change — summering in New 
 Zealand or Tasmania, wintering in Queensland, and spending the 
 intermediate time in one of the other colonies ? — for we have all 
 climates with us. To arrive at any definite conclusion on these 
 and many other matters, a consensus of opinion is required, and this 
 can only be obtained by such a gathering of the profession as T see 
 before me now.
 
 14 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 If our environments are healthful, and certainly they should Ite so, 
 the young manhood of this country, who, for the past few 
 years only, has become an influence in its Councils, should present 
 a type of the highest class. His birthright, the jjolitical freedom which 
 has been handed down by his fathers ; his inheritance, the home life, 
 the decorum and gravity of a race bred under a cold ungenial sun : 
 untrammelled educational establishments at his very door; no class 
 distinctions to sneer him down, and every opportunity to gratify any 
 inclination either in the playground, the workshop, or study — the 
 Australian native should stand forth as the creature best able on eartli 
 to resist disease, and the mo.st willing to listen to wholesome advice on 
 sanitation. His love of out-door sports, engendered by easy hours 
 of labour and the many open reserves, sa\'es him from the several 
 temptations which surround life at the time of its pubertal development; 
 whilst the constant sunshine, the frequently recurring holidays, and 
 variety of amusements relieve his toil from the chilling monotony that 
 in other countries is the parent of habitual intemperance. Why then, 
 in such an apparent paradise, peopled by those who ought to be Hercules 
 and Apollos, are our death rates so high 1 This is a question thtit 
 doubtless tliis Congress will enquire into, and its deliberations will, I 
 trust, throw some light upon these vexed matters of drainage, 
 ventilation, and the other items that so intimately affect the sweetness 
 and healthfulness of life. 
 
 I wish,^ however, to draw attention to one or two points which, 
 though perhaps well known to the profession, are not generally 
 recognised by the public at large. In all English-speaking communities, 
 the mortality bills are swelled ])rincipally by three affections — alcoholic 
 intemperance, tubercular deposits, and typhoid fever — scourges in the 
 main j^reventable ; but the remedies for which, either from their 
 expense, or from other causes, we will not boldly and manfully face. 
 
 Firstly then, with regard to drink. You all know how inimical to 
 treatment its effects are, and how great is the misery it occasions. I have 
 no wish to read you a teetotal lecture ; there is, however, one peculiarity 
 which stands out rather prominently, and which I think should have 
 weight with us all, when, as medical men, we are called upon to 
 prescribe spirits as a drug; and that is the fact that alcohol is much 
 more potent with us than it is at home. If we turn to the statistics 
 that Mr. Hayter annually furnishes to the Government of Victoria, 
 we find that the deaths set down to drink are numerous compared 
 with those of even the most intemperate countries ; and such a 
 calculation would naturally lead to the assumption that we Australians 
 are an extremely drunken peojjle. I do not desire to go out of my 
 way to find excuses for much excess in this particular, nor
 
 THE president's inaugural address. 15 
 
 would it be proper for me to say that tliere is no di-unkeniiess in 
 Australia, but I assert with the strongest emphasis that habitual 
 drunkenness is an exception with us. Visitors from abroad 
 who have been to any of our great gatherings, at military displays, 
 ar.d racing carnivals, or who have seen the crowded attendances 
 at athletic meetings in any of the colonies, must have noticed the 
 absence of drunkenness and rowdyism. What really is the case is, that 
 alcohol, in whatever form it may be taken, is not suited to the climate 
 or the conditions of the people, so that hei)atic and renal atTections are 
 sooner and more frequently engendered by its use tlian they would be 
 under the same circumstances in a colder country. 
 
 Looking at the habits of Eui'opean populations, however, I cannot 
 but regard it as a slander upon our manhood, to charge them with 
 systematic drunkenness. A great number of our native-born youths are 
 total abstainers from birth, and, while not forgetting the intemperate 
 opinions sometimes expressed by temperance advocates, I must admit 
 that tem[)erance societies have worked a great deal of useful reform. 
 As a food in the low delirium of fever, and as a means of preventing 
 waste of tissue in erysipelas and kindi'ed diseases, and for the aged, 
 alcohol is doubtless essential and of great service. Yet the death-rate 
 ought, I think, to teach us the necessity of care in the use of 
 intoxicating liquor, and that, as medical men, we should be veiy 
 cautious, far more so than our brethren have need to be in colder 
 climates. What we have to regard is the great probability of its 
 continued and over-modei-ate use being prolonged when the necessity 
 for its employment has ceased, and of its setting up local congestions, 
 which, in time, destroy the functions of the organs they aifect. 
 
 Of Phthisis and Typhoid Fever, I have already said that the former 
 appears to be nearly as common in Australasian as in English towns; 
 and typhoid, both in urban and rural districts, is nearly of twice as 
 frequftnt occurrence. I think it offers occasion for the gravest 
 consideration to discover how, in a country so richly endowed, and 
 with a climate so genial, we should yet be afflicted to so terrible an 
 extent with two diseases of parasitic origin, both of which, pathologists 
 assure us, are eradicable. It is curious to notice how the etiology of 
 phthisis has varied amongst physicians from time to time. In my 
 early days, it was impressed upon us that consumption chiefly arose 
 from defective ventilation, and the inhalation of irritant [)articles. 
 Then came the catarrhal or pneumonic origins — neglected colds and 
 so forth, and now we find that neither nor all of the.se i-easons will 
 suffice to account for the large bills of mortality from phthisis in tliis 
 land. In my opinion, next to its hereditary incejjtion, the greater 
 part of phthisis will be found to be associated with defective drainage,
 
 16 INTERCOLONIAL MEDICAL CONGRESS OF AUSTUALASIA. 
 
 and this, I believe, will be proved by bacteriology. I cannot but 
 think, therefore, that it will always be endemic with us until we 
 devise some proper and complete method of carrying ofF our sewage 
 and fluid house refuse. 
 
 Typhoid fever is with us a true opprohrium medicorum. It is 
 with us, of us, among us, upon us. It is a spectre we apparently 
 cannot exorcise. It is truly " the pestilence that walketh in darkness, 
 and the destruction that wasteth at noonday." It is at once a terror 
 and a reproach. It defies legislation and administration, it laughs at 
 boards of health, and triumphs ruthlessly and always. Are we never to 
 cope with this terrible affection 1 As far as Melbourne is concerned, we 
 hope much from the Commission which is now holding its meetings ; 
 and we trust that whatever scheme is decided upon, it will be adopted 
 without the long delay that generally follows the decisions of such 
 bodies. But in the meantime, the same things go on. Streets are 
 marked out, and houses are built without the semblance of drainage. 
 Then the warm weather comes, and fever stalks each year more greedily 
 and viciously than before. No doubt the section constituted to discuss 
 matters relating to hygiene and public health will indicate what 
 steps modern sanitation should take towards the suppression of this 
 conspicuous evil. The views of medical men and health officers are 
 always valuable when they take some practical form, especially on such 
 a subject as public health. On such matters they alone, from their 
 educational training, are capable of expressing opinions worth listening 
 to. I sincei-ely trust our health boards will derive information from 
 the deliberations of the Section of Hygiene. 
 
 Gentlemen, all branches of our profession seem steadily to advance. 
 Annually some new surgical measures are contrived, some new drugs 
 are introduced, some disorders discriminated. What future is there for 
 Sanitation 1 Sanitation, unlike other divisions of our art, must go hand 
 in hand with the educational progress and mental improvement of the 
 people. Without the schoolmaster, all efforts we could make must 
 inevitably prove futile. An intelligent conception of its purposes by 
 the authorities, both parliamentary and local, is absolutely necessary. 
 It is here that I hope much may result from such a gathering as this 
 Congress, for in all matters that relate to medical and sanitary require- 
 ments it seems to be nearly an invariable rule for legislative enactments 
 to l)e considerably in arrears. With borough and shire authorities, I 
 believe these bodies do, in the main, the best their lights permit them, 
 ))Ut the insanitary conditions of their respective localities are attributable 
 I conceive to either a want of information, or a reluctance to exercise 
 their powers. Ijccause diphtheria happens to be absent for a time from 
 their district, they fail to see danger in a cesspit, or the necessity of
 
 THE pjjksidhnt'.s inau(;ukal audhkss. 17 
 
 milk inspection, and so fortli. Doubtless the advanced education the 
 young are receiving, in at least the better class of schools, the instruction 
 in the elements of physiology and the general principles of hygiene, will 
 in time have its etiect on our future statesmen and councillors. And 
 in this direction I think much benefit might accrue from the ajjpointment 
 of a few thoroughly trained and carefully chosen sanitary instructors, 
 whose duty it should be to travel from town to town, and even from 
 house to house, with the object of teaching the principles and the 
 ad vantages of Health Laws, and the consequences of a disregard of them. 
 For it is certain that the value of cleanliness cannot be properly iinder- 
 .stood until the dangers of filth are comprehended. 
 
 I should like while on this subject to say something in strong praise 
 of the hygienic an^angements that have been carried out in Adelaide. 
 The method of diainage apjiears to be as nearly perfect as it can well 
 be, and as there is a large model of the system in the South Australian 
 Court of the Exhibition, it would be well that every one interested in 
 this subject should see it. If it be i)0ssible to adopt in this much larger 
 city the same system, 1 am jirepared to say that the death rate would be 
 lowered to an extent now hardly dreamed of. Nor is the incidental 
 advantage in connection with this system of the disposal of the sewage 
 to be lost sight of. The Adelaide sewage farm is a very joy of 
 scientific agriculture. In Sydney they ,ai'e commencing Avith earnestness 
 to drain their busy city ; and although the undergi'ound drainage of 
 Melbourne is at present little more than rudimentary, we have at least 
 made a beginning. 
 
 But what is more encouraging, and prognosticates well for the 
 generation that is to follow us, is the lusty out-door life, and the sturdy 
 games the Australian so dearly loves. Amongst those who ever have 
 seriously revolved the subject in their minds, some doubt must have 
 arisen whether the youth of these great colonies would walk in the 
 stej)s of their parents, or, influenced by a hotter sun, follow in the wake 
 of their American kinsmen, and forsake the green sward for light 
 amusements, ease, and luxury. I rejoice to say that this question is 
 entirely set at rest, the Australian's prowess on the river and the 
 cricket field has settled that matter, and he promises, as far as physical 
 development goes, to even surpass his fathers. It is rather extra- 
 ordinary that the out-door life and national games of the mother 
 country should have taken such a hold on the young folk of 
 Australasia, for I believe in no other ]iart of the world have the sons 
 of the Anglo-Saxon or Celtic emigrants done the same. Certainly, 
 in America or South Africa, neither cricket or football is generally 
 played. Now the love of these manly games must ]m\e an influence 
 for good on the manhood of this countr}-. Personally, I have no 
 
 c
 
 18 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 sympathy with those who would decry these athletic exercises, 
 either because at tiuies they may be carried out too roughly, or 
 sometimes are accompanied by some degree of danger. The very 
 roughness of football is an element of good. It developes courage and 
 good temper; one hears too much now-a-days about gentleness and the 
 velvet hand. We require a little fibre which these games tend to 
 impart. When I look at the footballer ready for action, I cannot help 
 admiring his muscular frame, and sympathising with him in the pride 
 he takes in his sturdy limbs, his form and activity. Contrast him with 
 the boy one meets with on the Continent, ))arading through the streets, 
 W^hich is the more likely to grow up a self-reliant, useful citizen, the 
 footballer or the young gentleman who spins his tops and bowls his 
 hoops in gravelled enclosures 1 Depend upon it, these games are 
 important factors in the formation of the moral tone of this country. 
 We should encourage them to the best of our powers, and endeavour to 
 allay the fears of timid over-anxious parents. If a few limbs are broken 
 annually, and even now and then unfortunately a death occurs, it would 
 be better that four times the number of casualties should be told, than 
 that our boys should grow up hypochondriacal and dyspeptic. 
 
 Looking round this assemblage of representatives of the great Guild 
 of Medicine, drawn here from every province of Australasia, I cannot 
 deny myself the pleasure of thinking that we are all students, still 
 engaged in the work upon which we entered, some of us, many years 
 ago. We have had our ambitions, our difficulties, our trials, our 
 disappointments, and now and then our successes. We have been 
 ensased in the hard business of living ; we have had to contend 
 with opposition on many occasions, and sometimes we have had 
 good reason to believe we were not too fairly dealt with. However, 
 I am sure it has been the consolation of all of us to feel, that 
 in the acquirement of the knowledge necessary for the exercise of 
 our craft, wc commanded a source of enjoyment tliat nothing in the 
 way of fret or ill or mere professional failure could take from us. We 
 have thus all added something to the common store of medical 
 knowledge. We have in this way experienced a delight compared with 
 wliich the greatest material success holds only subordinate place. Like 
 another God-like attribute, the ars medendi " blesseth him that gives 
 and him that takes." It is a deliglit to make discovery in our science ; 
 but I am sure it is a delight still greater to know that the discovery 
 may be of service to our professional brethren in relieving suffering 
 humanitj'. It is thus a privilege to thank God for, that our domain of 
 discovery can never be exhausted, and that no matter how great may be 
 the researches of others, there is still left room for us to go on exploring. 
 It is the very glory of medicine that it is not finite. It has been brought
 
 THE puesidext's inaugural adduess. 19 
 
 against it as a reproach, that both its principles and its practice are 
 always undergoing changes. I reply, with a feeling of triumph, that 
 these changes are the very evidence of our progress. If we have a 
 motto at all, it is " Onward." It is not our despair but our boast, that 
 medicine is not an exact science. We are not content with what we 
 have done, but we look forward to the greater, the better, and the 
 higher doing. *' Still achieving, still pursuing " we " learn to labour," 
 and if we " wait " at all, it is not in the dull apathy of contentment at 
 what has been done, but in the belief that " the Greatest is behind." It 
 is with this feeling, this liope, this ever constant and unswerving faith, 
 that I regard the coming together of my brethren on this the opening 
 day of the Second Session of the Medical Congress of Australasia. 
 
 The Hon. Mr. Creed (Sydney) moved a vote of thanks to the 
 President for his learned and useful address. Mr. FitzGerald, as the 
 head of his profession in Victoria, was fitly appointed President of the 
 Second Session of the Intercolonial Medical Congress of Australasia, 
 and his medical brethren were proud to elect to that high and honour- 
 able position a gentleman who was not only the most illustrious 
 sursreon in Australia, but who had also a world-wide fame. No two more 
 worthy representatives of the profession could be found than the 
 Presidents of the First and Second Sessions of the Congress. At 
 the close of the Session held in Adelaide, it was suggested that 
 three years should elapse before the next meeting, but no definite 
 decision was made on this point, the question being remitted to the 
 medical societies of Victoria. The practitioners throughout all the 
 colonies rejoiced that the interval had been reduced to eighteen months, 
 for the jDrogramme of work now submitted showed such a mass of 
 interesting matter to be dealt with by learned and distinguished men, 
 that the assembling of tlie Second Session at this early date must be a 
 gain to society and to the profession. Members were indebted to the 
 President for many useful and practical suggestions, wliich must lead 
 to earnest thought on tlie part of his hearers, and thus sooner or later 
 bring benefit to the public. Even to the latest years of tlieir pro- 
 fessional lives they were still students, ready to learn from anyone 
 wlio could help them to higher knowledge of their science. This was 
 an age of federation, and to the medical profession of Australia 
 belonged the credit of making the first practical suggestion of a federal 
 character, viz., the establishment of a federal quarantine .station, 
 the absence of which was dangerous to the health, commerce, and 
 prosperity of the colonies. 
 
 Dr. E. C. Stirling (Adelaide) had very great pleasure in seconding 
 the vote of thanks to the President. No one was better qualified tlian 
 
 C 2
 
 20 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 Mr. FitzGerald to speak with authority to tlie Intercolonial Medical 
 Congress, and his address was marked by that thoughtful suggestiveness 
 which characterised all his work. The President had also shown to the 
 public that a medical address need not be dry and uninteresting. 
 Mr. FitzGerald's name was a household word, not only in Victoria, but 
 throughout tlie Australian Colonies, and it was, therefore, unnecessaiy 
 for him to say one word to induce the Congress to carry the vote of 
 thanks by acclamation. 
 
 The Congress rose en masse, and cheered long and lustily. 
 The President said: — Your Excellency, Ladies and Gentlemen, 
 ■ — T really feel too overwhelmed to say anything in acknowledgment of 
 your most hearty vote of thanks. I can only thank you, and I do 
 thank you very sincerely. 
 
 Dr. Manning (Sydney) proposed a vote of thanks to His Excellency 
 the Governor, for the kind and gracious manner in which lie had 
 opened the Congress, and also for his address. His Excellency had 
 shown such a warm feeling for the profession, such a sympathy for 
 its woi'k, and such a general appreciation of its liigher aims and objects 
 as must have gone straiglit to the heart of every member of the 
 Congress. 
 
 Dr. J. Davies Thomas (Adelaide) seconded the motion with great 
 cordiality. His Excellency liad honoured tlie medical profession by 
 his pi'esence at the Congress, and its members had also to thank him 
 for the generous and liospitable welcome he had gi\en them. 
 The motion was carried Ijy acclamation. 
 
 His Excellency the Governor, in acknowledging the compliment, 
 said : — Dr. Manning, Dr. Thomas, Mr. President, Members op the 
 Congress, and Ladies and Gentlemen, — I thank you very sincerely for 
 the kind reception whicli you have given to the vote of thanks which 
 has just been accorded to me. I can assure you it has given me very 
 great pleasure to come here to-day to declare this important Congress 
 open, and I only wish I may be permitted to be present on some of 
 the occasions when the valuable papers, of which I have seen a list, 
 will be read before the Congress. Dr. Manning referred to the fact 
 that Mr. FitzGerald's address was so interesting that it could be 
 appreciated by laymen as well as by medical gentlemen. I can assure 
 you that many of the papers which will be re;ul at the Congress, can 
 and will be appreciated by laymen just as much as by gentlemen of the 
 medical profession. Altliough they may not lie so well understood by 
 laymen as by medical gentlemen, they will lie equally interesting to 
 laymen, and as higlily appreciated by them. Mr. FitzGerald, in his 
 address, has referred to many matters of very great importance — 
 of importance not only to the medical profession and the world at large.
 
 RECEPTION HY THE MAYOR OF MELBOURNE. 21 
 
 but of special iniportaucc as art'ecting this colony, and this great city 
 of Melbourne in particular. He has referred to those questions and 
 sanitary considerations which are now occupying the attention of the 
 (rovernnient and of the public very deeply, and I trust that the 
 deliberations of the Congress on the important questions that may 
 arise, will lead to wise aTid sound conclusions. I thank you xevy 
 sincerely for the cordial reception you have given me, and I can only 
 say on my own Ijehalf, and on liehalf of Lady Loch, that we are looking 
 forward with very great pleasure to receive you on Wednesday night. 
 
 The General Secretary announced the succeeding business of the 
 Congress. 
 
 The President then declared the Congress adjourned until 8 p.m., 
 at the Freemasons' Hall. 
 
 RECEPTION BY THE MAYOR OF MELBOURNE. 
 
 At half-past 1 o'clock the members of the Congress, with other guests, 
 were received by the Mayor of Melboui-ne (Alderman B. Benjamin) at 
 the Town Hall. The reception took place in the Council Chamber, and 
 at 2 o'clock the guests were invited to partake of luncheon in the main 
 hall. 
 
 The Mavor occupied the chair, having on his right the President of 
 the Congress (Mr. T. N. FitzCerald), the Minister of Public Instruction 
 (Mr. Pearson), the Speaker of the Legislative Assembly (Mr. M. H. 
 Davies), the Government Statist (Mr. H. H. Hayter, C.M.G.), and the 
 Chairman of the Board of Railway Commissioners (Mr. R. Speight). 
 On the left of the Chairman were Sir Henry Parkes (Premier of New 
 South "Wales), the President of the Legislative Council (Sir James 
 MacBain), the Minister of Education of South Australia (jNIr. J. C. F. 
 Johnson), the Chancellor of the University of Melbourne (Dr. A. C. 
 Brownless), the General Secretary of the Congress (Professor Allen), 
 iuid the Government Botanist (Baron F. von Mueller, K.C.M.G.) 
 
 After the customary loyal toasts had been honoured, the Mayor 
 proposed " The Governments of the Sister Colonies." 
 
 Sir Henry Parkes, on rising to respond, was received with loud 
 applause. In the course of an eloquent speech, he said : — I have no 
 doubt that this great assemblage of learned doctors will result in great 
 good to the cause of science, and if so, as a consequence, great good to 
 our common humanity. I happen to be one of those who have learned 
 as one of the sums of my experience, that several of the greatest men 
 in all acts of practical benevolence, and in all acts that tend to 
 ])romote the progress of the world, are enlightened jihysiciaiis. 
 Certainly, there is no sphere of human action which opens grander 
 avenues of usefulness than that of the physician, and to the honour of 
 the profession there have been no greater men — no more bene^•olent 
 benefactors — than many men who have honoured that most honourable 
 profession. 
 
 Mr. Pearson, in responding to the toast of "Her Majesty's Ministers 
 in Victoria," said that a few yeai's hence, when it fell to the lot of the
 
 22 INTERCOLONIAL MEDICAL CONGRESS OF AUST8ALASIA. 
 
 Mayor of Melbouine at that time to ]jropose the healtli of Her Majesty's 
 Ministers in and for Victoria, the toast might be replied to by a 
 Minister of Public Health. He had carefully said that such an e\ent 
 might come about some few years hence, not because he had the slightest 
 doubt that such an office was terribly necessary at the present time, but 
 because he was convinced that public opinion was not ripe for it. To 
 create a })ortfolio, and to entrust it to the charge of a gentleman who 
 had not the power to carry out what he knew to be needful, would be 
 the most tremendous of raockei'ies, and at the present time people valued 
 certain constitutional rights too highly to admit of that desirable change 
 — the right of a man to pollute running water, the right of a man to 
 spread contagious disease descending even to the third generation, the 
 right of a man in every possible way to poison the life springs of the 
 comniiuuty — and many men would oppose to the death any interference 
 with the piivileges he had named. The corporation of Melbourne had 
 honourably endeavoured to do its best to promote the health of the 
 community, but he could not say the same of some of the boards of 
 health in the metropolitan suburbs. He looked forward with dread to 
 the time, which was certainly approaching, when the diseases which had 
 been deliberately created, and against the fostering of which medical 
 men and scientists had raised their voices for years })ast, would visit 
 almost every household like the angel of death, and take away their 
 spoil. A Minister of Health wonld be appointed when the community 
 deu>anded a reform in regard to matters affecting the [lublic health, and 
 told the Government of the day to arm the Minister of Health with all 
 powers necessary to sweej) away all the evil products of the vested 
 rights to which he had referred. But he felt that he was wandering 
 from actual life into Utopia. We were living in the nineteenth 
 century, and if such a reform were proposed, it would be denounced by 
 the press as grandmotherly legislation, because it would be an inter- 
 ference with the vested right of ever}' Englishman to carry death into 
 his neighbour's household, and the Government that took the step 
 would be swept out of power. 
 
 The Mayor, in ])ropo8ing " The Intercolonial Medical Congress," 
 expressed the pleasure which it had given him to be present at the 
 inaugural ceremony. The Congress had assembled for the i)uri)ose of 
 discussing matters of the gravest importance to the whole of Australasia, 
 and he had no doubt that the result of the deliberations would be highly 
 satisfactory. 
 
 The President of the Congress, in proposing *' The Health of the 
 Mayor," retui-ned thanks to him on behalf of the Membeis of Congress, 
 for the ma'niiticent manner in which he had entertained them. 
 
 EVENING SITTING. 
 
 The Congress re-assembled at 8 p.m , in the Freemasons' Hall. His 
 Excellency the Governor was present. Mr. T. N. FitzGerald, President 
 of the Congress, occupied the chair. 
 
 The Address in Medicine was delivered by the Honorable W, F. 
 Taylor, M.D., M.P. (Brisbane), President of the Section of Medicine.
 
 THE phksident's dinner. 23 
 
 The Address in Anatomy and Physioiogy was delivered by Professor 
 T. V. Anderson Stuart (Sydney), President of that Section. 
 
 On the motion of the President of the Congress, hearty votes of 
 thanks were accorded to Dr. Taylor and Professor Stuart. The Congi'ess 
 then adjourned till the following day. 
 
 SECOND DAY. 
 TUESDAY, JANUARY 8, 1889. 
 
 At 10 a.m., in the Pathological Museum at the Medical School, 
 Dr. Maudsley demonstrated a collection of gynaecological si)ecimens. 
 
 At 11.30 a.m. the Congress re-assembled in the Wilson Hall, the 
 President, Mr. T. N. FitzGerald, occupying the chair. 
 
 The Address in Surgery was delivered by Dr. E. C. Stirling (Adelaide), 
 President of the Section of Surgery, and the Address in Obstetrics and 
 Gvmecology by Dr. Batchelor (Dunedin), President of that Section. 
 
 Cordial votes of thanks were passed to Dr. Stirling and Dr. Batchelor, 
 on the motion of the President of the Congress. 
 
 The Congress then adjourned for luncheon, which was prepared in one 
 of the large rooms of the ^Medical School. 
 
 In the afternoon, the Congress was divided into its Sections, which 
 met in the various lecture theatres of the University. 
 
 THE PRESIDENT'S DINNEPt. 
 
 In the evening, the President of the Congress, Mr. T. N. FitzGerald, 
 entertained the fliembers and other gue.sts at dinner in the Town Hall. 
 His Excellency the Governor was on the President's right, and the 
 Premier of Victoria (Mr. Gillies) on his left. Among those present 
 were the President of the Legislative Council (Sir James MacBain), the 
 Speaker of the Legislative Assen)bly (Mr. M. H. Davies), the flavor of 
 Melbourne (Alderman B. Benjamin), the Minister of Public Instruction 
 (Mr. Pearson), the Commissioner of Public Works (Mr. Nimmo), the 
 Chancellor of the University (Dr. Brownless), Mr. Justice Wrenfordsley, 
 and the Executive Vice-President of the Centennial International 
 Exhibition (Colonel Sargood). 
 
 The toast of "Her Majesty the Queen" having been honoured, 
 
 Thk President proposed "His Excellency the Governor." He 
 remarked that His Excellency was always associated with everything 
 good and charitable, and was ever ready to lend his support to any 
 public movement of a pi-ofessional or scientific character. The success 
 wliich had attended the opening of the Congress, was in no small measure 
 due to His Excellency's influence and to the gi'eat interest he had taken 
 in the Congress. 
 
 His Excellkncy thf: Govehnou, in responding to the toast, said 
 he took a great interest in the Congress, as he was of opinion that it would 
 ])rove of immense benefit to the Colony of Victoria and to Australasia. 
 He trusted that the visiting members would thoroughly enjoy liiemselves 
 M'hile peiforining the important duties which had brought them 
 together. Amongst the various {lapers that would be read at the
 
 24 IXTERCOLOyiAL MEDICAL COXHRESS OT AUSTRALASIA. 
 
 Congress, anrl the discussions which would take place, there were none 
 which would interest the people of this Colony more than those on the 
 subject of sanitation. In the ])apers which he had heard read the 
 previous evening, reference was made to the death-rate in England and 
 the death-rate in these Colonies. There must be some cause for the 
 death-rate amongst children in the Australian colonies being so much in 
 excess of that at home, and it behoved the medical gentlemen who were 
 now assembled in Congress to inquire into the nature of these causes. 
 We were vei-y apt in Australia to l>e seized with alarm at the bare 
 pi'ospect of cholera being imported here, and yet we were most neglectful 
 in providing against typhoid fevei'— a disease which was carrying oft" 
 thousands of the population. The Minister of Public Instruction had, 
 at the jNIayor's luncheon, referred to the a])athy of the public with regard 
 to the steps which it was requisite should be taken to guard against 
 typhoid fever. He cordially agreed with the expression of opinion that 
 Ixad fallen from the Minister on that occasion. It was wonderful that 
 there should be such an apathetic state of feeling amongst the peo))le of 
 this country on the subject of health. It was that apathy which 
 ]irevented the necessary steps being taken to guard against the fell 
 disease which was decimating the population. He earnestly trusted 
 that the result of the conference would be to awaken public opinion upon 
 this important matter, and that something definite would be done 
 towanls imjtroving the sanitary condition of the Colony, and of 
 Melbourne especially. The subject he had touched upon was not a 
 political one, and therefoi'e he had felt himself justitied in referring to it. 
 
 The Premier (]\Ir. Gillies) proposed "The Intercolonial Medical 
 Congress of Australasia." The toast was not merely a personal one, as 
 it involved the success of the mission of the members. Tiiat mission 
 Avas a noble one, as it aimed at relieving human suffering. The medical 
 profession was one of the grandest under heaven, for it had probably 
 done more good for humanity than any other. The study necessary to 
 make men acquainted with all the known facts of medical science was a 
 lifelong one, and members of the profession had often to undergo hard.ship 
 in order to alleviate the sufferings of [tatients. 
 
 The President, in responding, said that there were over 550 mem- 
 bers in the Congress, and the success of the gathering was already 
 assured. The members were deeply indebted to the Government — and 
 to Mr. Cillies personally — for the assistance and encouragement they 
 had received from the State. 
 
 The Chancellor op the University of Melbourne (Dr. 
 Broavnless) in i)roposing ''Visiting Members of the Congress," referred 
 to the progress which had been made by the medical profession in the 
 colonies. 
 
 THIRD DAY. 
 WEDNESDAY, JANUARY 9, 1880. 
 
 At 10 a.m., in the Pathological Museum at the Medical School, 
 Professor Allen demonstrated a large collection of hydatid cysts in 
 various organs. Sjtecial deiuonsrratioiis and operations were conducted 
 in the various Hospitals.
 
 RECKPTIOX AT GOVKHN'MKNT rrOUSK. 20 
 
 At II a.m., a General ftfeeting of tlie Congress was held in the Wilson 
 Hall, when papers were read and discussed concerning the geographical 
 distribution, jiathology and treatment of Hydatid Disease. The Chair 
 was occujned by Dr. E. C. Stii'ling, President of the Section of Surgery. 
 
 i\rend)ers were in\ited by the Connnittee of the Hospital for Sick 
 Children, to visit that Institution at any time. 
 
 At the close of the meeting the Congress adjouined for lunch, which 
 was ])rovided in the Medical School. 
 
 The afternoon was devoted to Sectional INIeetings. His Excellency 
 the Governor visited the Congress during the afternoon, and was present 
 at the Physiological Demonstrations conducted by Professor Anderson 
 Stuart. 
 
 PvECEPTION AT GOVERNMENT HOUSE. 
 
 In the evening. His Excellency the Governor and Lady Loch 
 entertained the Members of Congress at Government House. The 
 company numbered upwards of a thousand ladies and gentlemen. All 
 the state rooms were thrown open for the use of guests, who were 
 welcomed by His Excellency and Lady Loch. 
 
 FOURTH DAY. 
 THURSDAY, JANUARY lU, L^S9. 
 
 In the forenoon, a large number of Members visited the AVomen's 
 Hospital, and were received liy the Ladies' Committee and the Honorary 
 Medical Stafl'. 
 
 At various other hos[)itals operations were conducted, and cases were 
 exhibited in the wards. 
 
 At 10 a.m. in the Pathological Museum at the Medical School, Dr. 
 INfaudsley demonstrated a laige collection of medical specimens. 
 
 At 11.30 a.m. a General ^Meeting of Congress was held in the Wilson 
 Hall, the President, Mr. T. N. FitzGeiald, occupying the chair. 
 
 The Address in Hygiene, Forensic and State Medicine was delivered 
 by Dr. H. N. MacLaurin (Sydney), President of that Section, and the 
 Address in Pathology by Di-. W. Caniac Wilkinson (Sydney), President 
 of the Section of Pathology. Hearty votes of thanks were tendered to 
 Dr. ^lacLaurin and Dr. Wilkinson. 
 
 The Congress then adjourned for lunch, which was again served in 
 the luncheon I'oom at the Medical School. 
 
 The afternoon was devoted to Sectional Meetings. 
 
 THE SPEAKER'S DINNER. 
 
 In the evening, the Speaker of the Legislative Asseud>ly (Mr. M. H. 
 Davies) entertained the MemVters of Congress and other guests at dinner 
 in the Town Hall. About five hundred gentlemen were pre.sent. The 
 Speaker occupied the chair, and had on h's right the President of the 
 Congress (Mr, T. N. FitzGerald), the Minister of Public Instruction 
 (Mr. Pearson), Dr. Kirtikar (India), the Commissioner of Pul)lic Works 
 (Mr. Nimmo), and Judge Molesworth. On his left were Dr. J. C,
 
 26 IXTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Verco (Adelaide), President of the First Session of the Congress, the 
 Minister of Justice (Mr. Cuthbert), the Mayor of Melbourne CAldernian 
 Benjamin), Professor Anderson Stuart (Sydney), the General Secretary 
 of the Congress (Professor Allen), and Colonel Sargood, M.L.C. 
 
 The loyal toasts having been duly honoured. 
 
 The Speaker j^roposed " Success to the Intercolonial Medical 
 Congress." It was a good thing for any profession to have such 
 meetings from time to time, so as to interchange views and cultivate 
 friendly relations. The legal profession would reap great advantage.s 
 if, at stated intervals, its members came together to carefully consider 
 questions of general interest, and advise the public concerning necessaxy 
 legislation. The medical fraternity occupied so important a position in 
 relation to public health, that it could command tlie hearty sympathy of 
 the community whenever it assembled in such Congresses as this. It 
 must be acknowledged that whatever tended to advance medical know- 
 ledge, tended also to the saving of life and to the amelioration of ])ain. 
 Everyone should therefore be willing to give a very earnest welcome to 
 those gentlemen, who had at great sacrifice to themselves come to 
 Melbourne, to assist their brethren resident here, in arriving at con- 
 clusions which would be beneficial to the profession generally. He had 
 been asked — "Is it not time that a Minister of Public Health should be 
 one of the leading members of any Ministry ? " The question had been 
 introduced at the Congress, and it had gone forth to the people of the 
 Colony, and possibly it would be asked by electors at the approaching 
 election. It was satisfactory to find that the Congress was likely to be 
 more beneficial than the most sanguine had anticijiated. 
 
 The President of the Congress (Mr. T. N. FitzGerald), in 
 responding, said that the session of the Congress had not alone served 
 to benefit members individually, but it had done more to federate the 
 j^rofession in Australasia than anything that had occurred in the past. 
 
 The General Secretary of the Congress (Professor Allen) also 
 responded. He expressed his belief that a time of great change was 
 coming in medical and sanitary matters. He could not agree that a 
 Minister of Public Health was exactly what was needed. A permanent 
 Commissionei- of Health was required. A man was wanted who would 
 be trained steadily year by year in the duties of his position, and who 
 Avould come forward and be the leader of medical and sanitary work in 
 the colony. Such a man was wanted, and not a Minister of Health, 
 who must come and go with each Administration. To keep the Congress 
 supi)lied with original material, .schools of research were needed in every 
 colonial University ; and in Sydney, Mr. Macleay, M.L.C, had 
 bequeathed to the University the noble gift of £40,000 to endow 
 research scholarships. These scholarships were to be open to everyone 
 who had the degree of Bachelor of Science, and, owing largely to the 
 influence of Professor Anderson Stuart, that degree was open on com- 
 paratively easy terms to every graduate in medicine. Who was the man 
 who would make some like provision in Victoria 1 Without it great 
 success could not be achieved. We must have research, and an endow- 
 ment must be secured. He returned his hearty thanks to the local and 
 sectional Secretaries for the valuable assistance they had given him in 
 connection with the Congress.
 
 THE speaker's dinner. 27 
 
 Mr. Pe.arsox (Minister of Education), in })roposin<:; " Our visitors," 
 and welcoming guests from other colonies, said : — The public which 
 looks only superficially on what is being done — which sees the reports 
 of essays in which the learning is almost overpowered by the eloquence, 
 followed by pleasant and animated discussions, combined with such 
 social gatherings as this — may be apt to think that the ])ursait of 
 science is an extremely light and even fascinating matter. But I need 
 not say to members of the medical profession, that the duties of your 
 lives are of a very different kind. I do not propose to fall back upon 
 the commonplaces of medical history, on the fact that day by day the 
 commonest country doctor, or even town doctor for that matter, is 
 called upon to expose himself to the rigor of the elements, to face 
 infectious disease, and to endure any amount of fatigue. I don't wish 
 to recall here such facts as that of the noble English surgeon, who, 
 when a ship had hoisted the yellow flag, and was without a medical 
 man, went there to die among the patients who were suff"ering from 
 yellow fever. Nor do I intend to speak about such topics as the 
 cholera at Naples, when medical men flocked thither from every part of 
 Europe, to take up the posts left vacant by the medical men who had 
 succumbed to the disease. These doings, gentlemen; you all know, are 
 part of your everyday duties, and yoix accept them in that way ; but 
 it is a different matter when we come into the boundless domain of 
 science. There are those who undoubtedly think that the life of a 
 scientific man is utterly divested of these heroic incidents. I speak 
 from most imperfect knowledge, but even I know that not a single 
 great discovery in the treatment of disease has been made except at 
 the cost of more or less lives, and to the ruin of a certain number of 
 constitutions. For men have died of ])oisoned blood in experimenting 
 with poisons and gases, and in making researches in deadly disease, 
 which they have followed up with as sublime a devotion to science, as 
 ever a mis.sionary felt in the cause of religion. The faith which 
 inspires that devotion, and which animates those sacrifices, is a faith 
 which makes men heroic, and lifts their profession far above that which 
 common men can aspire to. And it is not only in this splendid desire 
 to penetrate into the secret of God's lav that the medical profession 
 has distinguished itself. There is another side to the matter. Every 
 scientific man who has studied disease, as you gentlemen have, goes 
 about the world armed with a mysterious knowledge. Not only is he 
 entrusted with the secrets of families which he never divulge.s, but he is 
 the father confe.ssor to hundreds of men whom it may be he onh' 2)asses 
 by in the streets, but whose histories he reads in their faces or in their 
 gait. In this poor tattling, scandal-mongering world, the fact that you 
 get a regiment of men, recruited indiscriminately from every class, 
 armed with this tremendous knowledge of the secrets of humanity, and 
 keeping it as secretly as the Catholic |)riest keeps the seal of confession, 
 is a fact which in itself marks the profession as no common one. I am 
 called upon to propose the toast of the visitors to the Congress, who 
 have shown that zeal to decipher the secrets of science which I have 
 mentioned as one of the grand attributes of the profession, and who 
 share with others that splendid reserve by which the pi'ofession at large 
 is guarded. To be able to devote lives to the study of divine law, to> 
 be able to draw the veil impenetrably over personal secrets, are, it
 
 28 INTEKCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 strikes me, qualities of tlie veiy liighest kind. I propose the health 
 of our visitors. 
 
 Professor Anderson Stuart (Sydney), in acknowledsfing' the toast, 
 said that the visitors from the other colonies came to Melbourne filled 
 with the most agreeable anticipations, which had been almndantly 
 realised. Their sojourn had been made both pleasurable and profitable, 
 and they would regret to leave Victoria when the time of their depar- 
 ture arrived. This was a wonderful colony, and Melboui-ne was indeed 
 a marvellous city. I£e never saw the metropolis of Victoria without 
 feelings of admiration for the energy and enterprise of its citizens, and 
 he never left Melbourne without feeling that he had been intellectually 
 stimulated by contact with its leading citizens. For its age the colony 
 had attained to a wondei'ful degree of progress. He hoped the Inter- 
 colonial Medical Congress would one day visit old Sydney, and he could 
 ensure them a hearty welcome to the metropolitan city of Australia. 
 
 Dr. J. C. Verco (Adelaide), President of the First Session of the 
 Congress, likewise acknowledged the toast. When the First Congress 
 was held in Adelaide eighteen months ago, they exchanged congratula- 
 tions on the fact that there were 150 members, whilst now there were 
 5.50 members. The ])apers had been of a higher ordei', and the 
 discussions had l)een more complete. 
 
 FIFTH DAY. 
 FRIDAY, JANUARY 11, 1880. 
 
 In the morning, operations were performed and demonstrations con- 
 ducted at the various hospitals. 
 
 At 10 a.m., in the Pathological Museum at the Medical School, Dr. 
 Maudsley exhibited a large collection of surgical specimens. At the 
 invitation of the Committee of Management, a large number of members 
 inspected the Melbourne Hospital. 
 
 At 11.30 a.m., a General Meeting of the Congress was held in the 
 Wilson Hall, tlie President (Mr. T. N. FitzC-erald), occupying the Chair. 
 
 Dr. F. Norton Manning (Sydney), President of the Section of P.sycho- 
 logical Medicine, delivered an Address on " Lunacy in Australia." 
 
 Dr. M. J. Symons (Adelaide), President of the Section for Di.seases 
 of the Eye, Ear and Throat, delivered an Address on " Specialism." 
 
 Votes of thanks to Dr. Manning and Dr. Symons were carried by 
 acclamation. 
 
 The Congress then adjourned for luncheon, which was served in the 
 Medical School. 
 
 At 2 p.m., a General Meeting of the Congress was held in the Wilson 
 Hall, when pai)ers were read and discussion instituted concerning the 
 l)revalence, etiology, jtathology and treatment of Typhoid Fever. The 
 Hon. Di'. Tayhor, President of the Section of INIedicine, occupied the 
 ('hair.
 
 CONCEKT AT TJIK ICXIUHITIOX. 29 
 
 At the close of the discussion it was unanirnonsly resolved, on the 
 motion of Dr. Verco (Adelaide), seconded by ])\: D. Colquhouu 
 (Dunedin) : — 
 
 " That the members of the Intercolonial Medical Congress regard it as proved 
 that Typhoid Fever is a preventable disease, which owes its prevalence mainly to 
 insanitary conditions, and above all to contaminated water supply, defective drain- 
 age, and improper disposal of night-soil." 
 
 The following motion was also carried, on the ])ropo.sition of Dr. 
 Turner (Melbourne'), seconded by Dr. J. Davies Thomas (Adelaide) : — 
 
 " That while there is reason to believe that the source of water supply of 
 Melbourne is carefully guarded, it is certain that as regards drainage and night-soil 
 disposal the arrangements are very unsatisfactory, and to these defects must be 
 ascribed in a great measure the excessive prevalence of Typhoid Fever year after 
 year. " 
 
 On the motion of Mi". E. M. James (Melbourne), seconded by Dr. 
 Bright (Hobart), the Congress unanimously agreed : — 
 
 " Tliat in the opinion of the Congress it is the imperative duty of the Govern- 
 ment to take immediate steps for bringing about an improvement of the sanitary 
 condition of Melbourne, and specifically for the construction of a proper system of 
 underground drainage, which shall include the removal of night-soil by water- 
 carriage." 
 
 The Congress then adjourned. 
 
 CONCERT AT THE EXHIBITION. 
 
 In the evening, at the invitation of the President (Sir James 
 MacBain) and the Conunissioners of the Centennial International 
 Exhibition, the members of the Congress were entertained at a Special 
 Concert at the Exhibition Building. The magnificent Orchestra, under 
 the baton of Mr. Cowen, performed a splendid selection of music. 
 
 SIXTH DAY. 
 SATURDAY, JANUARY 12, 1889. 
 
 At 10 a.m., a General ^Meeting of the Congress was held in the 
 Wilson Hall, the President (Mr. T. N. FitzGerald), occupying the 
 Chair. 
 
 The Address in Pharmacology was delivered by Baron Ferdinand 
 von Mueller, K.C.M.G., President of the Section of Pharmacology. 
 
 Dr. Neild proposed that a vote of thanks to the ilhustrious savant 
 who had just addressed the meeting, and expressed the hope that the 
 learned i)aper thus submitted would give an impetus to the study of 
 Pharmacology in Australasia. The unceasing devotion of Baron von 
 Mueller to his scientific studies was known everywhere, and his name 
 was held in high honour. The Congress would have been incomplete 
 Lad he been absent from it. 
 
 Dr. Thomas Dixsox (Sydney) .seconded the motion. Coming from a 
 neighbouring colony, he had been somewhat surprised and much 
 delighted that the Section of Pharmacology had fully justified its 
 existence. 
 
 The motion was carried bv acclamation.
 
 30 INTEHCOLONIAL MEDICAL COXGRESS OF AUSTRALASIA. 
 
 SPECIAL MEETING. 
 
 A special meeting was then lield to determine the place and time, 
 and to elect the President of the next Session. The President (Mr. T. 
 N. FitzGerald) occupied the chair. 
 
 Dr. Philip Sydney Jones (Sydney) said he had the honour to 
 submit, for the consideration of the Congress, a motion which he felt 
 contident would receive the most hearty support, and an invitation 
 which he lioped would be accepted with the same cordiality with which 
 it was given. The motion was as follows : — 
 
 " That the Third Session of the Intercolonial Medical Congress be held in 
 Sydney in the year 1892, or at such earlier period as the Medical Societies of New 
 South Wales may determine." 
 
 It was not the desire of the Sydney representatives present, to bring 
 about the holding of the next Session of Congress in twelve months 
 from the present time, but it might possibly be found more convenient 
 to meet at the end of the year 1891, or to hold the Congress at a 
 pleasanter season of the year, as the summer heat in Sydney was very 
 tiying. For these reasons it was desirable to leave the matter in the 
 hands of the medical profession of New Soutli Wales, who were anxious 
 that the Sydney meeting of the Congress should conduce not only to 
 the editication of the minds of the visiting members of the ])rofession, 
 but also to the invigoration of their bodies. The medical men of New 
 South Wales could not hope to surpass their friends in South Australia 
 or Victoria, either in the perfection of the arrangements for the 
 Congress, or in the sumptuousness of their hospitality, but they 
 certainly tendered to the Congress a most cordial invitation, and would 
 do their best to make the Sydney meeting a thorough success. 
 
 Dr. Knaggs (Sydney) seconded the motion. 
 
 The General Secretary (Professor Allen) said he had received from 
 Dr. Dawson, who represented the Medical Association of New Zealand, 
 an invitation for the Congress to meet in that colony as soon as possible; 
 but the New Zealand representatives did not desire that their invitation 
 should interfere with the invitation which had been so graciously given 
 by the representatives of New South Wales. 
 
 The motion was then put to the meeting, and carried by acclamation. 
 
 Mr. E. M. James (Melbourne) said it was with great pleasure and 
 confidence that he submitted the following motion : — 
 
 " That Dr. MacLaurin, the Medical Adviser of the Government of New South 
 Wales and President of the Board of Health, "ue elected President of the Third 
 Session of tlie Intercolonial Medical Congress of Australasia." 
 
 The Hon. Dr. Creed (Sydney) seconded the motion, remarking that 
 110 better choice could be made. Dr. MacLaurin not only held first 
 phice in the profession in New South Whales, but also first place in the 
 alfections of his medical brethren, who would feel that the interests of 
 tlie colony would be thoroughly conserved by that gentleman during his 
 tenure of office. 
 
 The motion was carried unanimously amid loud cheering. 
 
 The President. — It is extremely gratifying to myself to know that 
 you have selected such an able member of the profession as Dr. 
 MacLaurin, and I am sure you could not possibly have chosen a better 
 President.
 
 HEALTH LEGISLATIOX AM) UXQUALIFIKD PUACTITIOXEUS. 31 
 
 PRESENTATION TO DR. POULTON. 
 
 Dr. M. J. Symons (Adelaide) then ro.se, on behalf of the South Austra- 
 lian members, to present to Dr. Poulton a token of ai)iireciation of his 
 services during the First Session of Congress. All members were 
 greatly indebted to him for the enormous work which he did as 
 Secretary to that Congres.s, and iii addition, they remembered that 
 Dr. Poulton was the first to suggest that an Intercolonial Medical 
 Congress of Australasia should be held. A meeting was accordingly 
 heM in Adelaide, and a circular was addressed to the South Australian 
 Members by a Committee consisting of Drs. Gardner, Stirling, Stewart, 
 Thomas, Verco, and Way, with i)i-. Symoiis as Treasurer. In con- 
 sequence, the Committee was enabled to present Dr. Poulton with a 
 silver inkstand, appropriately inscribed, in place of the one which he 
 had worn out in their service, and to add to it a purse of sovereigns, 
 which he now requested the President to pre.sent to Dv. Poulton. 
 
 The President said it was his most pleasing duty to hand the 
 souvenir to Dr. Poulton, to whose great ability, care, judgment and 
 discretion as General Secretary, the success of the First Session of the 
 Congress was, in a large measure, unquestionably due. He (the 
 President) attended the Congress, and had found Dr. Poulton ready to 
 give information on all needful points, and he only regretted that he 
 had beenexcluded asa Victorian memberfi'om joining in this presentation. 
 
 Dr. Poulton said: — Mr. President, Dr. Symons and Gentlemen, — 
 I cannot describe the peculiar satisfaction and pleasure with which I 
 receive from my brethren of South Australia this handsome and alto- 
 gether unnecessary memento of a time which I shall never forget. 
 It did fall to my lot as a member of the Council of the local Branch of 
 the British Medical Association to make the first suggestion, so far as I 
 am aware, with regard to holding Medical Congresses in Australasia. 
 Dr. Symons has said that the Congiess is indebted to me ; but I feel 
 myself much indebted to the Congress. I shall always remember the 
 kindness of my Committee, the unfailing energy of its members, and the 
 general cordiality and good feeling which prevailed. I feel deeply the 
 very great kindness which, actuates my friends in giving me this 
 beautiful present. I thank you, Mr. President, for your kind words, 
 and my friend Dr. Symons and my colleagues in South Australia for 
 this expression of their goodwill. 
 
 Dr. KiKTiKAR (Bombay) said he had the pleasure to offer for the 
 acceptance of the President (Mr. T. N. FitzGerald) and the General 
 Secretary (Professor Allen), co[)ies of one of the oldest native Indian 
 medical works in Sanscrit. He then read a sonnet addressed to the 
 Congress. 
 
 The President and General Secretary accepted the souvenirs with 
 thanks. 
 
 HEALTH LEGISLATION AND UNQUALIFIED 
 PRACTITIONERS. 
 
 Dr. Springthorpe said that, by the instructions of the Section of State 
 ^ledicine, he had to submit the following resolution, which had been 
 drafted by Dr. iNIacLaurin, the President of the Section : — 
 
 (1) " That this Congress urges upon the notice of the different Governments of 
 Australasia the necessity which exists for fresh legislative enactments in all the
 
 32 INTERCOLONIAL MKDICAL CONGRESS OF AUSTRALASIA, 
 
 colonies, with a view to obviate the grave dangers to public health which every- 
 where prevail, and which in many cases are due to easily removable causes." 
 
 (2) " That in the interests of the public, this Congress urges upon the various 
 Governments of Australasia the necessity for amendments in the lawr. relating 
 to the position of medical i^ractitioners, in order that the public may be in a position 
 at all times to protect themselves against the impositions of unc^ualified persons.'' 
 
 (8) " That copies of these resolutions be forwarded by the secretary to the 
 Federal Council, and also to the Governments of the different colonies." 
 
 Dr. Morgan (Newcastle, N.S.W.) seconded the motion, whicli was 
 carried unanimously. 
 
 The General Secretary reported that numerous lettei-s had been 
 received from leaders of medical thought in Europe and America 
 regretting their inability to be present at the meetings of the Congress. 
 
 VOTES OF THANKS. 
 
 Dr. Verco (Adelaide) said that an imperative duty yet remained ; 
 the Session would be incomplete if it were not performed ; and 
 accordingly, it was an honour and a pleasure to propose a vote of 
 thanks to the President, Mr. EitzGrerald. It was evident to 
 visitors from the other colonies that Mr. FitzGei-ald was the idol 
 of the Victorian practitioners, and all visitors would agree, after 
 the experience of this Congress, that the idolatry was deserved. He 
 therefore moved that a vote of thanks be tendei'ed to Mr. FitzGerald 
 for his Presidency over this Congress. 
 
 The Hon. Dr. Taylor (Brisbane) said he had much jileasure in 
 seconding the vote of thanks. He had received from Mr. FitzGerald 
 personally every courtesy and kindness, and he believed that every 
 member of Congress could say the same. The amount of labour 
 which the President and the Executive Officers must ha\'e bestowed 
 in bringing this Congress to so happy an issue could be appreciated 
 only by those who had experience of such undertakings. 
 Undoubtedly, the Session had been an unqualified success from 
 beginning to end. All members would leave Melbourne with 
 feelings of com]ilete satisfaction, and with gratitude to the President 
 for the way in which he had fulfilled the duties of his higii office. 
 
 The motion was supported by representatives of all the colonies, 
 and was carried by acclamation. 
 
 The President said he sincerely felt the kind remarks which 
 had been made concerning him. If he had done anything in a 
 small way towards the success of the Congress, he should feel more 
 than compensated by the presence of so many able men. He was 
 not accustomed to the duties of the chair, and he owed much to 
 the forbearance and goodness of the members of the Congress, 
 
 The Hon, Dr. Creed (Sydney) proposed a vote of thanks to the General 
 Secretary, Professor Allen, for his invaluable services. The work 
 which he had done would have been overwhelming to anyone less 
 capable. Nothing had gone wrong. No other man could so 
 thoroughly and so efficiently have filled the i)osition. All members 
 must join in wishing Professor Allen long life and prosperity, and 
 hope to see him president of some future congress. As time was 
 pressing he would join in the same vote of thanks the names of the 
 Chairmen and Secretaries of the Sections.
 
 VOTES OF THANKS. 33 
 
 Dr. J. Davies Thomas (Adelaiile) said it Avas unnecessary to 
 emphasise the claim of Professor Allen upon the gratitude of members. 
 For a long time before the Congress was inaugurated, he had been 
 working unceasingly to ensure its success. 
 
 The President referred to the enormous amount of pains and 
 trouble which the General Secretary had taken. Speaking generally, 
 the whole work of the Congress was on Professor Allen's shoulders, 
 and to him its success was laigciy due. 
 
 The motion was put and carried unanimously. 
 
 Professor Allen said : — 'Mv. President, Dr. Creed, Dr. Thomas, 
 and Gentlemen, — -I thank you very much for the kind words which 
 have been spoken, and for the kind way in which you have received 
 them. If, unwittingly, in the press of business I have by any neglect 
 given oftence to any members, I express my sincere regret. I cannot 
 properly acknowledge your kindness ; but I shall have much pleasure 
 in conveying your thanks to the officers of the Sections. 
 
 Votes of thanks were also accorded to the members of the various 
 Committees, to the hosts who had entertained the Congress, and to the 
 Chancellor and Council of the University for their kindness in placing 
 the University l>uildings at the disposal of the Congress. 
 
 ADJOURNMENT OF CONGRESS. 
 
 On the motion of Dr. Verco (Adelaide), seconded by Dr. Brgwxle.ss, 
 it was resolved that the Congress <lo adjourn until its next session in 
 Sydney. The Congress then closed. 
 
 GARDEN PARTY AT RUPERTS WOOD. 
 
 After the close of the Congress, the members and other guests travelled 
 by special trains to Sunburv, and were entertained at a garden party at 
 Rujiertswood by Sir William and Lady Clarke. The guests, who 
 numbered about seven hundred, were received by the host and hostess, 
 and were immediately afterwards invited to partake of lunch, which was 
 ))rovided in a s])acious marquee. Among those present were the 
 President of the Legislative Council (Sir James MacBain) and Lady 
 MacBain, the Speaker of the Legislative Assembly (Mr. M. H. Davies) 
 and Mrs. Davies, and the Executive Vice-President of the Centennial 
 International Exhibition (Colonel Sargood) and JNIrs. Sargood. During 
 the afternoon a madiigal ])artv discoursed on the lawn ; solos and 
 concerted music were given in the drawingroom ; the Nordenfeldt 
 battery went through a tournament in the fields, and a military band 
 2)erformed in the grounds. The visitors returned to INIelbourne by 
 special trains, i-eaching the city shortly after .six o'clock. 
 
 MONDAY, JANUARY U, 1889. 
 
 At the invitation of The Premier of Victoria (Mr. Gillies) and the 
 Members of the Government, the members of Congress and other guests 
 proceeded by train to Port Melbourne, and there embai^ked on the 
 
 D
 
 34 INTEKCOLOXIAL MEDICAL CON(a;lCSS OF AUSTKALASIA. 
 
 s.s. Courier, by wliicli they were conveyed to Port Phillii) Heads, and 
 then along the South Channel to Capel Sound, where H.IVI.A^.S. Nelson 
 was anchored. His Excellency the Governor went on hoard the Courier 
 at Port Melbourne. On arriving at the Heads the visitors had the 
 op[iortunity of witnessing torpedo experiments and artillery practice from 
 the forts. The visitors, who numbered over six hundred, then passed 
 from the Courier to the Nelson, the main deck of which was converted 
 into a covered banquet-room. Here a sumptuous lunch was served. 
 The healths of the Queen, the Governor, the Congress and the Ministry 
 were drunk with enthusiasm. The party then returned to the Courier 
 and were swiftly carried back to Port Melbourne. 
 
 In the evening, members were entertained by the Metropolitan 
 Liedertafel at a Smoke-night Concert in the ujtper hall of the Athenaiuui. 
 
 TUESDAY, JAKUAPvY 15, 1889. 
 
 At the invitation of the President of the Central Board of Health, 
 Mr. A. P. Akehurst, a number of members visited the Quarantine 
 Station at Point Nepean. 
 
 At the close of the Congress, the President forwarded a letter of 
 thanks to the daily press for the excellent reports which had been 
 published. 
 
 Dr. J. Carnegie MacMullen, of Melbourne, was empowered to 
 represent the Auckland Branch of the Kew Zealand Medical Associa- 
 tion at the Congress. 
 
 Messrs. Johnstone, O'Shannessy and Co. have undertaken to photo- 
 graph Members of Congress individually, so as to prepare a group 
 photograph, in accordance with the plan adopted in European 
 Congresses. 
 
 During the Congress, Messrs. Burroughs, Wellcome and Co. exhibited 
 a large special collection of their ])harmaceutical preparations. Messrs. 
 INIayer, JNIeltzer and Jackson also exhibited a large collection of surgical 
 instruments.
 
 SECTION OF MEDICINE. 
 
 PRESIDENT'S ADDRESS. 
 
 By The Hox. W. F. Taylor, M.D. 
 
 Tlie subject which I have had the honour to have been appointed 
 to preside over is one which embraces a vast fiehl of research and 
 careful critical observation. It is one which includes every science 
 in its limits, and is in touch, as it were, with nature and the laws 
 of nature to a very close extent. The laws which govern the universe 
 are to the same extent the laws which are applicable to the human 
 being. Man is composed of body, soul, and spirit, and the union 
 of these three constitutes the Ego or individual being who is the 
 subject of the physician's study, both in health and disease. In 
 health, the being is in the perfect exercise of all his constituent parts, 
 and may truly be said to be spiritually and physically a complete 
 being. He exercises his various functions of nutrition, growth, 
 mental development, and spiritual evolution. No man can be said 
 to be in perfect health, whose spiritual being is clouded ; and to 
 liim who can, whilst earnestly and faithfully discharging his duties 
 to his fellows, cultivate his spiritual being, is vouchsafed that condition 
 of existence which may justly be denominated the mens sana in corpore 
 sano. The healing art is eminently associated with man's higher 
 and more spiritual faculties. For centuries the leech and the pm^st 
 were the same indi^"idual, and to such an exalted status was medical 
 art raised in the time of the earlier practitioners, that a Deity was 
 created to preside and rule over its practice. No one who has 
 seriously considered the question, can fail to grasp the vast extent 
 of the knowledge necessary to enable an earnest follower of ^sculapius 
 to fathom the occult causes of disease and death, and no one can too 
 seriously consider the conditions of our being, which give rise to 
 such causes. We are living in a state of constant change, we ourselves 
 are constantly changing, and the vital processes are constantly 
 elaborating new tissue and discarding old. In such incessant 
 alteration many causes may arise to interfere with the ^■ital processes, 
 and such causes may lead to effects, which may not only become 
 permanent, but may endanger the existence of the organism. The 
 study of the vital processes, therefore, is one which ought to form 
 the fundamental basis for all observation and research, and those 
 ^^■ho make themselves acquainted with the life history of the 
 
 D 2
 
 36 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 ultimate component parts of the organism, the cell develo))- 
 ment and growth thereof, are in a better position to realise the 
 changes which may ensue from any interference with . the natural 
 condition of those parts. As each cell is as it were a miniature 
 representation of the whole, so each cell has an autonomy which 
 practically makes it influence the well-being of the whole, and the 
 life history of such cell is the life history of the whole. It is evident, 
 therefore, that so long as life lasts, so long will the condition of the 
 being be influenced by the healthfulness or otherwise of the cellular 
 elements which go to form it. Man is the highest and noblest work of 
 nature, and the study of man as an individual living being is the 
 highest and most difficult of all studies. Endowed with intellectual 
 faculties capable of high development, and influenced in every way by 
 his powers of reason, he is eminently fitted for the study of himself, and 
 by such study to advance- his knowledge of nature and her laws. No 
 one can make real progress in that highest of all knowledge — the 
 knowledge of one's self — who does not reverently and in all humility 
 appeal to the Essence of Knowledge for guidance and support. Man 
 is in the highest sense a progressive being, both intellectually and 
 spiritually. Contrast the beginning or dawn of man's existence, with 
 what is, in many cases, the close of his earthly state — the instinct 
 of the child with the knowledge and intellectual vigour of the adult 
 — and who can tell to what knowledge the human being may attain ? 
 We Western nations are too apt to rely on what we consider our 
 intellectual qualities, regardless of the fact, that those qualities are the 
 gifts of nature's God, and that the proper use of them is as much 
 a duty incumbent upon us as the preservation of our life and health. 
 How then should we use them, but in endeavouring to gain a know- 
 ledge of ourselves, a knowledge not only of our outward form and the 
 manifest workings of our organism, but of the inner occult being 
 which forms the imperishable part of the Eyo. But some may say, 
 how is all this to aid our diagnosis and treatment of disease 1 
 Gentlemen, no one can separate the body from the soul and spirit, 
 in his study of the life and habits of the individual being. Everyone 
 present must have met with many instances of the influence of mind on 
 matter, not only in those so-called nervous conditions included under 
 the sweeping term hysteria, but also in cases where actual alteration in 
 the nutrition and growth of a part has resulted from mental ideas or 
 emotions. Who has not seen the efiects of the mind in cases of so- 
 called neuralgia suddenly cured by magnetic passes made over the 
 painful part? No doubt many such cases would have as speedily 
 recovered under any strong mental emotion ; but the quiet operation of 
 the mind, influenced by the operator, eflectually restored the disordered
 
 president's ADDUESS — SECTION OF MEDICINE. 37 
 
 condition of the nerve to its healthy state. So also the insensibility to 
 pain when in the hypnotic state — a condition of mental rest which 
 enables surgical operations to be performed with im})unity. This 
 condition may be termed one in which the influence of mind over 
 matter is exercised in a veiy marked degi-ee, inasmuch as it is the mind 
 of the opei'ator which influences the sensibility of the operated. The 
 condition termed hypnotism, mesmerism, or animal magnetism, is 
 one well worth the careful study of every medical practitioner. 
 Unfortunately, the subject has generally been treated as unworthy of 
 consideration, as one in which humbug on the one side, and credulity on 
 the other, played the chief, if not only, part. But now-a-days, with 
 that spirit of enquiry so distinctive of the age we live in, many 
 medical })ractitioners of eminence have investigated the phenomena 
 occurring in the hypnotic state, and some valuable results have been 
 arrived at. 
 
 The progress in medical science during the last quarter of a century 
 has been more remarkable in the direction of jmthogeny and pathology, 
 than in therajieutics, although in the latter branch much real advance- 
 ment has been made. Whilst deploring the fact that this most 
 important subject has not made greater strides towards combating 
 disease, one is supjwrted in the hope that we are now fairly launched on 
 a new era in this respect, and that as our means of critical observation 
 of disease and its causes become more perfect, this most necessary 
 branch of medical science will soon emei'ge from the obscurity which has 
 so long enveloped it. Our knowledge of physiology has made rapid 
 strides of late years, and as we gain a more intimate acquaintance with 
 the natural processes of the human economy, so shall we be in a better 
 position to detect any departure from the condition of health, and 
 adopt means to mitigate if not prevent the eftects of such. Valuable 
 additions have recently been made to our therapeutical resources, such 
 as cocaine, strophanthus, antipyrin, eucalyi)tus, and others, and our 
 knowledge of the action and mode of administration of the older 
 remedies has been much increased by the researches of Ringer, Brunton, 
 Fraser, and the observations and clinical facts constantly noted in our 
 medical journals. But probably the greatest advancement has been 
 made of late years in the treatment of neuroses and uterine affections 
 by Weir Mitchell in the former, and Apostoli in the latter. The 
 treatment by massage is not, however, of such recent date, for it is over 
 ten years since I became acquainted with its details as first published by 
 Weir Mitchell, but its application has now become better understood 
 and much more general. This method of treating neurotic affections is 
 well known, therefore it is unnecessary for me to enter into any details 
 respecting it. I cannot refrain however from regarding the author of
 
 38 INTERCOLONIAL MEDICAL CONCJRESS OF AUSTRALASIA. 
 
 massage, Sic. as at present practised, as one of the greatest benefactors of 
 humanity in our times. 
 
 Shortly after the system was first introduced, a girl about eighteen 
 years of age came under my care, who for two years previously had 
 vomited all food and even small quantities of water. How she lived 
 was a mystery, as everything she swallowed appeared to be at once 
 ejected. She had been treated by several medical men of ability and 
 experience; and, although no apparent cause existed for the vomiting, 
 nothing in the shape of remedial measures liad any appreciable effect in 
 even mitigating her distressing state. Feeling quite satisfied from 
 observation that the condition was not due to ulceration of the stomach, 
 or any other disease of that organ, I proposed, and was allowed to 
 examine the uterus, which was found to be anteflexed with a pin hole 
 OS externum. Under the impression that this condition of the womb 
 might probably contribute to the production of the vomiting, if it did 
 not cause it, I performed Marion Sims' operation for division of the 
 cervix and enlargement of the canal. This was followed by some 
 amelioration, but not sufficient to enable food to be taken at all freely, 
 without vomiting ensuing. I fortunately came across the first cases of 
 ti'eatment by massage reported in the Lancet by Playfair, and was so 
 impressed with the results obtained by him that I determined to adopt 
 it in this case. I did so, and the eff'ect in a few days was most 
 satisfactory. The patient could retain solid food on the fourth day, and 
 the bowels, which before were a source of constant trouble, acted freely 
 of their own accord. The progress towards complete restoration to health 
 was rapid, and slie is now, and has been for many years, in the enjoyment 
 of such strength as enables her to pursue her occupation as a State 
 School teacher. The neurotic tendency still exists, and shows itself at 
 times by some uterine trouble, but the fact remains that this person 
 was, by the treatment alluded to, restored from a condition of utter 
 weakness and misery, to one of comparative strength and comfort. My 
 experience since then has served to confirm the great value of this 
 method in suitable cases, most if not all of which were, before its 
 introduction, relegated to life-long misery, and to become a permanent 
 burden on their friends. 
 
 If the boon which has been conferred on sniffering humanity by the 
 introduction of massage into medical practice has been great, that which 
 electricity bids fair to confer is greater still. To Duchenne belongs the 
 honour of being one of the first to drag electricity out of the hands of 
 charlatans, and give it a distinct place in the list of remedial measures. 
 Formerly it was looked upon with the same suspicion that is shown to 
 animal magnetism now, and was regarded, by even the most enlightened 
 members of the medical profession, as humbug to a great extent. But
 
 PKKSIDKXt's ADDKKSS — SKCTION OF MEDICINK. 39 
 
 it has emerged from tlie uncertainty and doubt which formerly 
 ■surrounded it, and now in the hands of Apostoli has become an agent 
 in the cure of a certain class of disease, both tractable and positive in its 
 results. In the treatment of fibroid tumours of the uterus, it has in his 
 hands been successful, and in such diseases as chronic endometritis and 
 metritis it aj)pears to be almost a specific. Its action in arresting 
 hi^morrhage from the uterus, no matter from what cause, is both prompt 
 and permanent, and in induration of the womb it exercises a most 
 salutaiy effect in promoting aV>sori)tion of the hyperplasia and in 
 rendering the organ less sensitive and painful. It is most gratifying to 
 know that this class of diseases is at length likely to become amenable 
 to treatment, and that tlie unfortunate victims of uterine troubles are 
 likely to be saved by this means from the unsatisfactory and painful 
 methods of procedure hitherto in vogue. And who can foretell where 
 the use of this agent in the treatment of diseases will end ! So with 
 animal electricity or magnetism. At present relegated to persons having 
 little or no scientific knowledge, the time will, I believe, soon come when 
 its use will be clearly demonstrated by some member of the profession. 
 Already it has been proposed to use hyi)notisni in midwifery, and in 
 France it has been actually employed instead of chloroform in such cases. 
 The physician is called upon to treat many, diseases resulting from 
 over indulgence in alcoholic stimulants, and he is brought into frequent 
 contact with those vices which owe their origin to habits of drinking. 
 Insanity is a common result of these habits, and our lunatic asylums 
 contain many examples of such cases. It is not to be supposed that 
 the medical ])ractitioner should become a temperance lecturer, but he 
 may do much to stay the r;ipid progress that is being made in the 
 habits of intemperance, which lead to such sad results. In these 
 colonies where wealth is so easily obtained, and where the pursuit of it 
 occupies so much time, to the exclusion of the cultivation of a taste for 
 art and science, time is apt to hang heavily on the hands of those who, 
 having acquired riches, or having inherited them, find no necessity for 
 occupying their minds with business, and so are apt to indulge in 
 habits of drinking from having nothing absolutely to do. The 
 following aj)pears among the editorial notes in the Lancet of 
 December 24, 1887 : — " We have lately remarked with pain on the 
 drinking habits of some of our colonies, notably New South Wales. A 
 Iloyal Commission has been occupied for many months in taking 
 evidence on this subject, and arrives at conclusions which should excite 
 the concern of every inhabitant of the colony. The premier colony has 
 the distinction of drinking more intoxicating drink, and that of a worse 
 quality, than almost any other English-speaking community in the 
 world. This is a bad distinction, which the following figures seem to
 
 40 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 confirm. The drink bill of the United States per head is £1 13s. 6d. ; 
 of New Zealand, £3; of the United Kingdom, £3 7s. lOd. ; of 
 Victoria, £4 13s. lid.; of New South Wales, £5 14s. In the city 
 of Sydney alone, there are said to be 3000 persons known to ]je 
 habitual and absolutely hopeless drunkards. We are informed that 
 not only does the colony drink more than other similar communities, 
 but that it drinks much more than it did twenty years ago," &c., &:c. 
 It is a great pity that our universities are not more attended by the 
 youth of these colonies, for it is only by that higher education 
 which induces an inclination for science, art, or literature, that any 
 real stand can be made against the evil mentioned, an evil which is 
 ever growing with increased wealth and population. In the mother 
 country, where a university career affords a certain social distinction, 
 it is very much the practice for the wealthy to send their sons to 
 college, where if not veiy much is learnt by the student, he is brought 
 under restraining influences and a certain amount of discipline, at 
 a period of life when habits are more easily formed, and the mind 
 more readily bent than at any other time. It is our duty as medical 
 practitioners, having by reason of the nature of our profession opportuni- 
 ties of coming into close contact with the inner life of the community, 
 to endeavour to point out to parents the advantages which accrue from 
 a University career, and the dangers which such a career may save their 
 sons from. In the mother country wealth brings with it certain 
 responsibilities, the neglect of which condemns the individual to social 
 exile, and that, in a country where the struggle is as much after social 
 position as after wealth, is regarded with feelings of dismay. A social 
 system, which makes such strong class distinctions as that of Great 
 Britain and Ireland, is not to be thought of here, and no one having the 
 well being of the community at heart would wish to see such established. 
 What we should aim at is to create an aristocracy of intellect, the 
 passport to which would be a cultivated mind, and a high sense of duty 
 to one's self and one's fellowmau. It should be our aim, therefore, to 
 encourage any movement which may have for its object the promotion 
 of means for furthering the higher education of the youth of both sexes, 
 and for enabling those who may display an inclination for scientific and 
 literary pursuits to follow out their desires to the fullest extent. In 
 all walks of life may be foimd genius, talent, and a high order of 
 intellect, and it should be our aim to bring about such a state of things 
 as will enable the son of the humblest member of the community to 
 cultivate the talents with which God has endowed him. Genius and 
 talent are as much the proi)erty of the whole community as of any one 
 individual member thereof, and it is as much the duty of the community 
 to cultivate that genius and talent, as it is of the individual himself.
 
 1'KKSIDENT's address — SECTION OF MEDICINE. 41 
 
 The part which bacterial orgunisius play iu t]>e production of disease 
 is daily becoiuiiig more clearly understood, and the time is, I lielieve, fast 
 approaching, when our knowledge of thehal)its and life history of micro- 
 parasites will enable us to mitigate, if not to prevent, their pathogenic 
 action in the human being. Already, it has been pretty clearly demon- 
 strated that certain diseases, suchaswoolsorters'disease, malignant pustule, 
 an<l intestinal anthrax, are caused by the anthrax bacillus. Micrococci are 
 said to be associated with })ytemia and all acute suppurations, erysipelas, 
 diphtheria, measles, vaccinia, typhus, scarlatina, variola, whooping cough, 
 dysentery, pneumonia, epidemic cerebro-spinal meningitis, infective 
 periostitis, endocarditis, and acute yellow atrophy of the liver. Bacilli 
 are found in connection with cholera, malaria, typhoid fever, tubercle, 
 lejjrosy, and glanders ; and relapsing fever no doubt owes its cause to 
 s[)irilluni, or spirochaete Obermeieri. The colourless blood cells appear, 
 from the observations of MetschnikofT, to resist the invasion of these 
 micro-organisms, and cases of immunity froui disease after exposure of the 
 individual to contagion, are supposed to be due to the successful action 
 of the leucocytes. With' reference to the bacillus of anthrax, 
 Metschnikoff says " that the virulent rods, when introduced l)y inocula- 
 tion into an animal liable to take the fever, such as a rodent, were not 
 absorbed l)y the blood cells, or oni}^ in excejjtional instances, they were 
 readily absorbed by the blood cells of animals not liable to the disease, 
 as frogs and lizards, provided the temperature was not artificially raised, 
 and then disajjpeared inside the cells. The same thing happened when 
 susceptible animals were inoculated with bacillus anthracis which had 
 been attenuated to the harndess state." He infers " that the bacillus 
 is harmless, because it is absorbed and destroyed Ijy the blood 
 cells, and injurious because this does not happen ; or at least that 
 it becomes harmless, if the destruction by the blood cells takes place 
 more lapidly, and to a greater extent, than the growth and 
 multiplication of the bacillus; the converse being also true." 
 Cheyne says : — " When bacteria are injected into the tissue.s, there 
 follows a struggle for existence between them and the cellular elements. 
 Leucocytes quickly accumulate in the neighbourhood of the mass of 
 bacteria, and then follows a fight for the mastery between these cells and 
 the bacteria. The cells take up the bacteria into their interior, and 
 when tlie bacteria are non-pathogenic for the animal employed they are 
 destroyed." It would appear, therefore, that if from any cause the 
 vitality of the blood-cells be lowered, the bacilli will grow and enter the 
 blood-stream, and, in the case of pathogenic bacteria, will give rise to 
 certain pathological results. Dr. P. W. Latham, in the Harveian 
 Oration delivered before the Royal College of Physicians on October 18, 
 last, says : — "From the data which I have placed before you I wish to
 
 42 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 draw the inference tliat, in the living animal organisms, owing to slight 
 departures from the normal nutrition of parts, arising probably 
 through nervous agency — the trophic nerves — various substances such 
 as extractives or alkaloids will be produced which, if not eliminated or 
 neutralised, will lead to jtathological changes in the system, absolutely 
 and entirely independently of any bacterial action. If, then, from any 
 cause due to glandular, nervous, or other derangement in the system, 
 these poisonous substances are developed or not eliminated, they will 
 alter the composition and constitution of the blood ; the white corpuscles 
 may be destroyed, or their movements enfeebled, and by any such 
 changes the blood, which previously could resist the attacks of the 
 various parasitic micro-organisms, is so modified as to render it a 
 suitable soil in which these organisms may develop and thrive." Dr. 
 Latham advances the theory that non-pathogenic micro-organisms may, 
 under suitable conditions, develop j^athogenic properties, and gives 
 some very strong proof in support of this view. He mentions the fact 
 that "Instances are not rare of vegetable cells possessing jtoisonous 
 properties at one time and not at another. jSIaegeli has called attention 
 to one of the most striking, which is thus described by De Bary : — 
 ' The bitter almond tree is poisonous from the amount of amygdalin it 
 contains, though it is not very dangerous to human beings ; the sweet 
 almond contains no amygdalin, and is not poisonous. The sweet 
 almond tree does not differ specifically from the bitter ; a tree with 
 bitter seeds may be produced from a sweet seed ; bitter and sweet 
 seeds may even he borne on the same tree in flowers and fruits not 
 morphologically distinguishable from each other.' What the origin 
 or cause of this difference is, has not yet been discovered, and no 
 exjilanation can as yet be off"ered ; but the fact will help us to 
 understand that cells may be developed by these micro-organisms, 
 capable of jjroducing very different effects upon the system ; and I 
 incline therefore to the view that, probably from the simple neglect 
 of ordinary sanitary measures, innocuous micro-organisms may become 
 virulent, and that diseases may arise de novo." Time will not permit 
 me to refer at greater length to these micro-organisms, nor to their 
 connection, either as to cause or effect, with the ptomaines and 
 leucomaines of Gautier, Selmi, and Brieger ; but I think that the 
 obvious conclusions to be drawn from what is known with respect 
 to them is, that we must rely on hygienic rather than on medicinal 
 means to combat their eff'ects on the human economy, that our 
 efforts must be directed to fortifying the system to resist the attacks 
 of these insidious foes, rather than to rely on curative measures 
 to nullify the effects of their presence in the blood or organs of the 
 body. Dr. Green, in his work on "Pathology and Morbid Anatomy,"
 
 president's address — SECTIOX OP MEDICINE. 43 
 
 says: — "Attention to general hygiene is the only way at present 
 known to prevent invasion of the system by fungi wliich cause 
 ' medical ' diseases. Once organisms have gained access to tlic tissues, 
 it is extremely difficult to destroy them without also destroying the 
 tissues. Improvement of the general health probably often enables 
 the tissue elements successfully to resist invasion." In the case of 
 disease, therefore, arising from the introduction of micro-i:)arasites 
 into the human system, the action of medicines must be limited to 
 their physiological effects on the organism — their stimulating and 
 tonic effects on the nerves, blood, and cellular elements — and not on 
 any supposed therapeutic action. Preventive medicine, then, appears 
 to afford the only satisfactory means of defending the organism from 
 the inroads of disease, and of rendering its surroundings less liable 
 to generate or promote the propagation of the specific virus of disease. 
 Hygiene, in every sense of the term, must take the place of curative 
 medicine to a great extent, and in time we may see real cities develoj) 
 after the model of Richardson's ideal Hygeia. 
 
 But a glance at the vital statistics of each colony will speedily 
 dispel any hope that siich a .consummation is at all likely to be arrived 
 at in the near future of Australia ; for we find that the mortality 
 from preventable diseases was as great during 1887, if not gi-eater, 
 than in any year during the previous ten ; and the deaths of children 
 under five years have, in the case of Queensland, steadily increased 
 during the four years from 1884 to 1887, the proportion per cent 
 of such to the total deaths in the colony being, in 1884, 33"95 ; 
 1885, 38-80; 1886, 41-26; 1887, 41-35. In New South Wales the 
 proportion per cent, was in 1884, 43-79; 1885, 43-26; 1886, 43-15; 
 1887, 41-67. In Victoria the proportion per cent, was in 1884, 35-87 ; 
 1885, 36-07 ; 1886 not received; 1887, 36-90 ; and in South Australia 
 the proportion per cent, was in 1884, 48*59. 
 
 The Registrar-General of Queensland dravv's forcible attention to 
 the mortality amongst children of infantile years, which, he says, " is 
 a matter of widespread importance, especially to young countries like 
 Queensland, where the increase of population is an important factor 
 in its prosperity, and where there is a high marriage and birth rate." 
 2136 children under five years of age died in 1887, and of this 
 number 1856 were under two years old. Perhaps I cannot do better 
 than quote at length the Registrar-General's remarks. Referring to 
 Table xiv. of the Report, he says : — " This shows that out of a total of 
 2136 deaths, 1668 children under five years- died from the diseases 
 mentioned, and it is a matter of serious consideration whether in many 
 cases the diseases specified were not brought about by the administra- 
 tion of improper food to the children, by want of care, or by
 
 44 IXTERCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 injudicious exposure of the cliildren by those in. whose care they are 
 placed. The whole subject is fraught with interest to the community, and 
 is one which slioukl receive early attention from medical men and others, 
 with a view to devise means lyy which at least a portion of the large 
 annual loss of life amongst our juvenile population might be prevented." 
 
 However, gentlemen, it is not my province to discuss fully the many 
 causes which may operate to bring about this great mortality among 
 our infant population. That is a point which can only be satisfactorily 
 elucidated by some combined action on your part, and I tru.st that 
 before this Conference terminates, some steps will be taken to bring 
 about such action, so that we may each succeeding year be in a better 
 position to grapple with this momentous question. I have not been 
 able to obtain any returns of deaths of children under five years, 
 occurring in England and Wales since 1884, but that year the pro- 
 portion per cent, of the total deaths was 23-04, as against 33-95 
 Queensland, 35 -87 Victoria, 48-59 South Australia. Surely some 
 special reasons must exist to account for this large mortality in Australia, 
 over that in England and Wales, other than that referred to 1 
 
 There are other subjects of scarcely less importance which, I trust, 
 will occupy the attention of this Section, such as the pi'evalence of 
 tyjihoid fever, diphtheria, phthisis, and the gradual increase in the 
 number of deaths from cancer. The first two being decidedly preventable 
 diseases, the numerous deaths from them year after year does not reflect 
 much credit on the sanitary condition of these colonies. It is amazing 
 to witness the stolid apathy of governments and local authorities, with 
 respect to the all-important matter of sanitation. So long as such 
 diseases as small-pox and cholera can be kept out by rigid quarantine, 
 little or no heed is taken of the unhealthy state of our cities and towns, 
 and of the numbers who perish annually from diseases which, under 
 proper hygienic conditions, would not exist. The constant cry of each 
 colony is for increase of population, and large sums are annually spent 
 by some of them to obtain such increase. But little or no care is taken, 
 by either governments or local authorities, to preserve the lives and 
 health of those already in the country, beyond enforcing arbitrary and 
 harsh quarantine regulations, and making the cities and towns reek with 
 foul-smelling so-called disinfectants, whenever a small-pox or cholera 
 scare arises. In the meantime, the jDeople are lulled into a state of 
 complacency, and congratulate themselves that their representatives, both 
 in parliament and the municipal councils have by quarantine and disinfect- 
 ants saved them from small-[)ox or cholera; but seem to think that ti/phoid 
 fever and diplitheria stalk unchecked amongst them by the special will of 
 Providence, and therefore ought not to be interfered with. Surely it is 
 high time that a little common sense in matters sanitary were infused
 
 president's address — SECTION OF MEDICINE. 45 
 
 into our governing bodies, and that the free expression of the views of 
 aspirants for political or municipal honors i'es])ecting such matters should 
 be required by the electors. Nature has done much for this country, 
 and in its climatic conditions has been especially bountiful, in providing 
 a sanitary measure of extreme importance, in the hot dry winds which 
 prevail at a season of the year when disease-spreading germs are most 
 active. These hot winds perform the duty of scavengers in an efl&cient 
 manner by drying up effete organic matter, and thereby doing away 
 with one of the conditions necessary to the development of pathogenic 
 organisms. But there is a limit even to Nature's beneficence, which, 
 when reached, may render man's carelessness disastrous in the extreme. 
 That innocuous micro-organisms may, under suitable conditions, develop 
 into disease-producing germs, is at least })robable, and it is also 
 probable that such organisms, capable of developing the specific virus of 
 cholera in all its virulency, may be constantly in our midst. How then 
 can we maintain our lurking foe harmless, but by strict intelligent 
 ap})lication of well-known sanitary facts 1 Dr. Buchanan sayr; that the 
 .sanitary arrangements of Great Britain are suflicient to stamj) out cholera 
 should it break out in that country ; are the sanitary arrangements of 
 Austi-alia capable of dealing with this fell disease in a similar manner. 
 
 ^lan is the sum of ever-changing conditions, both internally and 
 externally. His mind is formed by imjjressions conveyed to his brain 
 by the senses, and his intellectual development is caused by the circum- 
 stances of his surroundings. No one of God's creatures is so aflfected by 
 early influences or conditions ; and so great are those causes in making 
 or marring his mental attributes, that one is led to infer that man is 
 not a free agent, but merely the result of his surroundings. But 
 I would point out that no matter how sunk in ignorance and 
 crime a fellow-being may be, we should not condemn him absolutely, 
 but rather pity him for not having had those o^jportunities of 
 developing his mental and moral attributes, which would raise him above 
 his present condition of degradation. It is a very gratifying fact to 
 contemplate that the medical practitioner regards all suffering humanity 
 as fit objects for his sympathy and care, and bestows as much skill and 
 attention on the uncultivated savage as on the highly endowed intellectual 
 sample of modern civilisation. What calling can l)e nobler than that of 
 alleviating pain and sickness wherever found 1 and who can claim more 
 usefulness in doing good than the conscientious medical practitioner ? 
 
 In all countries, and under all conditions, the work of alleviating 
 human suffering is incessantly going on, and to those engaged in such 
 work all honour and praise are due. May we continue steadfast in our 
 efforts, and may we have the satisfaction of feeling, when our earthly 
 career terminates, that we have done our duty to our fellow man.
 
 46 INTERCOLONIAL MEDICAL CONGUESS OF AUSTKALASIA. 
 
 SOME NOTES ON DISEASE IN BRITISH 
 NEW GUINEA. 
 
 By Sir William McGregoe, M.D., K.C.M.G. 
 
 During the three months I have been in British New Guinea, so 
 many subjects of importance have come under consideration, that I 
 have beeu unable to devote much time to medical subjects ; but the 
 few rough notes below, incomplete and unpretentious as they are, 
 may be of some interest to those that study the distribution of 
 disease. 
 
 The first disease that came under my notice in British New Guinea 
 was : — 
 
 Tinea JDesquamans. — This malady, known in some places as Tokolau, 
 or Solomon Island Bingworm, was named tinea desquamans by 
 Dr. Turner, late of Samoa, who had ample opportunity of studying the 
 disease there. Many thousands of cases of this ringworm have come 
 under my observation, and I deem the name given to it by Dr. 
 Turner to be appropriate, and it is therefore used in these notes. My 
 first acquaintance with tinea, desquamans was made in Fiji, where the 
 disease was unknown until within recent yeai's. It came to Fiji, 
 however, with imported plantation labourers from two different 
 quarters, from the Line Islands, and from the Solomon Islands, and 
 the result is that the disease has become domesticated in that colony, 
 and been sown all over the New Hebrides, by laboui-ers, who have 
 caught it from fellow-labourers in Fiji, and taken it home with them. 
 Fiji is not to blame solely for this distribution of tinea desquamans, 
 as Solomon Islanders and natives of the New Hebrides have been 
 employed to work together on plantations in Samoa, Queensland, and 
 elsewhere. 
 
 It is my misfortune to have to witness the further distribution of 
 this loathsome malady in this part of the world. When I had been 
 a few days at Port Moresby, I noticed a man covered with this form 
 of ringworm, and on making inquiry, I was told he came from a 
 place on the coast about thirty miles to the eastward. It appeared 
 that there was only one case of the disease in a native of Port 
 Moresby, that the Port Moresby people knew it to be contagious, 
 but they were not afraid of it, as it had been long to the east of 
 them, and they had not got it. They assured me it had not got 
 to the west of them, and that it does not exist inland. 
 
 At a day's journey eastward of Port Moresby, there were three cases 
 in the village where we camped. During the second and third days' 
 journey in the same direction it gradually became more frequent, and 
 fift}' or sixty miles east of Port JMoresby, the disease is common, 
 affecting probably from a fourth to a half of the population. I have 
 not been on the portion of the mainland that lies between the east end 
 of the island and a point about seventy miles east of Port Morcsb}^, but 
 have seen that a veiy large })roportion, probably fifty per cent, of the 
 inhaltitants of the coast along the north-west end of the mainland, suffer 
 from it. It is not less common in the Louisiade and D'Entrecasteaux 
 groups of islands. The natives dislike the disease, but make no efforts,
 
 SOME XOTKS OX DISEASK IN" BlilTISH XKW firiXKA. 47 
 
 SO far as I have seen, to cure or control it. Tt is niucli to V)e feared 
 that it is only a question of time, when it will Ije distributed over the 
 whole of New Cruinea. At Port jMoresl>y, tinea <fei<'jvama7is is called 
 by the natives " hekopa," that is, "excoriated." From thirty to 
 seventy miles eastward, it is generally known as " lebo," "lebu," or 
 " lewe," or by some dialectic moditication of this name. On the east 
 end of New Guinea it is named "siprian)," or ".'lipoma," a name applied 
 to it, with local differences of pronunciation, all over the great islands of 
 the Louisiade and D'Entrecasteaux Groups. This name may probably 
 throw light on the introduction of the disease into the islands and 
 mainland of the Possession, as it is used whei^e many diverse languages 
 are spoken, and may therefore be supposed to* liave been introduced 
 along with the disease. The probability is that no efforts that can be 
 made will be sufficient to stop the further extension of this fell disease, 
 which disfigures a clotheless race, and renders the unfortunate 
 individual suftering from it very uncomfortable, besides entailing on 
 him at times a certain amount of social disqualification ; for example, 
 young women not affected by tinea desqiuonaxs sometimes refuse to 
 marry men sufiering from it. A few weeks ago, when inspecting the 
 island of Ferguson, my party explored a lai-ge bay, on which is a flat 
 several squai'e miles in ai'ea, containing hundreds, if not thousands, of 
 small fuming vents, from which volatilised sulphur is constantly arising, 
 depositing pure sublimed sulphur ; in the same locality are hot springs 
 giving off sulphurous vapours. Here then is a remedy close at hand 
 for the treatment of tinea desquamans, but to take advantage of this, 
 time, patience, and control over the natives is required, in order to get 
 them to bathe in the fumes and sidphur springs of Seymour Bay ; and 
 the chances are that those that will ever be cured there will be only 
 few in number, although there is ami)le material in the bay to 
 extinguish the disease all over the Possession. 
 
 Yaws constitute the first disease that one is likely to notice in 
 British New Guinea, in those places not yet invaded by tinea desqua- 
 mans.. This disease is indigenous in the Solomon Islands, the New 
 Hebrides, Samoa, Tonga, Fiji, aixl the islands adjacent. It was 
 unknown, however, to the Line Islanders, until they got infected by it 
 on plantations in countries employing foreign labourers among a native 
 jiopulation, where the disease is endemic. The natives of British New 
 Guinea say they have always had this disease, biit they think nothing 
 of it. It seems, in reality, to be of an extremely mild character here, 
 one rarely seeing any sore on those affected Ijy it, beyond the usual 
 ])athognomonic superficial ulceration at the corners of the mouth. So 
 mild is the disease, that in many large towns I have hardly noticed an 
 example of it at all, without close inspection. But here, as in other 
 countries, where the disease is endemic, all young children suffer from 
 it once ; but I am assured that it generally lasts only two or three 
 months, and creates in the majority of cases no constitutional 
 disturbance. Occasionally, however, according to native accounts, "the 
 disease goes inward, and then the child dies." I have heard of no 
 treatment being used for it by the natives, and they appear to be 
 indifferent as to whether their children contract it or not, and they do 
 not seem to think, as some other people do, that it is necessary to have 
 the disease once, in order to be healthy afterwards.
 
 48 IXTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Tinea circiiiata and chloasma are occasionally met with, but they are 
 not common. They are known by separate names in certain places, but 
 in other districts are not distinguished, and are called by the same 
 name. No treatment is used for either. 
 
 Itch, caused l)y the ordinary acarus scabiei, is not a common disease 
 among the natives here, in fact, I have seen only a very few doubtful 
 cases. Europeans suffer much in certain districts, however, from scrub 
 itch, which is a very irritating and annoying disease. 
 
 Leprosy in any form is rare. I have seen only about half a dozen 
 cases among all the natives I have as yet visited. The type of the 
 disease met with here seems to be very similar to that occurring in 
 Polynesia, which is mifd and chronic, compared to the malign tuberculai- 
 form I was accustomed to in the Seychelles Islands. 
 
 Elephantiasis is not more common than leprosy, only one severe case 
 having come under notice. It is certainly less common here than in 
 Polynesia, but the natives of the Possession are much more judicious 
 than Polynesians in selecting sites for their villages, which probably 
 has something to do with their comparative immunity from this 
 disease, and with their freedom from j^l^thisis i^^^i^ionalis, which 
 is certaiidy not of frequent occurrence, as I have met with only four 
 or five well marked cases. As a rule, the natives of those parts 
 of the Possession that I have seen build their houses on dry, stony, 
 narrow ridges, from which there is perfect drainage ; then the floor 
 of the house stands on posts never less than five feet high. The 
 houses built high up in trees, so often seen in photographs of New 
 Guinea scenery, are rarities, so exceptional that they need not be 
 taken into account in this connection ; Ijut the dwellinghouses, as 
 actually constructed, are admirably suited to avoid the evil effects of 
 damp sites, &c., in producing and developing chest disease. 
 
 Dysentery — that scourge of the tropics — I have not, as yet, met 
 with in New Guinea. Tliis disease I have long regarded as contagious, 
 and as being the greatest cause of mortality among the coloured 
 races I liave been brought into contact with, and I therefore 
 consider that we are very fortunate in })0ssessing here what seems 
 to be almost exemption from it. 
 
 Ophthalmia, of the contagious kind, common at several places in the 
 Pacific, I have not so far observed in New Guinea. It is quite rare 
 to meet a native here who has lost an eye from ophthalmia, or who 
 has a spot of leucoma on the cornea. In this connection, it might 
 be mentioned that there is little or no venereal disease among 
 the natives, a coincidence that goes some way to strengthen a suspicion 
 I have entertained that the contagious ophthalmia so common in Fiji, 
 for example, may have had gonorrhceal matter for its inception. 
 At all events, I have seen no case of gonorrhoea, and no case of severe 
 ophthalmia in New Guinea. Of course, with the recent influx of 
 Europeans, venereal disease will in all human probability have been 
 imported and communicated to natives. But 1 do not know how 
 this could be prevented. 
 
 Fever is the bug-bear of British New Guinea, but of this disease I 
 have fortunately seen so little that I am not in a position to speak of it. 
 The few cases I have seen have had the character of simple continued
 
 .IN KIl.AHIA. 49 
 
 fever, but attended witli luucli jn-ostnitioi), lieadacln', and iiTitid)ilitv of 
 the stoniacli. The natives do not a|i})car to suffer much from it, but 
 then they, as already })oint<Hl out, generally avoid l)uilding on low wet 
 ground, and seem to keep in their lionses at iiig^ht. 
 
 So far as I am able to judge, tin; natives of Xew Guinea are at present 
 a healthy race, and tiierc arc, with tlie exception of fever, no serious 
 diseases from which Europeans ai-e likely to suffer great inconvenience ; 
 but then it must be remembered that I have not as yet been in the 
 interior of the country, which would of course be )nuch more inteiestin," 
 ufround tliau tlie coast. 
 
 OX FILAKIA. 
 
 Uy Dr. Joseph Bancroft, Brisbane. 
 
 1 am asked by my good friend Professor Allen to contribute to the 
 liistory of tilaria and allied diseases of a parasitic nature in Australia, 
 and I ])ut my hand to paper feeling how imperfect the investigations 
 are, and how much is needed to be searched into, before the various 
 ])earings of blood-parasitism, as a cause of disease, can be in any small 
 degree understood. 
 
 It will be much easier to indicate the standing timber that may fall 
 as a Iiarvest to the inquiring student, than to expatiate on the limited 
 fields cleared by the ]>ioneers in this l)ranch of knowledge ; but sufficient 
 lias been done by Lewis and Cobbold, now retired to their rest, by 
 Manson and our .South American investigators, still struggling with a 
 difficult ])roblem, to encoui'age our youthful naturalists to work at the 
 subject of blood-parasitism, not merely as it afflicts the human race, but 
 in the wide tield of animal life, as there can be little doubt the more 
 extensively the work is prosecuted, the clearer will be our views as to 
 the measures necessary for human sanitation. 
 
 The sul)ject after a time becomes an interesting study, more fascinating, 
 if possible, than diatomes, and is intimately bound up with the welfare 
 of ourselves and onr animal friends. 
 
 Few things fill the mind with greater surprise than the discovery that 
 the heai-t of our faithful dog is so tilled with worms that his life cannot 
 be exjiected to last long. <3n examining a drop of blood of a dog, we 
 can ascertain by the presence of tilaria? whether such is the case ; and if 
 we find it necessary to sacrifice our servant, we shall discover in the 
 right side of the heart, and in the pulmonary artery, worms from four to 
 ten inches long, more or less, interfering with the circulation of the 
 blood, leading to dyspnoea, fatness and dropsy. 
 
 Filarise, whose embryos float in the blood, may in all cases require the 
 intervention of some blood-sucking creature to assist in their distribution, 
 mosquito, sand-fly, louse, or Hea, all of which will need to be examined. 
 
 With regard to the dog, the study of which is very convenient, as he 
 is always at hand, nuicli information has yet to be got. Some years 
 ago, I found the louse of the dog with its meal of Ijlood, and in the Ijlood 
 the emljryos of Filaria immitis. This information was connnunicated to 
 the Queckett ^Microscopic Club by Dr. Cobbold in February 1880. Dr. 
 
 B
 
 50 INTERCOLONIAL MEDICAL CONCiRESS OF AUSTRALASIA. 
 
 Prospero Sonsino, of Pisa, wliose researches on blood parasites in 
 E^ypt are so well known, in a recent letter reminds me of the com- 
 munication, and is anxious to gain any further information obtainable in 
 our country with regard to this iilaria. 
 
 The dipteron Stomoxys calcitrans also absorV>s with the dog's blood 
 the embryo worms. Of these, I once counted tifty-nine in one insect. 
 Tiie stomoxys-fly, distended with blood, it is not difficult to capture on 
 sunny walls. It may be distinguished from the common house-fly by 
 the set of its wings, more divergent })Osteriorly, and lying Avitli their 
 tins resting on the wall. When captured, the sharp penetrating beak 
 at once contii-ms its generic title. 
 
 These flies are a great annoyance to horses in summer, gorging 
 themselves with their blood, but I never found fllaria? taken up, except 
 in the instance referred to, and then T had seen the fly feed on the dog. 
 Dogs clean themselves of fleas and lice by biting, and so probably acquire 
 the parasite; they frequently also snap at flies. Feeding exj)eriments 
 with various insects, containing blood, are however wanting, to trace the 
 life history of the parasite; and from careful scrutiny, knowledge may be 
 gained that would be of the greatest help in understanding what is 
 wanted to arrive at the history of the human filaria. 
 
 The embryo of F. immitis has no sheath, and is niore active than the 
 embryo of F. sanguinis hominis. 
 
 In dissecting dogs known to have embryos in their )>lood, the ]>ortal 
 cii'cnlation should be searched, in case the jiarent worms, not being 
 found in the heart, are obstructed in their ]jrogress by the cajnllaries of 
 the liver. When F. immitis is extracted from the heart, and placed in 
 a vessel of blood or blood-serum, it writhes about with a slow motion, 
 and as the coils rise above the level of the li(|uid, they api)ear pure 
 white, as if greasy, A dead or injured worm rapidly becomes stained 
 red. The worms have much rigidit}- while alive, and at times cause 
 the death of their bearer, by rupture of the ventricle when hunting. 
 There is no history of the tilaria of the dog living in the human subject. 
 
 I have examined the blood of many dogs belonging to the aborigines 
 of this colony, but failed to find the parasite.* It has yet to be deter- 
 mined if the embryos of F. immitis observe the i)eriodicity in activity, 
 shown by Manson to obtain in F. sanguinis hominis. 
 
 In the sheaths of the tendons and burs.ie, about the knee joint of the 
 great kangaroo, theie are often ibiind worms as large as those in the 
 dog, but not of such rigid textux'e. They are easily seen when the 
 liind-quarters are skinned. The embryos of this worm never, so far as 
 I have examined, enter the blood-\'essels, but are plentiful in the 
 synovial secretions of the bursas inhabited. How the embryos are 
 transferred from their resting place is not known ; but I would expect 
 that the mosquito, probably the large grey sort, has the power of pene- 
 trating into the burste with its piercer. The ease with which the 
 nioscpiito penetrates oiir trousers when tigiit over the knee, would 
 indicate the possibility of this being the case, as the kangaroo sits with 
 the integuments tense over the knee joint. The })arasitic fly, that lives 
 among the hair of the kangaroo, may ^ilay some part in the life history 
 of this worm. None of the smaller species of kangaroo in this 
 neighbourhood have any worms near the knee. 
 
 * Since found in the blood of blackfcUows' dogs, June 1889.
 
 ox FILARIA. 51 
 
 I have often lieard it mentioned that fishes in some parts of 
 Anstralia have worms in their flesh, and that after cutting a fish 
 in pieces, and leaving them on a ])late all night, the worms may be 
 found crei)t out of the muscles in the morning. I have not seen 
 an instance of" this parasite, but am told that fresh-water fishes near 
 Melbourne are so ati'ected. >Some student at your University might 
 undertake the inquiry. 
 
 The resting place of the mature filaria in the human body is hard 
 to determine. It is found in the lymphatics of the arm ; there, dying 
 jirobably from bruises or the excessive muscular action of the 
 labourer, it forms an abscess, the structure involved becoming brawny 
 and tumid. liigors mostly occur. If the abscess is opened early, 
 the parasite may be percei\ed, more or less broken and undergoing 
 disintegration; the embryos, also dead, escaping from the ruptured 
 ovarian tubes. 
 
 The particulars of tlie discovery of the first parent filaria sanguinis 
 homini.s, were published in the Proceedings of the Pathological 
 Society of London, in Vol. 29, A.D. 1878, but as access to this work 
 is not easy, I will repeat briefly some of the cii'cumstances. 
 
 In this colony, the embryo worms in the blood were first 
 found in Ipswich by the late Dr. Thomas Powlands, by following 
 the researches of Lewis, of Calcutta. Dr. Jno. Mullen was the first 
 ])ractitioner to discover a case of chyluria in Brisbane. A case of 
 cjiyluria happened to l)e under my care when Dr. Rowlands informed 
 rae of the observations of Lewis. This was in December 1874. A 
 few days later I observed the parasite in my patient's blood. 
 Specimens in blood and in glycerine were sent to Dr. William Roberts 
 of Manchester, in 1874, and subsequently in 1875, with a request 
 to interest Dr. Cobbold in the inquiry. Dr. Cobl)old examined the 
 tubes of blood in May 1876, and published this .statement: — "There 
 cannot, I think, be much doubt as to the identity of all these 
 sexually immature nematoids." — See British Medical Journal, June 24, 
 187G. ' 
 
 I received this on September 28th, 1876. 
 
 Then there must be a parent worm to be found, but where '? 
 Reading up the history of filaria medinensis, of which I had no 
 practical acquaintance, it is recorded that Guinea-worms, when not 
 extracted with care, form abscesses. I had by this time found several 
 cases of filaria disease, and had gathered some record of those patients 
 sufiering from abscesses. I resolved therefore, on receipt of Dr. 
 Cobboki's communication, to carefully examine all abscesses my patients 
 might have. This I did, without finding anything until December 
 21, 1876, when I opened an abscess in the arm of a youth emi)loyed 
 as a butcher. I collected the matter as usual in a small vessel. As 
 a preliminary inquiry, the blood had to be inspected for embryonic fllarise. 
 This was the second case in which the blood contained the pai'asite 
 in question, but in the former the abscess, which was an old steatoma, 
 gave negative results. On examining the matter in the present case, 
 a thread-like body came in view. Under the microscope it was 
 without doubt a worm, and embryos were seen coming out of its 
 body. 
 
 E 2
 
 02 INTERCOLONIAL MEDICAL CONCJHESS OP AUSTRALASIA. 
 
 On March 21, the following year, I tapped a liydrocele, in an elderly 
 patient. M'ith a trochai- and canula combined, which I had raade by 
 McLennan, our siirgical instrument maker. On withdrawing, a lash of 
 hair-like bodies was caught in the eyes of the instrument. At once 
 suspecting their real nature, I ])ut them in the hydrocele fluid, when 
 they began to move about with great activity. Embryos in abundance 
 were found in the hydrocele fluid, and in the patient's blood. jNIy friend. 
 Dr. Mullen, I sent for to see the live worms. I kept them for over a 
 day, during which time they remained entangled. On immersing them 
 in pure water they ntretched out and became quiet, on restoring them to 
 the hydrocele fluid they recovered their activity. Uncoiling them in 
 fresh water occupied me over an hour. The specimens were now 
 transmitted to Dr. Cobbold, with a communication, which appeared in 
 the Lancet of July 14, 1877, ]). 70. 
 
 In the Lancet of September 29, 1877, Dr. Timothy Lewis records 
 dissecting an elephantoid tumour, lemoved by Dr. Gayer, on August 7 
 of the same year, from a young Bengalee in Calcutta, and after eight 
 hours' search discovering in a blood-clot the adult tilaria, thus verifying 
 my belief, previously published, that the tilaria would prove to be the 
 cause of such growths. 
 
 In the Lancet of October (5, 1877, Dr. Cobbold's drawings of the 
 parasites transmitted from Australia appeared, showing the sexual 
 organ of the female pai'asite. 
 
 jNIany adult fllariaj have since been found, but recently Dr. Pedro 
 S. de Magalhaes has kindly sent me an account of two parasites having 
 been found by Dr. Saboia in the right side of the heart of a boy who 
 died in the Hospital Misericordia of Bahia. The disease from which 
 the patient died is not mentioned. The worms are very ably figured, 
 after comparison with the drawings of Lewis and Cobbold ; one is a 
 female, the other a male, the latter having a spiral tail similar to that 
 of Filaria immitis. This is the first time the male parasite has been 
 described. Dr. Magalhaes also draws a peculiar band running along the 
 body of the female, an appeai-ance recorded in my lirst unpublished 
 drawings. I have also among them the sexual organ of the female, near 
 the head, the significance of which was not apparent to me when the 
 drawing was first made. I have to thank Mr. Birkbeck of the Railway 
 department for aid in translating the Portugese — Gaidci Medica da 
 Bahia, No. 3 de Setembro de 1886; also jiaper on the same by the 
 Faculty of Medicine of Eio de Janeiro, No. 3, 1886. 
 
 The ])athological conditions produced in the human subject by filariaj 
 are numerous. The movements of the embryos in the blood do not 
 appear to inflict injuiy. Dr. Manson has studied this subject with great 
 care, and showed the further development of the embryos in the 
 intestines of mosquitos — see Linnccan Societijs Transactions, March 
 1884, and in previous i)apers in 1877 and 1878 — also the greater 
 activity of the embryos in the evening. 
 
 Dr. W. W. Myers, of Shanghai, shows that the normal evening rise 
 of temperature of the human body may account for the greater activity 
 of the nematoids. How the parasite })asses from the mosquito to the 
 human subject lias not been satisfactorily traced, though it is likely that 
 it is drunk in water.
 
 ON FILAHIA. 53 
 
 The fact that few cases of youth suffering frou\ fihxria in Brisbane are 
 now to be found, seems to show that the city water suj^dy is purer 
 than tlie well and tank water foruiei-ly used. The new cases presenting 
 themselves in Brisl>ane are from country towns, where there is no public 
 supply of drinking-water. 
 
 The adult jiarasite probably, by its presence in the lymphatics, blocLs 
 them up, either by its own bulk, or by the inflammation it may cause. 
 If located in the heart and blood-vessels, as in the Bahia case, 
 thrond)Osis and embolism may happen. Little information is to hand 
 on this point. When the parasites live in a hydrocele, no harm can 
 follow. i\Iy i>atient, whose hydrocele contained four worms, was not 
 free from embryos in his blood for years after, showing that all the 
 adult worms weie not removed from his body. 8ui>pose the parent 
 worms are in the structures of the arm, a common occurrence, the 
 disease manifests itself, and is recognisable, by rigois and abscesses. 
 Cases that sutlVred in this way are now in fair health, others are weakly, 
 but able to work with feeble circulation. 
 
 Elephantoid growths and limbs do not develope in Brisbane. It is 
 not easy to account for this. People are better fed here than in India, 
 and the climate may be more salubiious. One patient here has intense 
 scleroderma of the head, arms, and upper part of the body ; but now, 
 after some years, the skin is becoming softer, and embryos are no longer 
 to be found in the blood. How could the lymphatics be blocked with 
 adult parasites, so as to cause this hardness of the integuments of the 
 head and shoulders? 
 
 Chyluria and elastic tumours in the groin are associated. When the 
 tumours are evacuated, an operation not easy of execution, as the sac is 
 very difficult to pierce by tiochar, they yield chyle, containing a very 
 small amoinit of blood, which deposits itself in the bottom of the 
 receiver after some hours. The blood is very bright, and seems to differ 
 from ordinary blood. May it be blood in a state of development? 
 Wlien urine becomes chylous, the elastic tumours, if present, lose their 
 tension. These elastic chyle-sacs, emptied of their contents and injected 
 with iodine, will solidify and close up. It is rather a perilous operation, 
 as the sac is partly intra-abdominal, and there is danger of peritonitis. 
 A patient, cured of these tumours by injection, afterwards suffered from 
 chyluria. A better course is to use a double truss, with concave pads. 
 A case so treated is now cured, and no embryos ha^'e been seen in the 
 blood for two years. 
 
 Chyluria is sometimes so severe as to threaten death from exhaustion. 
 A chyluric patient was confined of a living child, the chyle and blood 
 discharged from the bladder was in great abundance. She became so 
 weak as to faint on the head being raised. Hiemostatic remedies did 
 no good. A fatal issue being antici})ated, I injected the bladder with 
 tartrate of iron and port wine. After two injections, the discharge 
 ceased and the patient recovered. 
 
 Lymph vesicle on the skin of the leg or scrotum seems related to 
 chyluria. The lymjih discharge is intermittent, so is the chyluria. At 
 times it is scarcely possible to tind the minute aperture on the scrotum 
 which discharges the lymph. From this I had one patient die, with 
 ('pistaxis and frequently recurring rigors. It seems to me that in chyluria
 
 54 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 the aperture which gives out the chyle is a lymph vesicle on the walls of 
 the bladder. It would be difficult to verify this conclusion, even post 
 mortem, and the presence of parent worms among the pelvic lym})hatics 
 would be hard to find. 
 
 At the Medical Schools of India it ought to be possible to obtain 
 bodies of patients, known to suffer from tilaria diseases, for their dissect- 
 ing rooms. Preparations, showing the enlargements and varicosities of 
 the lymphatic system, could thus be made, tracing to their true cause; 
 these abnormal conditions. 
 
 BERI-BERI AS SEEN IN THE NORTHERN TERRITORY 
 OF SOUTH AUSTRALIA. 
 
 By Dr. Percy Moore Wood, Palmerston, Northern Territory. 
 
 As I have reason to think that this is probably the first time that 
 attention has been drawn to this disease in Australia, by one who can 
 speak from personal observation, I trust this short j)a})er may not be 
 without interest to you. 
 
 Owing to the great difficulties under which I have laboured, such as 
 visiting the patients in miserable huts, the patients l)eing oft-times 
 very ])Oor, and nearly always destitute of any knowledge of English, 
 the interpreters too being often grossly inaccurate ; the distance from 
 medical centres of knowledge being so great as to preclude the chance 
 of keeping up with the latest investigations of this disease ; the 
 insufficiency of ward space in the local hospital, preventing me from 
 taking in any but the very severe cases ; and finally, the rapid 
 decomposition that takes place in this climate, preventing any satis- 
 factory microscopical work by a bus}' man ; I am aware tliat what I 
 write may, in a measure, lack the seientilic value it would have had 
 if circumstances had been different. 
 
 The authorities that I have with me are Dr. Maclean, on '• Tropical 
 Diseases;" Sir Joseph Fayrer, on " Beri-Beri " in '• Ouain's Dictionary 
 of Medicine ;" and Dr. Broadbent's edition of Dr. Tanner's " Medicine,'' 
 a short account of this disease from the ])en of Dr. Aitken. 
 
 History of the Disease. 
 
 I have reason to think that it was during the years 1870 and 188() 
 that this disease first became endemic in the Territory, as, on referring 
 to the death register book, 1 notice that a great many deaths were 
 during that period registered under the headings of dropsy and paralysis. 
 These deaths all occurred among the Chinese, who were young men. 
 generally under thirty years of age, and never seen by a medical man, 
 but the record of death was simply given to the Registrar officially by a 
 trooper. The place where these deaths chief!}' occurred was Pine Creek, 
 but some apparently took i)laoe at Palmerston. This o[)iniori is 
 strengthened by the fact that I have shown some of my patients to 
 Europeans, who were resident in this country during 1879 and 1880,
 
 BtKI-niCHI AS ,S1:KN in THK XOHTIIERN TEinUTORY, i)i) 
 
 and they think that the cases look siniikir ; but what apjtears to strike 
 them most is the way that the convalescents at both outbreaks walk. 
 
 About two years ago, there was a small but fatal outbreak of this disease 
 in the gaol here, among the aboriginals. Seven were attacked, three 
 severely. Of these, two died ; the re.st recovered. The reason I mention 
 this occurrence is, that a few weeks before, the aborigines had been 
 placed on Chinese diet, which means rice instead of bi-ead, and half the 
 quantity of fresh meat, and during that time there was a scarcity of 
 fresh potatoes. The Chinese did not sutler at this time, and in fact 
 throve very well on the diet allowed them in the gaol. I could find no 
 other cause but the change of diet, so replaced them on the Eui'opean 
 scale, and as soon as ])ossible gave them fresh English ))otatoes, and they 
 were soon in good health again. 
 
 There is another circumstance, which occurred during the years 1879 
 and 1880, and this year, namely, malarial fever was very prevalent, and 
 several deaths were returned during the former yeai'S from that cause. 
 
 This year, hort-ever, no death has been returned from among the 
 Eui'opeans from this cause, but a few undoubted cases have been found 
 among the Chinese, owing, I think, to the fact that they have not come 
 under treatment early enough ; but here we must not forget one thing, 
 namely, that Euroiieans badly attacked with malarial fever generally 
 leave the Territory. 
 
 During my residence up here, I have had one fatal case of pernicious 
 anosmia in a European, vet. 4-6, who died in, the hospital during August 
 1887. I should not have mentioned this case, had I not noticed that Sir 
 Joseph Fayrer, in '• Quaiu's Dictionary of ^ledicine," page 106, on 13eri- 
 Beri, writes: " Possibly, iiernicious ant>3mia in Europe is the same disease."' 
 The notes of this case do not resendjle in any way beri-beri ; it simply 
 ran the course that cases do in England. 
 
 From what I have so far seen of this disease, it well retains its 
 character of being a very fatal one. I have had under treatment about 
 forty cases, and twelve deaths have been recorded ; but I have good 
 reason to believe that about tifty more deaths have occurred. What 
 percentage of deaths this really gives, I don't know, as I am unable to 
 say whether they kept among themselves cases that eventually recovered ; 
 a few I feel certain were so kej)t, but how many I cannot learn : I rather 
 think that probably the majority of the subacute cases came under my 
 notice, owing to the fact that as the local hospital was unable to receive 
 them. Dr. Stow, the Medical Officer in charge of the railway works, 
 supplied them with food and medicines at their own homes, and this 
 made them very ready to apply for assistance. It is with pleasure that 
 .1 may here report, that no cases of Beri-Beri have so far occurred among 
 the Europeans resident in the territory. 
 
 Causes. 
 
 According to authorities, I suppose I should commence with 
 (1) Malarial climate ; (2) Tropical tem])erature ; (3) Propinquity to the 
 sea ; (-i) Wet season ; (-o) Bad feeding. 
 
 (1) What the first cause may be, primarily, I cannot say. I 
 suppose, malarial fever being veiy jjrevalent in China, a great many of 
 the Chinese have ])robably suffered from it; but it is not necessary 
 to be in a malarial climate to have Beri-Beri, as is jiroxed by tlie fact,
 
 56 IXTERCOLOXIAL MEDICAL CON'GRESS OF AUSTRALASIA. 
 
 that Chinese crews, sent to Iv'ewcastle-on-Tyne to Ijring out Chinese 
 men-of-war, there developed an outhre:ik of this Bevi-Beri among 
 tliem. (A short accoiint of this outbreak is, I lielieve, to be found in 
 Braithwaite's " Retrospect of Medicine " for either last year or the 
 preceding year.) Moreover, in nearly all the cases that were under my 
 observation, there was no previous history of malarial fever. 
 
 (2) Ti'Opiccd Temperature. — Though this disease has generally been 
 known only in the troi^cs, the outbreak of it at Newcastle-on-Tyue 
 shows that it is not absolutely confined within these limits. 
 
 (3) According to Dr. Maclean, this disease is most prevalent near the 
 sea, generally within 50 or 6(1 miles. The cases that I have personally 
 noticed have never been less than 7o miles, some 05 : and, if I am right 
 as regards the cases in 1879 and 1880, they chiefly occurred at 145 
 miles from the sea, and at an elevation of about 700 feet above low 
 water level. 
 
 (4) Wet Season, — Undoubtedly tlie majority of my cases were deve- 
 loped towaixls the end of the wet season, but I have just seen a case, 
 and a very severe and well-marked one, that has been recently deve- 
 loped, and no rain has fallen for the last five montlis. 
 
 (5) Bad Feedinr/. — In all cases that I have had under my care, the 
 patients give the same answer to the question — What has been your 
 diet? Answer — Rice and salt fish. In one case, that had nearly 
 recovered, the answer was — Rice and salt eggs. In every case there 
 was a marked want of fresh meat and vegetables. 
 
 That the majority of cases occurred during the latter part of the wet 
 season was due, as far as I could make out, not to excessive exposure 
 to the wet, but to the fact that the wet made the roads impassable, 
 so that fresh supplies could not easily be brought ; and this was 
 important because, where these camps were, during that time, the 
 country immediately around was not able to sujiply the number that 
 required fresh food. 
 
 It was also a noticeable fact that all the jiatients (with three excep- 
 tions) had only been in the Territory from twelve to eighteen months, 
 and all were young men under thirty years of age, many under twenty 
 years, obviously those most likely to come off" badly in bargaining for 
 articles of diet, not knowing the al)solute necessity for obtaining them. 
 
 In conclusion, as to cau.se of disease, I cannot help thinking that, 
 for want of a better term, it is a scorbutic condition in a rice-eating race, 
 probably influenced by a tendency to nialaria : — 
 
 (1) High temperature is not required, as the outbreak at Newcastle- 
 on-Tyne proved. 
 
 (2) All cases, as will be seen further on, had a large si)leen, though 
 certainly not what I call a malaria one. 
 
 (."5) I think cases occurring 150 miles from the sea, can hardly be 
 considered as due to coast influences. 
 
 (4) The wet season, I have shown, is not necessary to jiroduce it. 
 
 (5) As 1 have shown, all cases that I have had jiersonally to do 
 with, have been fed badly. I have reason to understand, that the 
 outbreak at Pine Creek was chiefly amongst new comers, who were 
 badly paid, and ill-fed ; and I have previously shown how disastrous
 
 rsEni-HKin as skkx in 'iiik \oin iii;i;\ Ti:i;i!iroHV. ;>( 
 
 the rice diet was, ai»i)ai'ently, witli the aborigiues of Australia in the 
 fjaol here, and how heueficial was the cliango to the Kiir(»j)eaii scale. 
 
 Though I have called it a scorbutic affection, I have to admit that I 
 have never seen spongy gums, il-c. ; hut there is one constant symptom, 
 namely, pain in the muscles, and chiefly in those of the Ciilves ; l)ut 
 they do not hecome hrawny and hard from the deposition of any 
 infiaiiimatory material. 
 
 Symptoms. 
 
 Tliese occur in two forms, acute and sub-acute ; Init, as in all diseases, 
 the}- frequently pass into each other ; the acute, [)erhaps, easily becoming 
 subacute ; the sub-acute more frequently becoming acute. 
 
 Aa'tc. — Patient feels ill, and couqilains of great heat in his epigastric 
 region ; he seems to rapidly lose the use of his legs, so that he cannot 
 stand (l>ut can move them moi-e freely in bed), and he complains of 
 intense pain in their muscles, which, on account of the want of tonicity, 
 appear a-dematous. He rapidly becomes very Ijreathless, cardiac action 
 being very quick, and tiiere is always a soft bruit, which appears to be 
 more h^emic than anything else. The legs then become tedematous, and, 
 in fact, general anasarca ra|)idly counnences, which ajjpears to cause 
 acute pain, especially in the lumbar region (lumbar cushion frequently 
 well developed), and if the patient lives more than a few days, he has 
 the appearance of having acute Blight's disease ; but I have never seen 
 the scrotum swollen. He becomes very restless, the face assumes a very 
 anxious expression, the tongue becomes brownish-black, sordes collects 
 about the teeth and li[)S. Eespirations become quicker and shallower ; 
 cardiac action is so rapid, that the pulse cannot be coinited. He 
 assumes the sitting ]>osture, keeps moaning, and dies suddenly, some- 
 times crying out, as if in intense pain, Init he remains sensible almost 
 to the last, and frequently will take liquid food up to the same period. 
 In one acute case (fatal), marked jaundice existeil. I have never found 
 eithei- albumen or blood in the urine ; nor is thei^e any great (if any) 
 diminution in the quantity; sp. gr. generally about 1020. There is 
 generally no great jiyrexia ; tenqierattu'e frequently only about 99\ 
 tSome cases only last about 4S hours ; one case only lasted 26 hours. 
 
 Post-mortem examinations show generally the blood to be in a very 
 watery condition, and with a strong tendency not to coagulate, 
 especially in Aery acute cases. The nniscles are pale, and look sodden 
 with a yellowish serous fluid ; sonietimes this colour is very marked. 
 Lungs extremely cedematous, and generally a small quantity of Huid 
 in the pleural sacs. Pericardium. — -This sac I have seen distended 
 with Huid, but in the majority this was not the case. Muscular tissue 
 of the heart, pale and flal)l)y. There were ali''a>/s ante-mortem clots, 
 sometimes very large, extending into the blood-vessels which pass from 
 this organ. The other blood was dark, and had generally a granular 
 look, with a treacly con.sistenc}-. In only one case did I find valvular 
 mischief, and that was mitral. This appeared to be old standing, and 
 was from the body of a Tamil, the only one of his race that suffered 
 out of l."iO working on the line. I attribute the fact of his suffering 
 from tills disease indirectly to his cardiac affection. As he was not 
 conqietent to do his work, he became badly j)aid, hence badly fed. 
 Chinese have a great antipathy to post-mortem examinations, especially
 
 58 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 if tlie head is opened, so I had iu many cases to respect this feeling ; 
 but in the cases in whioli the head was opened tliere was alwaj's a 
 marked increase of cerebro-spinal fluid. Brain otherwise healthy ; cord 
 not examined. Abdomen. — Liver generally healthy and firm. Spleen 
 considerably enlarged, soft, and of a kind of maroon colour. Kidneys 
 large and cedematous, otheiwise healthy looking, and capsule easy to 
 remove. Su]n-a-renal capsules, when found, healthy. There was also a 
 collection of serous fluid in the peritoneal cavity, but not very excessive. 
 
 Sub-acute Symptoms. 
 
 Patient feels pain in the ej)igastric region, with a sensation of heat, 
 rapid cardiac action, which evidently is the cause of great anxiety to 
 him ; muscular pain in the legs, which rapidly lose their power, so that 
 in a few days the patients are quite incapable of standing. The extensor 
 muscles seem first afl'ected, then the abductor and adductors. This 
 muscular pain is intense, so that they shrink when you ])UC your hand 
 near ihem ; but the skin does not seem tender, and at first, there is no 
 want of sensation. The legs seem cedematous, but only, as in the acute 
 cases, from the want of tone in the muscles. The muscles of the arms 
 may become affected, and assume the appearance of wx'istdrop, with verv 
 little power in the flexor tendons. In one case, the vocal cords became 
 affected, and the voice rendered falsetto. 
 
 I have never seen complete paralysis in the extremities ; all cases have 
 been able to move theiu in a limited degree, and T think that the psoas 
 and iliacus have never been paralysed, as I also think that the deltoids 
 do not become so. 
 
 The legs become ffiJematous after about 10 days, and then the skin 
 appears to become numl). I have never seen the ui)per extremities iu 
 that condition, unless the case is assuming the acute form. If the ])atient 
 is going to get well, he may remain in this helpless condition for some 
 time ; and if he sits up, in the Chinese fashion, which is squatting, or 
 rather squatting fashion, for he sits on his haunches, his legs ])ulled up 
 towards his abdomen, the legs beconie intensely cedematous. They may 
 then gradually improve ; the arms move first, then the legs ; the extensor 
 muscles seem the first to recover. While so ])aralysed, there appears to be 
 no electro-contractility, either to the continuous or interrupted currents. 
 
 When they are first able to stand, their attitude is very characteristic. 
 They all appear to feel that the knee-joint will give way backwards, and 
 appear to want support in their popliteal space. When commencing to 
 walk, they use a stick, and gi-asi)ing it with both hands, lean forward, 
 drawing their legs after ihem, keeping the knee stiff". The improvement 
 is slow, and generally three to four months elapse before they can walk 
 well. 
 
 When these sub-acute cases are fatal, they die in the same way as the 
 acute cases ; in fact, they ;ip))ear to develope acute symptoms, and they 
 may do this some weeks after ti'ey appear to be doing well, but why, T 
 cannot explain. I have sometimes thought that this, again, is due to 
 want of food, not because the i)atient had not got it, but because, being 
 sick for so long, unless he had plenty of cousins, etc., it was difficult to 
 get people to cook for them, and I fear that, even when they were getting 
 it cooked, they were ])aying for it, by giving away a ])art of their food. 
 I have never been able to jnake a post-mortem in\estigation of one of
 
 DISEASES OF POLYXESIAXS, AS SEEN IX QUEENSLAND. 59 
 
 these cases. The muscles waste enormously in this class of cases; but 
 I am unable to say how long it is Ijefore tiiey are able to return to work, 
 because they generally go back to China. 
 
 Prognosis. 
 
 This is, as far as I have seen, very unfavourable. I have never known 
 a ]iatient recover, when breathlessness set in, either eai'ly or after 
 a few weeks' treatment. The i)atient then generally dies within tifty- 
 six hours. 
 
 Treatment. 
 
 This being a disease of (for want of a better term) a scorbutic nature, 
 fresh vegetables, especially English potatoes, and fresh meat are abso- 
 lutely necessary. 
 
 As regards drugs, my colleagues, Drs. Bei'ill and Stow, and myself 
 have learnt to place great confidence in one, namely, digitalis. This 
 drug, combined with iron, we have found very beneficial, and if this 
 con)bination produces too much constipation, we combine it with 
 ammonia and cinchona. The patients find the benefit of the digitalis, 
 and frequently notice its absence if omitted by saying, " This medicine 
 not all the same as the last; this one no good." How it acts I do not 
 know, but I think its value is primarily due to its controlling power 
 over the heart, and then, jjcrhaps, to its action as a diuretic. 
 
 This paper is written with the full knowledge of my colleagues, and 
 if digitalis is found to be of any service elsewhere, the credit is due to 
 the observations of Dr. Berill, as he first gave it. I am further in- 
 debted to Dr. Berill for the great assistance he gave me in making the 
 post-mortem examinations, as he frequently made them uuder veiy 
 trying circumstances. 
 
 DISEASES OF POLYNESIANS, AS SEEX IN QUEENSLAND. 
 By F. BowE. M.B., Maryborough, Queensland. 
 
 In this paper, I shall endeavour to draw your attention to a few 
 points, in which diseases in Polynesians differ from the usual type. 
 
 In the first i)lace, disease is not accompanied by the usual amount of 
 pain and distress. For instance, one day I was surprised to see a boy 
 with j)neumonia of the right apex, with a tenqierature of 105°, sitting 
 by the tire in a ward, smoking a ])ipe ; and altliough this is an extreme 
 instance, yet, in the early stage of [)neumonia, few would remain in bed, 
 unless ordered to do so ; they would sit by the fire in cold weather, and 
 on the verandah, or in the i)addock, in warm. Yet, the type of the 
 disease, taking the tenqierature as a guide, is quite as acute as in 
 European races. In phthisis, too, the cough does not seem to distress 
 them much, and they generally manage to get about until within three 
 or four days of their death. In dysentery, you seldom see an expression 
 of pain on their features, although this is a most painful complaint. 
 This insensibility to pain must not be attributed to stoicism, as their
 
 GO INTEHCOLOXIAL MEDICAL CONCiRKSS OF AUSTRALASIA. 
 
 disiiosition is anything but tliat. Tliej strongly oV)ject to the pain of 
 H mustard plaster, and the sight of a lancet causes great disma}-, and an 
 incision is generally accompanied by a cry. These latter facts are not 
 what you would naturally expect — ^incisions of the skin by means of a 
 piece of glass form one of their native methods of treatment, and my 
 patients often arrive at the hosi>ital with a number of cuts, very like 
 those made by a cupping instrument, over the forehead, breast, or side, 
 wherever they have been experiencing ]>ain ; and when being tattooed 
 with a couple of pins tied on to the end of a stick, and some blacking, 
 they appear perfectly comfortable. I may mention, although this is not 
 now-a-days considered a surgical operation, that they can shave very 
 well indeed with a piece of broken glass. 
 
 As an instance of their great objection to any incision, I have seen a 
 man with whitlow die from pysemia. When I first saw him, he had an 
 ordinary whitlow of a foretinger ; he refused to have it incised, and went 
 away. He came again a week afterwards, when the back of his hand 
 had become very much swollen, but still refused either an incision, or to 
 come into hospital. He was finally admitted, aV)out ten days afterwards, 
 in a sinking condition, and died in a couple of days. At the post- 
 mortem, I found that the pus had burrowed nearly as high as the elbow, 
 and there were pysemic abscesses in the kidneys and lungs. They 
 generally neglect their whitlows, and I have had to amputate a finger 
 or a thumb on several occasions for it. 
 
 Another thing you notice, is the way in which these boys are able to 
 retain their appetite for solid food. Patients with high temperatures, 
 and when sutlering from acute disease, will dispose of their ration of 
 beef (fib., including bone, really i lb.), and a piound of bread. 
 Tuberculous patients retain their appetite a long time, and wben it 
 fails, they can still manage to eat potatoes, which they often appear to 
 consider a luxury. One might argue that a liking for milk is an 
 educated taste, from the fact that Polynesians, on their arrival in the 
 colony, Jiave all a very strong dislike to it ; and when it has been 
 essential tliat they shoidd take it, as in dysentery, I ha\"e occasionally 
 been obliged to give them a few doses of it by the nares. After that, 
 they generally make up their minds to take it. Those who have been 
 in the colony some time, do not apj)ear to have any objection to it. 
 
 The only disea.se, from which they suffer more distress than white 
 men, is influenza. In this they always complain a great deal of head- 
 ache, for which they often cut themselves, as I mentioned above, and at 
 the beginning of the attack it often ati'ects the lungs very much. There 
 is a great deal of dyspnoea, with rhonchus and n'des, and a high tempera- 
 ture, 103" or 104:° F., and when they are attacked at their work in the 
 field-', I am told that they are often seen gasping for breath, and then 
 they throw themselves down, saying that they are "close up dead" 
 (that is, nearly deail). They generally recover speedily, and I have 
 never seen a death from the complaint. 
 
 A very striking peculiarity is the occurrence of mania in connection 
 with }meumonia. It most frequently comes on a few days after the 
 commencement of the disease, and it might be regarded as replacing 
 delirium, but against this view it is to be noted that it lasts generally 
 three or four days after the temperature has subsided, and when you 
 would expect any delirium to have disappeared. In a few instances I
 
 DISKASKS OF I'OI.VNKSIANS, AS SKKN IN tJUEKNSL.ANU. t>] 
 
 have noticed tljat it lias made its aj^pearance after the ac-ute stage of tlio 
 pneumonia was over. The mania is sometimes accompanied by a good 
 deal of violence, and occasionally the ])atient will clutch the iron bars 
 which guard the windows of the strong-room, and shake them like a 
 wild animal trying to escape. It does not ap[)ear to be moie frequent 
 with pneuuionia of the a})ex than of the base, which is not what you 
 would naturally <!X))ect. Both ))neumonia and pleurisy frequently 
 resolve veiy imperfectly, and are often followed by tuberculosis, pai- 
 ticularly in the younger islanders. 
 
 Syphilis is seen almost exclusively as a local disease — a species of 
 chancroid. T have only once seen secondaiy synq)toms show them- 
 .selves, and that was a case of syphilitic roseola. In none of my patients 
 have ulcerated throat, or squamous syphilides, made their appearance ; 
 yet I hrndy believe that this chancroid does affect the system, as the 
 child of a diseased couple soon after its birth develojjed secondary 
 symptoms, snutHes, and a rash about the Imttocks. It improved for a 
 time, l)ut lelajjsed and died. Neither of its parents had had a sign of 
 secondary s3'nq)toms, and their sores had healed uj) under local treat- 
 ment, without any appearances that would suggest that they differed in 
 any way from the sores of ordinary ])atients. The same ^vas the case 
 with the woman who had roseola ; her sores differed in no respect from 
 the ordinary characters. The sore diHei's from the English soft so)-e, if 
 I may so call it, in not having the punched-out appearance oi- a clearly 
 defined border; it begins as a ])inqile, with a couple of drops of pus at 
 the top. Sometimes it is much larger and looks like a boil, but this is 
 chiefly seen in a secondary sore, which forms on the dorsum of the 
 jjenis. The skin breaks, the fluid escapes, and the sore begins to sprout, 
 throwing out weak flabljy granulations sj)reading at the margins. The 
 .situation of the first sore is generally either on the prej)uce or about the 
 fraenum. In intractable cases, the original sore either does not heal at 
 all, or heals very slowly ; and a .second one makes its appearance on the 
 dorsum of the jienis, throws out the same kind of granulations, and 
 assumes the charactei'S of the oiiginal sore. 
 
 The glands in the groin are next att'ected. These sometimes sui)purate, 
 without becoming sores, and after discharging for a time, they heal up. 
 In another case, in a woman, they became caseous, and kept discharging 
 through one or two sinuses, long after the original sores had healed. In 
 this case, I cut down on the glands, removed them, and cut away all the 
 unhealthy granulating tissue, and the woman made a good recovery. In 
 other instances, the skin over the glands breaks, granulations spring uj), 
 and the patient has got two more chancres. These often spread, 
 particularly downwards, in the direction of the perina^um. In the 
 worst cases, fresh places begin, and keep increasing in size ; the earlier 
 sores, I said, began by appearing as papules, or pimples, the size of a 
 small boil. In the later stages, swellings appear over the lower ^^art of 
 the abdomen, as large as a small orange, which ulcerate, and form large 
 •sores, giving rise to a disgusting discharge, and the condition of the 
 patient is miserable in the extreme. One islander, who came into 
 hospital in this advanced stage of the disease, asked if he might be 
 allowed to hang himself, and I believe he would have been glad to have 
 done so, if he had had the 0])portunity. In a woman, who had been 
 rejected by the inspecting medical officer on board one of the labour
 
 62 INTEUCOLOXIAL MEDICAL COXGKESS OF AUSTHALASIA. 
 
 vessels, the disease had destroyed the perinseuin and septum between the 
 vagina and rectum. 
 
 In the treatment of these cases, I think that mercurials and iodide of 
 potash do positive harm; they debilitate the patients, without exercising 
 any influence for good over the sore. The only internal medicines that 
 appear to do them good are tonics, iron and quinine, Arc, and these only 
 when the patient is weak. The local treatment, that I have found most 
 efficacious, is cauterising the sore once a week with strong nitric acid, 
 and if there are many granulations, using sulphate of copper as well, 
 and then ap})lying either iodoform or calomel, and zinc or tannin 
 lotion. Sometimes one application does good, sometimes another. 
 AVhen the sore has been situated on the prepuce, I have several times 
 performed circumcision, and with good results, the wound showing no 
 tendency to become infected, and indeed, in one instance, where there 
 was a considerable amount of ulceration, and in which it was necessary 
 to remove the prepuce, on account of phimosis, the incision terminated 
 in one of the chancres, and yet the wound healed, without Ijecoming 
 infected, and the greater ])art of it by first intention. 
 
 Wlien commencing the treatment of a patient, I can never tell whether 
 lie will get well or not. Some of apparently the worst cases ha\e got 
 well. One boy bad a large ulcerated sore in each groin ; another boy 
 had a large horseshoe-shaped sore, extending along the pubes, from one 
 groin to the other; both of these got well in time. In other cases, 
 where there has only been a small sore on the penis, the patient has 
 steadily gone to the bad, "the sore refusing to heal up, and fresh ones 
 breaking out. 
 
 It is noteworthy that the scars, in Polynesians who have had sy]ihilis, 
 are very aj>t to break out again, when the health breaks down from any 
 cause ; for instance, from tuberculosis. 
 
 With regard to tertiary .syphilis, I have seen a couple of cases of 
 syphilitic ulceration, or what I took to be such. They had all the usual 
 characters of the affection, but presented no scar, and denied ever having 
 luul a sore, but there may have been an inherited taint. They healed 
 quickly under treatment; bnt I now regiet that I did not try whether 
 they would have done so under strictly local treatment, before combining 
 it with constitutional remedies. 
 
 A fatty degeneration of the kidneys is present in nearly everv instance 
 in which I have made a post-mortem ; in fact, it is quite exceptional to 
 see a healthy kidney in a Polynesian, and this is frequently accompanied 
 l)y fatty disease of liver, but the latter is not so general nor so extensive 
 as that of the kidneys. I believe that fatty degeneration of the kidneys 
 is not usually accompanied by the changes comprised under the term 
 contracted kidney, but in Polynesians this is always the case, more or less ; 
 the size and weight of the kidney is diminished, varying from 3| ounces 
 to less than 3 ounces (the ordinary weight of kidney being 4^ ounces). 
 The capsule is adherent in places, tearing the substance of the organ 
 when detached ; in other patches, it is comparatively free ; the surface of 
 the kidney is mottled with stellate veins, and is often partially divided 
 into lobes by the contracted portions ; it is seldom, or never, granular 
 in appearance. On section, the cortical portion is generally diminished 
 in thickness to some extent, whitish or yellowish in colour, and the 
 jiyramids healthy in appearance, but not always so. C)n microscopic
 
 
 m^ 
 
 NECROSIS OF FINGERS AND TOES 
 (Dr. Bowe's Paper.)
 
 DISKASKS OF POLWKSIAXS, AS SKKV IN (^l lOKNsLANh. G3 
 
 section, the epithelium is seen to contain fatty granule?, and there 
 is a distinct increase in the connective tissue between the tubules, 
 the meshes of which contain a number of small round cells — in short, 
 the appearances of fatty degeneration, plus interstitial nephritis. 
 
 The existence of this kidney disease, however, does not ai)pear to 
 give vise to any symptoms, or to interfere with the general health. 
 There is no anasarca, frecpiency of micturition, nor albuminuria ; but I 
 have often thought that -its existence might be an explanation of the 
 low-resisting power these Islanders possess against some diseases, 
 dysentery and tyjjhoid fever in particulai'. From the former they die 
 very rapidly, if the attack is severe, and very often from extremely 
 mild attacks, even when carefully dieted and treated ; and on ])ost- 
 mortem examination, the apiiearances of the bowel are quite insutKcient 
 to account for death. I. may add that they seldom derive much benefit 
 from ipecacuanha in large doses. 
 
 Until a few months ago, T never saw a case of typhoid in a Polynesian ; 
 l>ut in October, a few cases occurred amongst some new arrivals at a 
 I)lantation. It was associated with dysentery, and X'an a very rapid 
 course, two of the boys dying after an illness of about 36 hours, and 
 two who died on the plantation in even a shorter time (under 24 hours). 
 I am informed that with new arrivals in the colony, it is generally fatal 
 within a very short time, whilst those who ha\e been in Queensland a 
 year or two, very often recover. 
 
 I should now like to draw your attention to the photographs of a 
 Polynesian named Lambar, who is suffering from a disease which is 
 new to me, and about whose cause and nature I have no idea : — 
 
 919. Lambar, a native of Motlap, one of the Banks group, about 
 24 or 25 years of age. Was healthy up to nearly two years ago, when 
 the ends of his fingers became swollen, the skin broke, and pieces of 
 bone came out, and four months afterwards the same process commenced 
 in his toes. He now has the appearance of having suffered from partial 
 amputation of all his fingers and toes. The following is a description of 
 his fingers in detail : — Left thumb is flexed at terminal joint, the 
 last phalanx is shortened to half-size, and it is doubtful whether there 
 is any bone ; it retains the nail. First finger. — The terminal ])halanx 
 has disappeared, and half of the next. There is still a small piece 
 of thickened and roughened nail. On the under surface there is a 
 superficial ulcer, due to pressure from using a broom one day. Second 
 finger. — No nail on this finger, and still less of the second phalanx. 
 Third finger. — Small piece of nail, no terminal phalanx ; the second 
 api)arently entire. Fourth finger. — No nail, the greater portion of the 
 second phalanx gone. Right thumb. — Small piece of thickened nail, 
 terminal phalanx gone. First finger. — A shred of nail, terminal phalanx 
 gone. Second finger. — The nail retained, smaller than natural, and 
 thickened ; both terminal and second phalanges gone. Third linger. — 
 Nail is retained, terminal phalanx gone, the second shortened. Fourth 
 finger. — Scale of nail, terminal jjlialanx gone, the second shortened. 
 
 The condition of the feet is much the same. The boy appears to be 
 perfectly healthy in every other respect, no loss of sensation. The only 
 l^eculiarity about him is the extreme tenderness of the skin. If he does 
 any kind of manual work, however light it may be, a large blister at 
 once rises, which soon afterwards forms a superficial ulcer.
 
 G4 INTERCOLONIAL MEDICAL CONfiRE.SS OK AU.STIJALASIA. 
 
 MALARIAL FEVERS OF TROPICAL QUEENSLAND. 
 By T. S. Dyson, M.R.C.S , Noniiantoii, Queensland. 
 
 Prevalence. 
 
 Malarial fevers aie generally prevalent in Northern Queensland, and 
 are not limited to one ])articular portion of it. We find them on the 
 eastern coast and in tlie (iulf of (Jarpentaria, and in those districts 
 where the dense scrubs with rich soil are found, and also in the low- 
 lying marshy country ; also wherever new or virgin soil is for the first 
 time worked, such as on the Palmer goldfield, also the Croydon, and 
 also where new railways are being formed. This is the case in those 
 districts where malaria was scai'cely or never known to prevail previously. 
 On the Johnstone River in the early days of settlement, before the 
 dense scrub was cut down, malarial fevers were very ]>revalent, and a 
 considerable number of Europeans first employed died tliere, or were 
 invalided in consequence; but as the ground became cleared, so the 
 fevers also became of a milder type and less prevalent. The same also 
 applies to Cairns, and to any other })lace where there is luxurious 
 vegetation and stagnant water, with decaying vegetable matter in it. 
 
 Malarial fevers are the prevailing sickness in the Gulf of Carpentaria, 
 especially at certain seasons. The jiroportion of fever cases treated in 
 the Burke district hos|)ital to all the rest has been for the past three 
 years about one to four, but this year the jiroportion will be much 
 greater, owing to the men working on the new line between Normanton 
 and Croydon being treated at the liosp.ital. 
 
 Season. 
 The regular malarial season commences after the wet season is over, 
 viz. from May to September, or that of the south-east monsoon, but 
 cases do occur all the year round. I lind in the Uulf district, that the 
 rainfall atiects this season materially. Should the wet season be })ro- 
 longed and the rainfall heavy, as in 1886-7, when we had about tifty 
 inches of rain during the season, fever does not appear until late, viz. 
 July ; but should, on the contrary, the wet season be short, as in 
 1887-8, when we had only about eighteen inches during the whole wet 
 season, then the fever season begins early, as it did tliis year, in April. 
 The reason why the autumn and winter months are pre-eminently those 
 of malarial fever is accounted for thus : After the rainy season is over, 
 the lagoons and low-lying lands become dry from the heat of the sun, 
 and consequent evajioration ; and the jirevailing S.E. winds, blowing 
 over this low-lying country, bring malaria in their course. 
 
 Locality. 
 Malarial fevers appear to confine themselves to the low-lying grounds, 
 dense scrubs where the soil is rich and luxuriant, or to those parts where 
 the earth is freshly disturbed. Fever is not heard of on the table-lands 
 or at any considerable elevation, except in imported cases. 
 
 Types, 
 (a) Intermiiteul ((quotidian, tertian, and quartan) ; (li) Remittent ; 
 (c) Tijpho-vialariaL
 
 MALARIAL FEVERS IN TROPICAL QUEENSLAXD. 65 
 
 The internuttent varieties of quotidian, and especially tertian, are 
 the most prevalent in the Gulf district. Remittent is rare, as I have 
 only seen two cases of it during my four years' residence. The typho- 
 malarial, observed by Dr. White at Geraldton, is decidedly a malignant 
 form of malarial fever, and is decidedly fatal. The system of the patient 
 appears charged with the malarial poison, and in several cases the illness 
 appeared to come on suddenly, and in others there was a history of 
 neglected intermittent or remittent fever for some time previously. In 
 most cases it has a tendency to run rapidly to a fatal termination, unless 
 checked by proper remedies. Dr. "White also says that in the early 
 days of settlement on the Johnstone River, when malarial fever may be 
 said to liave been at its worst, had cases became as '■'■yellow as a guinea," 
 and that lie has had three such cases (one European and two Kanakas) 
 which resulted fatally. In each of these, jaundice supervened before 
 death, but it is not the rule, as he did not obserA^e it in others of his 
 cases, whether fatal or not. 
 
 Severity. 
 
 The cases I have seen of intermittent fever are usually of a mild type, 
 especially if they are treated early and occur in an otherwise healthy 
 subject. One of the first cases admitted into the Burke District Hospital 
 was also one of the severest attacks I have seen, as the patient was 
 insensible and delirious for a week after admission ; but this was quite 
 accounted for, as it was ascertained that he liad been drinking heavily 
 for some days before. The most severe cases, and usually the most 
 prolonged, occur in those who have been living on poor diet for a con- 
 siderable time, and who have had no treatment. Of remittent fever I 
 liave only seen two cases, and these were both fatal ; one of them 
 had been subject to attacks of malarial fever whilst resident in the 
 Southern States of America. The typho-malarial, as mentioned above, 
 is a decidedly fatal form of fever. 
 
 Duration. 
 
 The duration of intermittent fever, when treated, is usually short in 
 first attacks and in healthy subjects, but in ansemic subjects usually 
 two or three weeks. But, as a rule, it is very liable to recur sooner or 
 later, if the person continues to live in the district where he contracted 
 it, and generally at the same season the following year, if not sooner. 
 The duration of remittent is from five to tvventy days, or longer, and the 
 convalescence from it is often very prolonged, if the patient remains in 
 the same district where contracted. The duration of typho-malarial is 
 from two to three weeks, but death may occur as early as the second 
 day : when convalescence is established, it is usually rapid and comj)lete. 
 When recovery does take place from an attack of typho-malarial fever, 
 it appears to render the patient proof against malarial influences for 
 some time to come. 
 
 Amenability to Drugs. 
 
 All these fevers, with the exception of the remittent type, are very 
 amenable to quinine, arsenic, eucalyptus, salicylic acid, or salicylate of 
 soda. Eucalyptus I used frequently at first, but found it so nauseous, 
 
 F
 
 66 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 that I have not used it lately. Quinine, in a mixture or in a pill, I 
 most usually rely vipon, and find it most efficacious ; hy])odevmically, I 
 have not used it, as I have not lieen able to get a soluble form of it, but 
 I hear of its being most satisfactor}^ so I may employ it later. Quinine 
 and salicylate of soda, together, prove also efficacious. I frequently use 
 at the commencement of an attack either an emetic, or a purgative of 
 calomel and compound jalap powder to unload the liver, and I find it 
 also satisfactor}'. In the convalescent stage, I usually give some pre- 
 pai'ation of iron. I intend also trying the picrate of ammonium as 
 recommended by Dr. H, M. Clai'k, of Amritsar, India, in the Lancet of 
 February 19, 1887, but the drug has been difficult to procure in the 
 Colonies. 
 
 Sequelae. 
 
 The spleen and liver are almost always enlarged to some extent during 
 an attack, but become normal later on. Repeated attacks leave the 
 spleen chronically enlarged, but to nothing like the size seen either in 
 India or in the Eastern Counties in England. Dr. White had recently 
 under his care some ill-fed children, who had had repeated attacks of 
 intermittent fever without any treatment, whose spleens were in each 
 case the real " ague-cake" and in each case, when first seen, the spleen 
 extended almost to the pubes. IMalarial cachexia is frequently met 
 with as a sequela to both intermittent and remittent fevers ; it some- 
 times, however, comes on without fever developing itself. Removal of 
 the person from the district effects, generally, a speedy cure. 
 
 In conclusion, I find that prolonged residence in a malarious district 
 does not render one insusceptible to attacks of fever, for I had a patient 
 recently who had been resident thirteen years in the Gulf, and was at 
 that time suffering from a first attack of malarial fever. I have also 
 several cases of residents of some years' standing suffering from a first 
 attack. The residents in the town are not so liable to attacks as those 
 living outside in the bush, or travellers. And this is accounted for 
 because of their better and more varied diet, and the superior quality of 
 their drinking water. The bushman and the traveller have frequently 
 to drink whatever water they can get, and this is frequently stagnant, 
 and from lagoons tilled with decaying and dead animal and vegetable 
 matter. Likewise, they sleep chiefly on the ground, and invariably in 
 the proximity of some water-hole, and exposed to the full force of the 
 malaria-carrying winds. 
 
 Dr. White, of Gei-aldton, who resided and practised in a malarious 
 district in India previoiis to coming to Queensland, states that the 
 fevers found in India are undoubtedly the same as those met with here 
 in tropical Queensland.
 
 THE HEPATIC ELEMENT IX DISEASE. 67 
 
 THE HEPATIC ELEMENT IN DISEASE. 
 By J. W. SppaxGTiiORPE, M.A., :\1.D. Melb., ZM.R.C.P. Lond. 
 
 Phj'sician to the ilelbourne Hospital. 
 Lectviver to the University on Therai^eutics, Dietetics and Hygiene. 
 
 Tlie for<=!going title is epigram inatic, rather than logically accurate. 
 It is the nitrogen-compounding, and bile-producing functions which 
 are under review, and not the glycogen-forraing or poison-sepai-ating, 
 otherwise than as they suffer synipathetically. Structural diseases and 
 degenerations are similarly outside present discussion. Thus restricted, 
 liowever, in scope, the hepatic element merits profound study. The 
 present paper raises the questions of the Made range of its operations, 
 some of the more impoitant of its ill-understood associations, and its 
 predominance amongst the factors of disease throughout the colony. 
 
 (1) Its WIDE PvANGE OF OPERATION. 
 
 The local hepatic action concerned is (a) the dehydration of jjejDtones 
 into insolul)le albumen, to be gradually served out to the blood stream 
 in compounds of complex fornuilai and feeble chemical affinities ; and 
 (6) the sejjaration of the bile for circulation, in the portal system for 
 purposes of fat digestion, fjecal disinfection, and extrusion. The fjeneral 
 hepatic action concerned is the resultant throughout the system of the 
 circulation of these explosive nitrogenous compounds. As only a small 
 portion enters into cell repair as fixed-albumen, or ]:)roceeds to form fac, 
 the function of the larger portion must be sought elsewhere. The view 
 is here taken, that in certain, at })resent ill-understood, but still, in 
 all probability, perfectly definite amounts and combinations, these 
 compounds are so essentially bound up with the local production of force 
 of all kinds, that they may be called the physiolor/ical stimuli necessary 
 for the functional activity of the tissue and organ. When they are 
 present in normal proportions, the course of organic life Avill run 
 smoothlj', and the appro]:)riate effects will follow other stimuli, ]:)eripheral 
 and central. 
 
 The key to the interi)retation of the part played by the hepatic 
 element in disease, lies in the recognition of a corollary from this law, 
 viz., that in disease, not only is the local action ill-performed, but 
 this state of physiological stimulation passes into a stage of pathological 
 irritation, by which functional disturbances may be produced in all 
 parts, but especially in the part vulnerable in the individual case. 
 Observation verifies the truth of this conclusion ; yet, neither the text- 
 books nor the practitioner are found, as a rule, attaching thereto its vast 
 clinical value. Hence, treatment is often found to be symptomatic, from 
 the non-i-ecognition of the basis, u])on which depends this system — 
 wide series of functional disturbances. The following table, therefore, 
 may be of use, since it contains a more complete list of the symptomatology 
 
 F 2
 
 68 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 than Las been found elsewhere, and since it is based upon clinical 
 expei'ience, and not upon a priori pi'obabilities : — ■ 
 
 Site of Disturbance. 
 
 lu the liver itself. 
 
 lu the tissues. 
 
 lu circulatory 
 
 system. 
 
 lu respiratory 
 
 system. 
 
 In miiscular 
 
 system. 
 
 lu mucous 
 
 membranes. 
 
 In serous mem- 
 branes; iu syno- 
 vial membranes. 
 
 In nervous system. 
 
 Symptoms Produced. 
 
 (a) Periodic hepatic stasis 
 
 and congestion. 
 {b) Periodic portal stasis. 
 
 (c) Irregular bile separation. 
 
 Pigmentary deposits, dating 
 even from fcetal hfe, and 
 continuous after Ijirth. 
 
 Tendency to local inflam- 
 mations, and interruiDted 
 healing of injured parts. 
 
 High tension of arteries, 
 accentuated second sound, 
 slow pulse, possible cardiac 
 hypertrophy. 
 
 Arterio-capillary fibrosis, endo- 
 arteritis, rupture of vessels, 
 even endocarditis. 
 
 Wheezing, asthmatic attacks. 
 Bronchial si^asm present 
 in ordinary catarrhal con- 
 ditions. 
 
 Musciilar cramps, " mus- 
 cular rheumatism," bron- 
 chial spasm, cardiac hyper- 
 trophy. 
 
 " Rheumatic sore-throat " 
 and catarrhs. 
 
 Tendency to inflammation, 
 pleurisy, synovitis, peri- 
 carditis, periostitis. 
 
 Explosibility and want of 
 control, headaches, vertigo, 
 restlessness, migraine, dis- 
 turbed sleep, irritable tem- 
 per, fidgets, haUucina- 
 tions, fits of passion, 
 strange modes of thought, 
 semi -insane acts, various 
 neuralgia;, even epilepsy 
 and mania in the markedly 
 neurotic, climacteric neu- 
 roses, well marked. 
 
 Remarks. 
 
 Hence the feeling of weight 
 and scapular pain. 
 
 Hence the tendency to piles, 
 varicocele, ovarian and 
 uterine congestion, dys- 
 menorrhcea, menorrhagia, 
 etc. 
 
 Hence the irregular bowels, 
 variable stools, flatus, colic, 
 coated tongue, mal-assimi- 
 lation of fat, the nasty 
 taste in the mouth, and the 
 jaundice of varied extent. 
 
 Hence the dark skin, hair, 
 and complexion , which 
 almost invariably charac- 
 terise the hepatic ; hence, 
 also, the black specks, &c. 
 before the eyes. 
 
 The first three almost in- 
 variably }5resent. 
 
 Generally more marked when 
 combined with renal de- 
 fects. 
 
 Earely absent, if sought for. 
 
 The former very character 
 istic. 
 
 Herein we have the possi- 
 bilities of the joint affec- 
 tions, &c., of acute rheu- 
 matism. 
 
 The endurance and deter- 
 mination characteristic of 
 the class may be ascribed 
 to the continued brain 
 stimulation. 
 
 The combination of the 
 hepatic and ncrvons seems 
 a colonial feature.
 
 THE HEPATIC ELEMENT IN DISEASE. 
 
 69 
 
 Site of Disturbaxce. 
 
 Symptoms Prodlxed. 
 
 Remarks. 
 
 In skin. 
 In kidney. 
 
 Outbreaks of papular cha- 
 racter — fiu'unculi, lichen, 
 urticaria, and also psoriasis. 
 
 Azoturia, with renal, vesical, 
 and urethral irritation, 
 grit, gravel, calculi ; finally 
 granular kidney, where de- 
 fective elimination is added 
 to mal-assimilation. 
 
 Eczema seems to occur 
 rather in the cases of renal 
 inadec^uacy. 
 
 Also an extremely common 
 combination. 
 
 In the foregoing, no attempt has been made lo se])arate the remote 
 effects of biliary disturbances from those of disturbance of the nitrogen 
 compounding function, because the two are so intimately related 
 that differentiation is practically impossible. Probably, however, 
 pigmentary discolorations connote graver disturbance of the bile 
 function, whilst the remote effects of the latter upon the brain, as 
 seen in hypochondriasis and jaundice, i)oint to depression rather than to 
 irritation, as is the case with the former. Again, in those whose 
 vulnerability is thus hepatic, obesity may follow from greater efficiency 
 of the glycogenic function, or diabetes supervene upon its disturbance. 
 
 Lastly, the temperament is generally inherited, and marked by the 
 above remote symptoms, in addition to the generally recognised visual 
 characteristics. But the symptoms may be produced even in these 
 without any such predisposition, by continued excess in meat, malt 
 liquors, or heavy wines. 
 
 (2) Some of the more important of the less recognised 
 
 ASSOCIATIONS OF THE HePATIC ElEMENT. 
 
 (a) Rheumatism in all its varieties, is hei-e placed by the writer : — 
 
 (a) Muscular rheumatlsni may be at once dismissed as admittedly 
 hepatic in origin. 
 
 (6) Charcot and others have remarked how frequently chroiuc 
 articular rheumatism in all its forms, is associated with migraine, 
 asthmatic attacks, muscular pains, skin eruptions, and othei' forms of 
 hepatic disturbance. The present paper adduces no further evidence in 
 sup})ort of this connection. Charcot, however, and others have clearly 
 shown that all varieties are causally connected with the acute articular 
 form — hence, this theory of the hepatic origin of rheumatism stands or 
 falls according as the hepatic element can be proven or not to be causally 
 connected with the acute variety. 
 
 (e) The evidence advanced in favour of this connection between the 
 hepatic element and acute rlwumatism, is as follows : — 
 
 (1) The connection already mentioned between chronic rheumatism 
 and the hepatic temperament. 
 
 (2) The recognised origination of an attack in hepatic derangement. 
 Thus, in " Quain's Dictionary," Dr. Mitchell Bruce remarks how " an 
 attack of acute rheumatism is occasionally referred to derangements of 
 digestion, and of the functions of the liver, especially in subjects who
 
 70 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 have previously suffered." Closer observation will show this to be the 
 rule rather than the exception, exposure to wet and cold often preceding 
 this derangement, and causing it. 
 
 (3) The fact that " indulgence in abundant, rich, or indigestible food 
 ■will certainly determine a relapse in persons convalescing from the 
 disease." — (Mitchell Bruce, loc. cit.) 
 
 (4) The fact that the preventative treatment generally advocated is 
 essentially that of hepatic vulnerability and the hepatic temperament, 
 viz.. diet simple, and largely vegetarian, free action of skin, bowels and 
 kidney, prevention of hepatic congestion by flannel underclothing, 
 avoidance of malt liquors and sweet wines, and preparation for damp 
 and sudden atmospheric changes. 
 
 (5) Direct observation as to the class of cases in whom acute 
 rheumatism has occurred. During the past 12 months, 62 cases have come 
 under the writer's observation in the wards of the hospital and outside, 
 either suffering from an existent attack of acute rheumatism, or with a 
 history of a previous attack. In 12, unfortunately, no note w^as made as 
 to temperament, but out of the remaining 50, no less than 44 are noted 
 as having been mai'kedly hepatic ; whilst in 3 of sanguine temperament, 
 there was a history of beer-drinking, and of the other 3 cases — of 
 gonorrheal rheumatism — one, at least, was unmistakably hepatic. 
 
 This shows, in the writer's opinion, that there is an hepatic element 
 in the causation of acute rheumatism, and from the analogy of other 
 effects of the same cause, thei'e seems nothing in the pathology or 
 symptoms of the disease to upset the hypothesis that the local irritant 
 at Avork is hepatic in origin. What may be the nature of the 
 nitrogenous compound, remains unsettled. That the joints are 
 affected may depiend, as Jonathan Hutchinson remarks, upon an 
 ai'thritic \'ulnerability, just as occurs in other parts in the same disease. 
 The co-existence of endocarditis is readily explained, but the characteristic 
 sweating and rise in temperature remain problems which are difficult 
 of satisfactory solution upon this, as upon all other hypotheses. 
 
 {d) As to gout and rlieuwatic gout, it is held by the writer, that 
 gout is a matter between the liver and the kidney, but more a disease 
 of defective elimination than of mal-assimilation. The theory of the 
 hepatic origin of rheumatism affords an explanation of rheumatic gout 
 as a distinct disease, in which both hep;vtic deiangement and renal 
 incomj)etence are present, but the former dominating the latter. 
 
 Thus, the general conclusion arrived at is, that all the varieties of disease 
 styled " rheumatism" and " rheumatic," are members of the one family, 
 and that, as a rule, which has been found invariable, the rheumatic are 
 also hepatic. 
 
 (b) The effects of the hepatic element in the nervous system are deeper 
 and wider than is usually recognised, and merit a higher place in clinical 
 medicine than is usually given them. This is especially the case in this 
 colony, wherein it is claimed the main tendency is towards the bilio- 
 nervous tem])erament. Thus, in ei)ilepsy, out of 61 consecutive cases, 
 the writer found no less than 19 markedly hepatic, and hepatic 
 treatment proved effectual, even after the .skilful and continued use of 
 specific sedatives had ))roved a failure. In colonial diabetes also, the 
 liepatic clement almost always exists, in conjunction with the neurotic. 
 The same element is the basis of the varied and numerous ailments
 
 NOTES OF SEVEN CASES OF TYPHLITIS. 71 
 
 which are enumerated in the foregoing table, inider the heading of 
 Ne7'i'oiis iSi/D/pfrims. It is found giving a special character to the 
 manifestations of influenza, and it is claimed as a prominent factor in 
 the })roduction of our exceptional lunacy statistics. 
 
 (3) The Predomixaxce of this Element in the Production of 
 Colonial Disease. 
 
 In the opinion of the writer, the hepatic element occupies, in the 
 production of Victorian disease, a position second to no other cause, 
 excepting, perhaps, insanitary arrangements and surroundings. Any 
 gathering of the general public will suffice to show the numerical 
 preponderance of the hepatic over all other temperaments, and the records 
 of hospital and private case books will be found to demonstrate the 
 same result, even in cases where the general derangement has led the 
 individual to seek for relief from his troubles. The writer believes that 
 the wide operation of the same cause may be further seen in the extent 
 to which rheumatism, renal, and neurotic diseases prevail. 
 
 The cause of this predominance of the hepatic factor amongst us seems 
 threefold : — 
 
 (a) The extreme variability of otir climate. 
 
 (6) The amoitnt and nature of our alcoholic stimulants. 
 
 (c) Our excessive use of meat as an article of diet. 
 
 Each of these points is fully discussed in a paper before this Congress, 
 on the "Hygienic Conditions Existent in Victoria." Further notice here 
 is, therefore, unnecessarv. 
 
 NOTES OF SEVEN CASES OF TYPHLITIS. 
 By A. S. Joske, M.B., Ch. B. 
 
 Late Eesident Medical Officer, Alfred Hospital, Melbourne. 
 
 The following brief notes are of cases of typhlitis that have occurred 
 in the Alfred Hospital in 1886, 1887, and 18»8, and of one case I have 
 seen in my own practice. 
 
 The occurrence of so many after typhoid fever has led me to believe 
 that a number of so-called relapses are, in reality, due to the formation 
 of abscesses in the neighbourhood of the ileo-ceecal valve. If my sur- 
 mise be correct, it helps to show that such a sequela is not altogether 
 unfavourable. 
 
 (1) M. C, ait. 31, female, was admitted into the Alfred Hospital in 
 September 1887. Twelve days previous to admission, while lifting, felt 
 a sudden pain in the light iliac region, which became persistent. On 
 admission, had some dulness on percussion in the right iliac region, with 
 drav^'ing up of right thigh. Her temperature was 103^ Had local 
 applications applied to seat of dulness. Had rigors on September 23. 
 The swelling was aspirated on the 27th September, and pus drawn off. 
 This aspirating was done three times. Tongue became red and raw. 
 Temperature continued persistent. Bogginess then felt posteriorly.
 
 72 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 Free incision was made in right lumbar region, and a quantity of pus 
 evacuated, and a tube was inserted. Temperature fell rapidly. The 
 pus soon stopped, and the patient was discharged, cured, on 11th 
 November. 
 
 (2) "VV. M., cet. 28, male, was admitted into the Alfred Hospital in 
 April 1887. Had mild typhoid fever, the temperature falling to normal 
 on the twenty-fifth day. He had pain in the right iliac region, with 
 rigors. Dulness in the right iliac region, on percussion. Temperature 
 ran up to 104'4° gradually, with exacerbations and remissions. On the 
 thirty-seventh day, passed about four ounces of pus. Pain disappeared, 
 and dulness diminished. Was quite well on the fifty-second day. 
 
 (3) A. F., ret. 29, male, was admitted into the Alfred Hospital in 
 April 1887. Had mild typhoid fever ; temperature fell to normal on the 
 sixteenth day ; then had pain in the right lumbar and iliac region. A 
 swelling gradually formed. Had rigors. Temperature rose to 104'6°. 
 On twenty-fifth day, passed a quantity of pus. The temperature fell to 
 normal on the thirtieth day, after passing a little more pus twice. 
 
 (■4) A. H., fet. 23, male, was admitted into the Alfred Hospital in 
 March 1887. Had bad typhoid fever, with pneumonia and haemorrhage. 
 Had rigors on the forty-second day. Had no particular dulness in the 
 right iliac region, but pain between that and the umbilicus. Passed 
 pus on several occasions up to the fifty-seventh day. Temperature 
 fell to normal on the seventy -seventh day. 
 
 (5) C. M., jet. 29, male, was admitted into the Alfred Hospital in 
 September 1887. Had bad typhoid, with some haemorrhage. Like 
 Case 4, had no particular dulness, but pain between the umbilical and 
 right iliac region. His temperature became normal on the thirty-eighth 
 day ; then he had shiverings, and passed pus on four occasions. This 
 patient, in addition to the pain, complained of peculiar rumblings in 
 the umbilical region until the pus came away. 
 
 (6) A. C, fet. 26, male, was admitted into the Alfred Hospital 
 in December 1886. He had a mild typhoid fever, the temperature 
 becoming normal on the 28th day. Then a hardening and thickening, 
 with dulness and pain on percussion, could be felt in tlie ileo-csecal 
 region. The temperature rose until the thirty-fourth day of illness, 
 when he passed two ounces of pus, when the temperatui-e fell to normal, 
 and the swelling gradually disappeared. 
 
 (7) E. S., ret. 15, female, had a mild form of typhoid fever in April 
 1888. Twenty-six days after first being laid up, had pain in the right 
 iliac region, with some dulness and pain on percussion. Had rigors, 
 with rise of temperature. She passed pus six days afterwards ; then the 
 temperature fell, and the swelling disappeared. 
 
 She again had an attack in August 1888, with pain in the right iliac 
 region and dulness, but recovered on passing pus on the eighth day of 
 illness. She had two other attacks, in September and October, but 
 since then has enjoyed excellent health.
 
 CONSTITUTIONAL FACTOR IN RELATION TO DISEASE. 73 
 
 THE IMPORTANCE OF THE CONSTITUTIONAL FACTOR 
 IN RELATION TO DISEASE. 
 
 By James Robertson, M.A., M.D. 
 
 Formerly Physiciau to the Melbourne Hospital, and Lecturer ou Medicine in the 
 TJniversity of Melbonrue. 
 
 Amidst the daily routine of professional life, and the cares and 
 anxieties incident to the active practice of our jirofession, it is difficult 
 to find time for study. Too frequently, after the duties of the day are 
 ended, the body is exhausted by fatigue, and the mind is unequal to 
 ovei'come the vim inertice with which it is oppressed. Another difficulty, 
 and no small one, that met me at the inception of my design to contribute 
 a paper to this Intercolonial Congress, was the choice of a subject. 
 This was surmounted by our very active and energetic Secretary allotting 
 one to me. Under the circumstances, I hope my subject and its 
 treatment may meet with the favour of a sympathetic audience. 
 
 The subject thus assigned to me, "The Importance of the Constitutional 
 Factor in Relation to Disease," is very comprehensive, and admits of 
 voluminous treatment; but it will be my aim to make my remarks brief 
 and practical, as far as possible. 
 
 It will be readily allowed, that a careful examination of the general 
 symptoms and physical signs is all-important in determining the nature 
 and locality of a disease; but to enable us to complete the diagnosis, and 
 to indicate the prognosis and treatment, it is not less important to 
 ascertain the " constitutional factor." It may be truly said, that the 
 "constitutional factor" is the key-note to treatment. It is therefore 
 necessary, in every case, to note particularly the appearance and physique 
 of the patient, to obtain a knowledge of his previous state of health 
 and tendency to disease, and, as far as possible, of his family history. 
 " Like produces like," is the general law of life. It is manifested alike 
 in the vegetable and animal kingdoms. The embryo plant unfolds its 
 leaves, and expands its branches, after the manner of the parent tree. 
 The child grows up in general likeness and bodily conformation, the 
 type of one or other parent. Even vices of formation, physical deformities, 
 are not infrequently inherited. The child also inherits the temperaments 
 of the parents, often so blended, that it is difficult to decide which 
 temperament predominates most, that of the father, or that of the mother. 
 The characteristics manifested by the ])hysiognomic appearance and 
 general conformation, the development and activity of the various organs, 
 enable us to recognise the temperament best marked or typified. 
 Although each temperament is said to predispose to certain diseases, yet 
 the most robust health may be enjoyed Ijy individuals of the sanguine, or 
 of the bilious temperament, and even by those of the lymphatic, or of 
 the nervous temperament, when their subjects are placed under conditions 
 favourable to health. 
 
 Children inherit not only the temperament, but the diathesis, of their 
 parents — that morbid tendency or predisposition to disease, liable to be 
 transmitted from parents to children. When both parents manifest the
 
 74 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 same diathesis, it may become strongly expressed in the children, by 
 external bodily features and conformation, as in the strumous (Jiathesis. 
 Again, a diathesis may be feebly or faintly marked, yet it is innate, born 
 with the individual, and liable to become developed under the influence 
 of exciting causes. 
 
 It cannot be said that diseases are, as a rule, actually inherited. Only 
 such peculiarities of constitution as predispose to them, and that favour 
 their development, are so. Children are not born with tuberculosis, 
 rheumatism, or gout, but with such latent conditions of constitution, as 
 lead to their development in after years, when influenced by the operation 
 of agents acting from without — exopathic; or, it may be, generated 
 within — endopathic. The morbid hereditary tendency may be so strong, 
 that disease may become developed under circumstances favourable to 
 health, and even when care is taken to prevent it. Tuberculosis may be 
 adduced as an instance in point. Again, when the predisposition exists, 
 the disease may remain latent until a certain age, and then become 
 actively developed, as occurs in phthisis, gout, cancer, itc. 
 
 Morbid tendencies are liable to be brought into activity at different 
 epochs. Syphilis and scrofula are manifested in early life ; phthisis and 
 rheumatism, at or about tlie age of puberty and adult age; gout, beyond 
 the middle period of life; asthma and cancer, in advanced years. Some 
 diseases are not marked by any external features, or other indications in 
 early life, but are none the less to be considered hereditary. I may 
 particularly instance diseases of nervous origin — chorea, mania, epilepsy, 
 apoplexy, paralysis, neuralgia; also diabetes, cancer, and some skin 
 diseases. 
 
 All the children of the same parents do not partake alike of their 
 morbid tendencies. When the parents exhibit diff'eient diatheses, some 
 of the children may inherit and manifest that of the father, and some 
 that of the mother, in a more pronounced form. It is generally allowed 
 that the morl)id tendency of the mother is more liable to be transmitted 
 than that of the father. 
 
 Another peculiarity of constitutional disease is the law of atavism. 
 The hereditary tendency may fail to be expressed in the children of 
 parents known to be the subjects of disease, and become developed in 
 the grandchildren. The tendency lies dormant, as it were, in one 
 generation, and becomes expressed in the next. 
 
 I have said that children are born with a tendency or proclivity to 
 disease, but in some cases they are born the subjects of actually existing 
 disease. The cachexia is transmitted, the disease is congenital — born 
 with the individual. This fact is well illustrated in congenital 
 syphilis. 
 
 Cases are reported of small-pox and measles, and also of intermittent 
 fever, being congenital, due to the specific poisons of those diseases 
 operating through the systems of the mothers. 
 
 In constitutional syphilis, a peculiarity is sometimes observable in 
 the transmission of the disease. One child may be born apparently 
 perfectly healthy, and free from the syphilitic taint, while the next 
 j)resents undoubted signs of the disease. The sy])hilitic taint is mani- 
 fested in a variety of ways, both externally and internally. The 
 
 I
 
 CONSTITUTIOXAL FACTOR IX RELATION TO DISEASE. 75 
 
 external appearances are readily recognisable in affections of the nasal 
 bones, and of the skin and umcous membranes, and, at a later stage, by 
 the appearance of the teeth. Tiie morbid changes induced in internal 
 organs are often very insidious and very serious, affecting, as thev do, 
 the brain, liver, lungs, &c., while the diagnosis is very o))scure, and can 
 only be determined by a process of exclusion, and a knowledge of the 
 " constitutional factor." This knowledge is still more imi)ortant in 
 enabling us to form a prognosis and indicate the treatment, inasmuch 
 as the treatment, to ))e successful, must be directed to the specific 
 constitutional disease. 
 
 To illustrate the importance of recognising the " constitutional factor," 
 I shall refer a little more in detail to the scrofulous or tubercular 
 cache,rut. I presume it will be allowed that scrofulosis and tuberculosis 
 may now be regarded as commensurate or convertible terms, seeing that 
 the bacillus tuberculosis finds a habitat alike in scrofulous glands and 
 tubercular lungs, and is said to be the cause of both conditions. Scrofula 
 may be regarded as the manifestation of tuberculosis in childhood, and 
 phthisis in adult age. In childhood, the bacillus tuberculosis appears 
 to have some special afiinity for the lymphatic glands of the neck, the 
 mesenteric and bronchial glands, and for serous and mucous membranes, 
 bones, and joints ; while in adult life it selects the lung.s, and other 
 internal organs, as ijoints of attack, as being, it is assumed, partes 
 minoris resistentice. The reason why, is problematical. We know, 
 however, that healthy vigorous children, with abundance of nutritious 
 food, living under favourable hygienic conditions, are able to resist 
 tuberculosis ; and that the weakly, badly fed, and neglected, are liable 
 to fall A"ictims to it. This is especially the case when the hereditary 
 predisposition is strongly expressed, for then the onset of the disease 
 occurs at an early age, and its progress is more rapid. In this Colony, 
 the conditions favourable to the development of tuberculosis do not 
 prevail extensively ; and consequently, we find that tabes mesenterica, 
 tubercular peritonitis, and meningitis, are comparatively rare, the 
 mortality from those diseases not amounting to one-half that incident 
 to England and Wales. 
 
 Children who have inherited the tubercular diathesis may, iinder 
 healthy conditions, pass safely through the trials of childhood, and reach 
 the age of puberty. Tuberculosis of the lungs is then liable to super- 
 vene, under the influence of some exciting cause — it may be, exposure 
 to cold. 
 
 Catarrhal bronchitis, or other inflammatory affections of the lungs, 
 such as sub-acute pneumonia or pleurisy, not infrequently merge in 
 pht/iisis piiJmnnum. The occurrence of any of the exanthemata, or 
 acute specific fevers, may so debilitate the system as to render it prone 
 to tubercular disease. Of course, the advent of phthisis under such 
 circumstances presupposes exposure to the influence of the bacillus 
 tuberculosis, and its introduction into the system. When, however, 
 care has been taken to promote recovery from debilitating diseases, to 
 restore the strength by suitable nourishment, to correct errors of diges- 
 tion, and thus promote healthy nutrition, immunity may be obtained 
 fronr the invasion of bacilli. 
 
 The important factor, therefore, in incij)ient phthisis, is the constitu- 
 tional ; for, without doubt, bacilli are often inhaled by many who come into
 
 76 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 contact with phthisical subjects, and yet the disease is not communicated. 
 We have also abundant evidence to ])rove that tuberculosis is often 
 arrested in childhood, youth, and adult age. This is shown by the 
 subsidence of well-inarked symptoms, and physical signs, by restoration 
 to Iiealth, by improved nutrition, and increased weight. Further 
 evidence of the curability of the disease is furnished by the presence of 
 calcareous or chalky bodies in glands, lungs, and other internal organs, 
 and by the cicatrices and small cavities in the apices of the lungs, so 
 frequently found after death. In such cases, we are constrained to 
 believe that bacilli die, or become inert, or that their inroads have been 
 arrested by healthy living tissues, and they have been cast ofi'. 
 
 The importance of studying " the constitutional factor," in indicating 
 the treatment of disease, cannot, perhaps, be more strongly enforced, 
 than by passing in review the treatment suggested by the bacilJary 
 theory of tuberculosis, and that directed to support and strengthen the 
 system, by such means as promote liealthy nutrition. The latter I cannot 
 but I'egard as the more rational, and, so far as yet demonstrated, the 
 most successful mode of practice. 
 
 The dominant idea, influencing the treatment of tuberculosis at the 
 present day, is the discovery of some agent calculated to destroy the life 
 of the bacilli, without injury to the system, and certainly the measures 
 adopted in accordance vv'ith this view cannot as yet be pronounced a 
 success. oSTumerous antiseptic and anti-j)arasitic remedies have been 
 introduced into practice. Their effects have been tested by their action 
 on bacilli and other micro-organisms, external to the bod}', in order to 
 determine the quantity, or strength, of the various parasiticides necessary 
 to arrest their development; but their action on bacilli, in the tissues of 
 the living body, cannot be thus estimated, for very obvious reasons. 
 The mode of administration generally adopted has been by inhalation, 
 subcutaneous injection, intra-pulmonary injection, and injection ^jer 
 rectum. 
 
 A mere enumeration of medicaments employed, will show the bias 
 given to therapeutical reseai-ch by the adoption of a theory. Mercury 
 perchloride and bin-iodide, iodine and its compounds, iodoform, carbolic 
 acid, creosote, lerebene, turpentine, eucalyptol, aniline, cai-bon-bisulphide, 
 et hoc genus omne, have been employed. Ingenious instruments have 
 been devised for inhalation, and for injection of gases 2^^^' Tectum, but 
 their use lias not been attended with any positive or permanent good 
 result. Bacilli are found to survive all efforts to destroy them, and the 
 means used are not always innocuous to the patients. 
 
 The most successful treatment yet discovered for the prevention and 
 cure of tuberculosis, is that directed to promote the general health. 
 When the tendency or proclivity to the disease is inherited, our hope 
 and strength rest in adopting measures of prevention. These consist in 
 removing a patient from all unhealthy surroundings, from all debilitating 
 causes, and in enforcing the observance of general hygienic measures — 
 early hours, bathing, cold or tepid sponging, and friction, regular habits, 
 exercise in the open air, change of air and scene. Special attention 
 should be given to the state of the digestive organs, as often a peculiar 
 form of dyspepsia ])recedes the morbid changes. Errors of digestion 
 should be corrected by the use of such medicines as are indicated, and of 
 
 I
 
 COXSTITUTIOXAL FACTOR IX UELATIOX TO DISKASE. 77 
 
 wholesome, nutritious, and easily-digested food. 80 long as the nutritive 
 processes are active and healthy, there is little occasion to dread the 
 inroads of bacilli. The means that prove most efficacious in the treatment 
 of tubercular disease, are just tho.se that give tone to the s3-stem, and 
 promote healthy nutrition. 
 
 The advantage of residence at a high altitude is, in a measure, due to 
 the diminished jn-essure and purity of the atmosphere, but still more to 
 the bracing effect of the cold, which invigorates the system, stimulating 
 the various functions, and esi)ecially the appetite, digestion, and 
 assimilation. Alpine air is not to be regarded as a specific, but rather 
 as a tonic plan of treatment, most beneficial in the early stages of the 
 disease, when lesions are not extensive, and in chronic cases uncompli- 
 cated with disease of the kidneys or circulatory system. A mild, warm 
 climate has been recommended, and without doubt has served to prolong 
 life in cases of advanced disease. Its effect, however, is not conducive 
 to recovery, as it induces languor, lassitude, and prostration of strength. 
 By its enervating influence, it unfits for exercise, tends to destroy the 
 appetite, and impair digestion, and thus leads to mal-nutrition, and 
 pi'ogressive emaciation. Sea voyages are beneficial, provided the cuisine 
 is good, and table liberal, the constant renewal of pure air favouring or 
 inducing healthy functional activity. 
 
 In the Australian Colonies, a climate suitable for consumptive patients 
 may be found at all seasons of the year, but only by migrating from 
 south to north, and again from north to south, according to the season. 
 In calculating the benefit to be derived from change of climate, not only 
 is the stage and extent of the disease to be considered, but the means of 
 the patient to procure suitable residence, food, and even luxuries and 
 amusements. If he has to earn his living by engaging in some in-door 
 employment, if he has to sacrifice his comfort to " the necessity of 
 living," change of climate will avail but little. 
 
 I shall now briefly direct attention to another constitutional disease 
 met with in middle age or advanced yeai's — gout, or lithiasis, a term 
 applied to it from the condition on which it depends. It is to gout 
 occurring in its chronic and irregular forms that my remarks are 
 particularly directed. The gouty diathesis is often inherited, but the 
 cachexia may be acquired, may become developed, even in those of 
 temperate habits as regards drink, when animal food is consumed in 
 excess of the wants of the system, and indolent habits are indulged, or 
 insufficient exercise is taken. The disease has always been attributed 
 to indulgence in the pleasures of the table, to wine and good living, but 
 it may arise at a certain age in those predisposed by heredity, induced 
 by some temporarily exciting cause. It is liable to assume many forms 
 or phases, to imitate or complicate many diseases. It is veritably a 
 protean malady. Although its most characteric manifestations are 
 observed in nodosities of the smaller joints, and effusions into the 
 synovial membranes of the larger joints, it is liable to implicate every 
 organ and tissue of the body. It affects the nervous, circulatory, 
 respiratory, alimentary, and emunctory organs. It is to be recognised 
 in cerebral affections, in severe headaches, vertigo, partial paresis, 
 temporary troubles of special senses, affections of the eye and ear, 
 neuralgia of different nerves, more especially of the sciatic. Its effects 
 on the iieart are indicated by palpitation, and irregularity of its action,
 
 78 INTERCOLONIAL MEDICAL CONnRESS OP AUSTRALASIA. 
 
 by flying pains, and a feeling of oppression in the cardiac region ; and on 
 the blood-vessels, by atheroma of the arteries ; on the respiratory organs, 
 by inducing or modifying chronic bronchitis and asthma ; on the 
 stomach and liver, bj' dyspeptic troubles — pain, acidity, flatulency, and 
 deranged bowels ; and on the kidneys and urinaiy^ tract, by degenerative 
 changes of the kidneys, and urinary irritation from elimination of 
 lithates. 
 
 It is not infrequently remarked, when a patient is suffering from 
 various anomalous symj)toms suggestive of what may be termed latent 
 gout, that a regular iic of gout would prove curative, as, usually, improved 
 health follows. It is like the bursting of a thunder-storm, which purifies 
 the atmosphere. Although gout and rheumatism are characterised by very 
 different and well-defined symptoms in the acute form, there is a very 
 close relationship between them when occurring in the chronic form. 
 Both are due to morbid poisons generated in the system and circulating 
 in the blood, which affect different tissues and organs, lithic acid being 
 accepted as the morbid factor in the one, and lactic acid in the other. 
 Both are manifested by derangement of the functions of assimilation, 
 and of secretion and excretion, and both yield to the same line of 
 treatment — alkaline, alterative, and eliminatory. 
 
 The importance of studying " the constitutional factor" is well 
 exemplified in all diseases associated with the gouty diathesis. In 
 inflammatory affections occurring after middle age, the possibility of 
 their being so associated, and thereby modified, demands inquiry. Not 
 infrequently it is found that diseases affecting the synovial and mucous 
 membranes are intractable to treatment ; that effusions into joints, 
 tonsillitis, laryngitis, bronchitis, asthma, and cystitis, do not readily 
 respond to treatment, unless it be directed to counteract the prevailing 
 diathesis. Rarely have we to treat simple inflammation ; but rather 
 some compound or complex disease, the lesult, it may be, of various 
 morljid factoi's mixed or blended together. We are, therefore, greatly 
 assisted in our treatment of the many anomalous and obscure affections 
 met with in advanced years, by bearing in mind their not infrequent 
 complication with the gouty cachexia. In obstinate dj^spepsia, with 
 hepatic derangement and urinary irritation, " the constitutional factor" 
 is often plainly disclosed by the so-called "Old Father Christmas" ftice 
 of the patient. In cases of dyspnoea, with feeble intermittent action of 
 the heart, palpitation, and flying pains about the chest, the gouty 
 cachexia may be revealed by nodosities, or tophi of the smaller joints ; 
 or perhajis, m the helix of the ear. When no such evidence is ajjparent, 
 and yet signs are })resent of impeded circulation, congestion of the liver 
 and kidneys, with functional disturbances, or irregularity of the heart's 
 action, we aie justified in referring them to the constitutional factor, 
 in the absence of e\idence of valvular disease. We may thus be enabled 
 to give a more favom-able prognosis, especially if we find, on enquiry, a 
 history of family predisposition, or heredity. 
 
 The connect diagnosis of a disease iss aid to be half its treatment ; at 
 all events, it is the most important element in regard to its successful 
 treatment. 
 
 In treating diseases complicated with gout, medicines require to be 
 given in jiidicious combination. The treatment to be adopted is
 
 PHTHISIS IN NEW ZEALAND. 79 
 
 suggested by " the constitutional factor," and ])y other indications 
 jiresent. If our object be to promote the elimination of effete and 
 excrementitious matter, that may be most readily acconiplishr'd by the 
 administration of natural saline alkaline aperient and diuretic waters, 
 with colchicum, in sthenic cases. The combination of iodide of 
 potassium, with ammonia, colchicum, and senega, is highly efficient in 
 some cases of chronic bronchitis, with a tendency to asthma. 
 
 In asthenic cases, characterised by feeble action of the heart, passive 
 congestion of internal organs, and general debility, treatment of an 
 active or depressing kind is contra-indicated, and such tonics as iron, 
 quinine, and strychnine may be demanded, especially when the heart 
 is very feeble, and perhaps dilated. Even under sucli circumstances, 
 tonics are not always attended with benefit. It may be necessary to 
 jirecede their employment by such medicines as promote the action of 
 the liver, bowels, kidneys, or skin ; or to combine a tonic and eliminating 
 plan of treatment. A very useful combination, in asthenic cardiac cases, 
 consists of iron and arsenic, or a compound of iron with a vegetable 
 acid and digitalis. The strength is to be maintained by tonics, 
 stimulants, and nutritious easily-digestible articles of food, secretion 
 and exci-etion being at the same time promoted, in order to eliminate 
 effete products from the system. 
 
 PHTHISIS IN NEW ZEALAND. 
 
 By D. CoLQUiioUxN, M.D. Lond., M.R.C.P. Lond. 
 
 Lecturer on the Practice of Medicine, Otago University. 
 
 A few months ago, a medical friend in England wrote to me about a 
 patient of his suffering from consum])tion, whom he had advised to go 
 to New Zealand. His patient had subsequently consulted a specialist 
 in London, who fell foul of the recommendation, and said that New 
 Zealand was the worst place he could go to. In a notice in the Lancet, 
 in July 1887, on a book by Dr. Lindsay on the Climatic Treatment of 
 Consumption, the reviewer remarks that " Dr. Lindsay wisely points out 
 the undesirability of this remarkable country (New Zealand) for the 
 invalid, however attractive for the tourist." It would not be difficult 
 to find among medical men in Australia and New Zealand many hold- 
 ing similar opinions, and I propose, in this paper, to discuss the subject, 
 rather from a statistical than from an impressional standpoint. 
 
 It will be convenient to liegin with the latest official statistics on the 
 subject, and I will first give the official returns for 1887, showing the 
 population in the various provincial districts of New Zealand, and the 
 number of deaths from ])hthisis in each. A glance at a map of 
 New Zealand will show the situation of the various districts, and I 
 will discuss further on the occupations and social conditions of the 
 inhabitants.
 
 80 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Table I. 
 
 Statistics of Phthisis for 1887. 
 
 
 Population. 
 
 Deaths from Phthisis. 
 
 Per 10,000 
 Living. 
 
 
 
 Males. 
 
 Females. 
 
 Total. 
 
 
 Aucldand 
 
 
 134,1*^8 
 
 81 
 
 43 
 
 124 
 
 9-3 
 
 Taranaki 
 
 
 
 18,737 
 
 10 
 
 5 
 
 15 
 
 8-0 
 
 Hawke's Baj- 
 
 
 
 25,509 
 
 15 
 
 8 
 
 23 
 
 9-0 
 
 Welliugtou 
 
 
 
 80,328 
 
 34 
 
 33 
 
 67 
 
 8-3 
 
 Marlborough 
 
 
 
 11,547 
 
 3 
 
 2 
 
 5 
 
 4-4 
 
 Nelson . . 
 
 
 
 30,979 
 
 10 
 
 5 
 
 15 
 
 4-8 
 
 Westland 
 
 
 
 16,242 
 
 14 
 
 6 
 
 20 
 
 12-3 
 
 Canterbury 
 
 
 
 125,2 GS 
 
 62 
 
 53 
 
 115 
 
 9-1 
 
 Otago . . 
 
 
 
 153,388 
 
 86 
 
 64 
 
 150 
 
 9-7 
 
 Chatham Islands 
 
 
 210 
 
 — 
 
 — 
 
 — 
 
 — 
 
 The total estimated population of tlie Colony (exclusive of Maoris) 
 was 590,374 ; the total number of deaths from phthisis was 534, or 
 8 '9 5 per 10,000 inhabitants, and 8*7 per cent, of deaths fi'om all causes. 
 As these are the statistics for one year only, they are evidently not to 
 be taken as showing the general incidence of deaths from consumption 
 in New Zealand, but they will be useful to compare with results taken 
 from a series of years. I am indebted to Mr. Brown, the Registrar- 
 General of New Zealand, for the data from which I have compiled the 
 following table. The i-eliable statistics of New Zealand extend from 
 the years 1872 to 1887 inclusive ; these, I think, will be sufficient for 
 our present purpose. 
 
 Table II. 
 Statidics of Phthisis and General Death-rate, from 1872 to 1887, inclusive. 
 
 General Death-rate 
 
 Deaths 
 
 FROM Phthisis. 
 
 Deaths from all Causes. 
 
 Deaths from Phthisis. 
 
 - 
 
 Per 1000 
 per aim. 
 
 Females 
 
 Males. 
 
 Total. 
 
 Females 
 
 Males. Total. 
 
 Per cent, of 
 Deaths. 
 
 Per 10,000 
 Population. 
 
 Otago 
 
 10-21 
 
 736 
 
 1030 
 
 1766 
 
 8242 
 
 12,090 120,332 
 
 8-68 
 
 8-34 
 
 Canterbury 
 
 11-99 
 
 597 
 
 686 
 
 1283 
 
 8303 
 
 10,538 
 
 18,841 
 
 6-8 
 
 8-17 
 
 Marlborough 
 
 9-88 
 
 37 
 
 51 
 
 88 
 
 528 
 
 826 
 
 1,354 
 
 6-5 
 
 6-42 
 
 Nelson 
 
 9-99 
 
 111 
 
 194 
 
 305 
 
 1733 
 
 2,515 
 
 4,248 
 
 7-18 
 
 7-17 
 
 Westland . . 
 
 11-35 
 
 83 
 
 118 
 
 201 
 
 1101 
 
 1,849 
 
 2,950 
 
 6-8 
 
 7-73 
 
 Wellington 
 
 12-63 
 
 343 
 
 434 
 
 777 
 
 4730 
 
 6,282 11,012 
 
 6-99 
 
 8-9 
 
 Taranaki . . 
 
 10-51 
 
 70 
 
 87 
 
 157 
 
 799 1,176 ! 1,975 
 
 7-94 
 
 8-3 
 
 Hawke's Bay 
 
 13-24 
 
 94 
 
 154 
 
 248 
 
 1387 2,034 3,421 
 
 7-24 
 
 9-6 
 
 Auckland . . 
 
 12-59 
 
 599 
 
 912 
 
 1502 
 
 7764 11,322 19,086 
 
 7-86 
 
 9-9 
 
 Average for 
 
 
 
 
 
 
 
 
 7-6 
 
 8-76 
 
 New Zealand 
 
 
 
 
 
 

 
 PiniHSIS IN NEW ZEALAND. 
 
 81 
 
 It will be seen, tVoiu this table aiul the first, that the average deatli- 
 rate from ]ihthisis was very sliglitly higher in 1887 than for the years 
 1872 to 1887. It is also seen that the death-i-ate is above the average 
 for New Zealand, in Auckland, Hawke's Bay, and Wellinirton, in the 
 north, and ])resuuiably the warmer island ; a little lower in Taranaki, in 
 the North Island ; and lower in Marlborough, Nelson, Canterbury, and 
 Otago, in the South Island. In Marlborough and Nelson the difference 
 is a very decided one, and in these provinces, we find that the general 
 death-rate is also lower than elsewhere. 
 
 It will now be convenient to compare these results with the statistics 
 of Great Britain and Ii-eland, from which most of the white poi)ulation 
 of New Zealand is derived, (jither directly or indirectly, and also with 
 tliose of the other Australasian Colonies, whose ])opulations have a 
 similar origin. 
 
 I am indebted for the following table to Mulhall's Dictionary of 
 Statistics, and to Hayter's Victorian Year Book for 1885-G, and to the 
 Reports of the Ilegistrai'-Ceneral of New Zealand. 
 
 Table III. 
 
 Comparative StaAistics nf Mm-iaiity from Phthisis in Australasia and 
 
 Grtat Britain. 
 
 England 
 
 Kcotlaud 
 Ireland 
 Loudon 
 Victoria 
 
 Melbourne 
 
 New South Wales 
 Queensland . . 
 South Australia 
 Western Australia 
 Tasmania 
 New Zealand 
 
 Ykar, 
 
 Deaths per 1i),000 
 
 
 Inhabitants. 
 
 1850-59 
 
 27-30 
 
 1870-79 
 
 22-05 
 
 188(i 
 
 17-18 
 
 1877 
 
 •22-94 
 
 1880 
 
 21 -Ho 
 
 1879 
 
 24-76 
 
 1861-85 
 
 12-98 
 
 1884 
 
 14-36 
 
 1885 
 
 14-19 
 
 1874-85 
 
 22-31 
 
 188(5 
 
 10-73 
 
 1886 
 
 14-86 
 
 1887 
 
 11-43 
 
 1886 
 
 6-42 
 
 1887 
 
 11-01 
 
 1887 
 
 8-95 
 
 1872-87 
 
 8-76 
 
 These statistics are unfaxourable to the Colonies and unduly 
 favourable to Creat Britain, inasmuch as many of the sufferers from 
 consumpdon acquired in Great Britain die abroad, while in the Colonies 
 a considerable proportion of those who die from consumption have 
 acquired the disease elsewhere. Mr. Brown, the Eegistrar-General for 
 New Zealand, notes in his report for 1887 that the exceptionally high 
 rate in Queensland is largely attributable to tlie mortality among the 
 South Sea Island labourers ; and he has, in his returns for 18SG and 
 
 G
 
 82 
 
 IXTERCOLONIAL MEDICAL COXGRESS OF AUSTRALASIA. 
 
 1887, shown the length of residence in New Zealand of those who died 
 from this disease. The following are the results for 18SG : — 
 
 Table IY. 
 
 Tlie Aaes, vitlt tJie Lewitli of Residence^ of those who (lied frora Phthisis, 
 in 1886, in New Zecdand. 
 
 I 
 
 
 
 
 
 
 Age 
 
 AT Death. 
 
 
 
 
 
 Len'gth of Residence 
 
 
 
 
 
 
 
 
 
 
 ? ^' 
 
 
 IN THE Colony. 
 
 S ■" 
 
 5 
 
 10 
 
 15 
 
 25 
 
 35 
 
 45 
 
 55 
 
 Cm 
 
 £2 
 
 
 
 ,Z <:€ 
 
 to 
 
 to 
 
 to 
 
 to 
 
 to 
 
 to 
 
 to 
 
 to 
 
 a s 
 
 Total. 
 
 
 ^t 
 
 10 
 
 15 
 
 2o 
 
 35 
 
 45 
 
 55 
 
 05 
 
 75 
 
 >" c. 
 
 
 Ihdo. 
 
 
 
 
 
 
 
 
 
 
 
 
 UniTev 1 month 
 
 — 
 
 — 
 
 — 
 
 — 
 
 1 
 
 1 
 
 — 
 
 — 
 
 — 
 
 — 
 
 2 
 
 1 to 6 months 
 
 — 
 
 — 
 
 — 
 
 5 
 
 2 
 
 — 
 
 1 
 
 — 
 
 — 
 
 — 
 
 8 
 
 (i to 1"2 months 
 
 — 
 
 — 
 
 — 
 
 3 
 
 1 
 
 1 
 
 — 
 
 — 
 
 — 
 
 — 
 
 5 
 
 1 to 2 years . . 
 
 — 
 
 — 
 
 — 
 
 3 
 
 6 
 
 — 
 
 1 
 
 — 
 
 — • 
 
 — 
 
 10 
 
 2 to '6 years . . 
 
 — 
 
 — 
 
 — 
 
 2 
 
 10 
 
 4 
 
 1 
 
 — 
 
 — 
 
 — 
 
 17 
 
 3 to 4 years . . 
 
 — 
 
 — 
 
 — 
 
 2 
 
 3 
 
 1 
 
 1 
 
 — 
 
 — 
 
 — 
 
 7 
 
 4 to .5 years . . 
 
 — 
 
 — 
 
 — 
 
 
 3 
 
 ■ — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 3 
 
 5 to 10 years 
 
 — 
 
 — ■ 
 
 — 
 
 4 
 
 11 
 
 9 
 
 6 
 
 1 
 
 — 
 
 — 
 
 31 
 
 10 to 15 years 
 
 — 
 
 — 
 
 — 
 
 8 
 
 9 
 
 11 
 
 3 
 
 4 
 
 2 
 
 — 
 
 37 
 
 1.3 to '20 years 
 
 — 
 
 — 
 
 — 
 
 1 
 
 2 
 
 5 
 
 4 
 
 — 
 
 — 
 
 — 
 
 12 
 
 20 to 25 years 
 
 
 — 
 
 — 
 
 
 2 
 
 19 
 
 20 
 
 4 
 
 2 
 
 — 
 
 47 
 
 25 years and upwards 
 
 — 
 
 — 
 
 — 
 
 — 
 
 3 
 
 7 
 
 <» 
 
 7 
 
 4 
 
 — 
 
 30 
 
 Not known . . 
 
 — 
 
 — 
 
 — 
 
 2 
 
 2 
 
 6 
 
 5 
 
 — 
 
 — 
 
 — 
 
 15 
 
 Eorn in colony 
 
 5 
 
 2 
 
 4 
 
 34 
 
 13 
 
 9 
 
 — 
 
 — 
 
 — 
 
 — 
 
 67 
 
 Totals . . 
 
 5 
 
 2 
 
 4 
 
 C4 
 
 (38 
 
 73 
 
 51 
 
 16 
 
 8 
 
 — 291 
 
 Fi-nuaeg. 
 
 
 
 
 
 
 
 
 
 
 
 
 1 to G months 
 
 — 
 
 — 
 
 — 
 
 — 
 
 1 
 
 — 
 
 — 
 
 — 
 
 — 
 
 — 
 
 1 
 
 () to 12 months 
 
 — 
 
 — 
 
 — 
 
 — 
 
 1 
 
 — 
 
 — ■ 
 
 — 
 
 — 
 
 — 
 
 1 
 
 1 to 2 years . . 
 
 — 
 
 — 
 
 — 
 
 2 
 
 3 
 
 — 
 
 1 
 
 — 
 
 — 
 
 — 
 
 6 
 
 2 to 3 years . . 
 
 — 
 
 — ' 
 
 — 
 
 1 
 
 1 
 
 2 
 
 1 
 
 — 
 
 — 
 
 — 
 
 5 
 
 3 to 4 years . . 
 
 — 
 
 — 
 
 — 
 
 3 
 
 3 
 
 1 
 
 — 
 
 — 
 
 — 
 
 — 
 
 7 
 
 4 to 5 years . . 
 
 — 
 
 — 
 
 — 
 
 1 
 
 — 
 
 1 
 
 — 
 
 — ' 
 
 
 — 
 
 2 
 
 5 to id years 
 
 
 — 
 
 — 
 
 7 
 
 8 
 
 4 
 
 1 
 
 — 
 
 1 
 
 
 
 21 
 
 10 to 15 years 
 
 
 
 — 
 
 2 
 
 5 
 
 18 
 
 9 
 
 3 
 
 1 
 
 — 
 
 — 
 
 38 
 
 15 to 20 years 
 
 — 
 
 — 
 
 — 
 
 4 
 
 2 
 
 5 
 
 — 
 
 — 
 
 — 
 
 — 
 
 11 
 
 20 to 25 years 
 
 — 
 
 — 
 
 — 
 
 2 
 
 7 
 
 9 
 
 4 
 
 2 
 
 2 
 
 1 
 
 27 
 
 25 years and upwards 
 
 — 
 
 — 
 
 — 
 
 
 4 
 
 2 
 
 4 
 
 3 
 
 1 
 
 • — 
 
 14 
 
 Not known . . 
 
 — 
 
 — 
 
 — 
 
 
 
 i 
 
 — 
 
 — 
 
 1 
 
 — 
 
 2 
 
 Born in colony 
 
 7 
 
 7 
 
 6 
 
 10 
 
 30 
 
 11 
 
 4 
 
 — 
 
 — 
 
 — 
 
 — 
 
 74 
 
 Totals . . 
 
 6 
 
 12 
 
 61 
 
 59 
 
 38 
 
 14 
 
 (5 
 
 5 
 
 1 
 
 209 
 
 Totals both sexes 
 
 12 
 
 8 
 
 16 
 
 :.. 
 
 127 
 
 111 
 
 65 
 
 22 
 
 13 
 
 1 
 
 500 
 
 It will be seen from this table that 25 '2 per cent, of those who died 
 liad V)een less than Id years in the colony, that 11 per cent, had been 
 less than 3 years in the colony, and that 28 }>er cent, had been born in 
 the colony. I have not the data at hand for coni[>ai'ing New Zealand 
 -,vith the other colonies on this point, but there seems to be no reason to
 
 PHTHISIS IN NKW ZEALAND. 
 
 83 
 
 doubt, that all the colonies sutler more or less from the same cause. Tt 
 is worth noting that Western Australia, which, compared with the other 
 colonies, is isolated from the great stream of European tratlic, has a 
 comparatively low death-rate from phthisis. 
 
 The following quotation, from Mr. Brown's report for 1S87, shows the 
 present evidence of phtliisis in the native-born population : — " Tlie New 
 Zealand born were, in ly86, in tiie proportion of 51-89 per cent, of the 
 whole ])opulation. If this proportion be api)lied to the mean population 
 in 1887, the result would give ;)0l',4;")S persons, out of 590,374, as having 
 been born in the colony. The total number of deaths fiom phthisis 
 gives a projiortion of 8 •1)5 per 10,000 of the population; of these deaths, 
 15G were of persons born in the colony. This number gives a pro[iortion 
 of only 5-04: deaths from this cause per 10,000 of the New Zealand 
 born population. The remainder gives a proportion of l.j'17 deaths 
 from phthisis per 10,000 of the population born outside the colony." 
 
 In order to get exact results on this point, it would be necessary to 
 com] tare the ages of the two classes, viz., the native born, and those born 
 outside the colony. It is probable, that a larger proportion of the native 
 born, than of immigrants, is of an age at which consumption is not 
 connnon. The following table, ta/ken from Mr. Brown's report for 1887, 
 shows the ages of patients who have died from phthisis in New Zealand 
 in 7 vears : — 
 
 Table Y. ■ 
 
 The Xumher and Proportion per 100 Deaths from Phthisis in New Zealand^ 
 at each Age Period, for the seven years 1881 to 1887, inclusive. 
 
 
 Males. 
 
 Fe.males. 
 
 Xi.y. AT Death. 
 
 
 
 
 
 No. of Deatlis. 
 
 Per 100 Deaths 
 from Phthisis. 
 
 No. of Deaths. 
 
 Per 100 Deaths 
 from Phtliisis. 
 
 Under 5 years 
 
 50 
 
 2-54 
 
 55 
 
 3-70 
 
 5 to 10 years 
 
 14 0-71 
 
 37 
 
 2-49 
 
 10 to 15 years 
 
 19 1 0-97 
 
 64 
 
 4-30 
 
 15 tu 25 years 
 
 401 1 20-42 
 
 447 
 
 3004 
 
 25 to 35 yeais 
 
 .565 1 28-77 
 
 443 
 
 29-77 
 
 35 to 45 vears 
 
 433 22-05 
 
 263 
 
 17-67 
 
 45 to 55 years 
 
 308 
 
 15-68 
 
 119 
 
 8-00 
 
 55 to (55 years 
 
 131 
 
 6-67 
 
 42 
 
 2-82 
 
 (15 to 75 years 
 
 35 
 
 1-78 
 
 15 
 
 1-01 
 
 75 and upwards 
 
 7 0-36 
 
 2 
 
 0-13 
 
 Not specified 
 
 1 0-05 
 
 1 
 
 0-07 
 
 
 1964 1 100-00 
 
 1488 
 
 100-00 
 
 Wc may reasonably look for a higher death-rate from i)hthisis, there- 
 fore, among the native born in future years, without any real increase in 
 the development of the disease. 
 
 To sum up the results shown by the foregoing statistics, it may be 
 fairly said tliat they show that, in New Zealand, phthisis is a less fatal 
 disease to those of European blood, whether born in the colony or 
 immigrants, than it is in the other Australasian Colonies, with the 
 doubtful exception of Western Australia, or in Great Britain and 
 Ireland, from which the bulk of the population is derived. It might
 
 84 
 
 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 have been better to have included in this inquiry the whole family 
 of tuberculous diseases, of which pulmonary tul)erculosis is only a 
 branch. But, without going into details, which would make this paper 
 unduly long, it may be said that the same general statement is true of 
 the whole family, as of this, the chief branch. Strumous diseases of 
 glands, of joints, of the nervous system, etc., are as strikingly below the 
 average as phthisis. It is also as well to note that these statistics refer 
 almost entirely to the white population of New Zealand. The Maori 
 and half-caste population are j^eculiarly liable to tuberculous diseases of 
 all kinds, and these diseases are very fatal to them. 
 
 To what circumstances is this lesser liability to phthisis due ? In the 
 lirst i)lace, much must be ascribed to the climate of New Zealand. 
 Among the few observations on this subject, which come to us from the 
 earliest known period of New Zealand history, are the statements of 
 Captain Cook, and some of those who accompanied him, that among the 
 New Zealanders, disease was practically unknown. The fine physique 
 of the Maoris, still noticeable, was evidence that, in spite of the 
 uncertainties of their food supplies, and their exposure to the vicissitudes 
 of an uncertain climate, the general climatic conditions were such as to 
 favour the development of a race with very high physical qualities. In 
 1849, Dr. Thomson, surgeon to the 58th Regiment, then quartered in 
 New Zealand, published careful observations which he had made on the 
 health of troo})s serving in the colony. He found that, out of 1000 
 soldiers serving in New Zealand, 440 were admitted to the hospital for 
 treatment for various diseases, while among 1000 men serving in Great 
 Britain, the number was 921. For diseases of the lungs, he remarks, 
 the admissions wei'e one-third less numerous than among the troops 
 quartered in Great Britain. He also quotes the opinion of Surgeon 
 Pendergast, of the 65th Regiment, who stated, " the climate of New 
 Zealand is peculiarly favourable towards the non-development of 
 pulmonary affections, and, in the majority of fatal cases, the seeds of 
 disease existed before their arrival in New Zealand. Among the five 
 fatal cases in the 58th Regiment, the symjitoms of consumption had 
 been observed in three of them before their arrival in New Zealand." 
 
 Dr. Thomson also published in his report the following taltle, showing 
 the annual mortality in New Zealand among troops, as compared with 
 other British Stations. (His experience was confined to the North 
 Island) : — 
 
 Table VI. 
 
 I 
 
 I 
 
 
 An 
 
 NUAL Mortality 
 
 Annual Mortality by 
 
 
 PER 
 
 1,000 FROM ALL 
 
 Disease of the Lungs 
 
 
 
 Diseases. 
 
 PER 1,000. 
 
 Malta 
 
 
 18 
 
 6-0 
 
 Ionian Islands . . 
 
 
 2S 
 
 4-8 
 
 Bermuda 
 
 
 30 
 
 8-7 
 
 Canada . . 
 
 
 20 
 
 6-7 
 
 (iibraltai- 
 
 
 22 
 
 5-3 
 
 Cape of Good Hope . . 
 
 
 15 
 
 8-8 
 
 Mauritius 
 
 
 80 
 
 5-6 
 
 United Kingdom 
 
 
 15 
 
 8-0 
 
 New Zealand . . 
 
 
 10 
 
 5-7
 
 IXTERCOLONIAI, MEDICAL CONCIKESS OF ADSTUALA5IA. 
 
 P 
 
 Table VII. 
 Meteorologij. — Comfamtim Table of Climate, as observed at the Meteorological Stations in Nem Zealand, during t)te Tear 1886. 
 
 
 
 (iidS'and°£r"'tId). I 1'amp.ratar. from Self-iesistering Inrtrirnient.. 
 
 Computed fi'om 
 ObBurvationB. 
 
 Bail. 
 
 Wind. 
 
 Cloud 
 Mean. 
 
 S,mi.r 
 
 ofD«) 
 
 
 
 .1.1= i.r= 
 
 1 
 
 Tsmparatuni of Air in Shade. 
 
 Solar 
 Raitiatiou. 
 
 Terrestrial 
 Radiation. 
 
 il 1 ll !§ 
 ft ! i| i|s 
 
 _o 1 g3 Is"- 
 
 i 
 
 s 
 1. 
 
 1 
 
 Number of Days it blew from any Point : 
 Morning Obaei-^-ations. 
 
 
 fill 
 
 m 
 
 4 
 
 4 
 
 1 
 
 1 
 
 ri 1 
 
 ; — 
 
 
 Stations. 
 
 5 
 If 
 
 1 
 
 e83q 
 
 lifi 
 
 
 i 
 
 III 
 
 ill 
 
 s' — ' 
 
 J 
 
 J, 
 
 Sis 
 
 i 
 
 
 H 
 
 a 
 
 a -Ji -Ji 'f 
 
 ^•'3 
 
 , 
 
 1 
 
 
 ' Aiickliind 
 Rotuiua 
 WolUngton .. 
 
 IJnraln, Caiiter- 
 Dunedlii 
 
 in. 
 
 29 058 
 20016 
 
 in. 
 30-700. 
 20 May 
 
 30-SSO, 
 10 April 
 
 30743. 
 20 Hay 
 
 S0-8S1. 
 ISApril 
 
 30840, 
 M,iy 
 
 ill. 
 29830, 
 2 Seiit. 
 
 20:250, 
 2 Sept. 
 
 2 Sept. 
 
 28-214, 
 22 Aug. 
 
 2805T, 
 22 Ang. 
 
 in. 
 1-130 
 
 1-000 
 
 1-070 
 
 1-0!0 
 1802 
 
 Fah. 
 501 
 
 55-1 
 
 64-4 
 
 51-9 
 
 Fah. 
 82-0, 
 
 22 Jan. 
 
 90-5. 
 
 23 Jan. 
 
 25 Jan. 
 7 Jan. 
 
 Fab. 
 
 28 Aug, 
 
 21 -5, 
 6 Aug. 
 
 32-0, 
 
 26 July, 
 28 Aug. 
 
 22 July 
 
 30 0, 
 "22 July 
 
 Fah. 
 40-0 
 
 080 
 r,4 
 
 Fah. 
 
 ■23-3 
 121 
 
 Fah. 
 1530, 
 11 Feb. 
 
 lSO-5, 
 8 Dec. 
 
 1500, 
 30 Dec. 
 
 Fah. 
 
 114 2 
 115-0 
 
 Fah. 
 
 28-0, 
 
 7 July 
 6,7,28Aug. 
 
 Aug. 
 
 27-0, 
 ■IS Aug. 
 
 13-S, 
 ■-'2 July, 
 
 Fah. 
 43-7 
 
 41-4 
 
 43-3 
 
 -374 
 -306 
 -338 
 
 ■288 
 •289 
 
 Fah. 
 
 44-5 
 47-8 
 
 43-4 
 43-7 
 
 70 
 
 76 
 
 in. 
 
 32-649 
 
 61-790 
 64-477 
 
 52-032 
 
 dayg. 
 
 169 
 
 138 
 178 
 
 1-670, 
 Feb. 
 
 3-100, 
 Sept. 
 
 3'400, 
 14 May 
 
 16 May 
 19 Aug. 
 
 28 
 30 
 3 
 
 12 
 
 86 
 63 
 19 
 
 104 
 93 
 
 7 
 
 13 
 
 
 
 19 
 63 
 
 21 
 
 62 
 60 
 
 10 
 13 
 
 93 
 61 
 114 
 
 32 
 
 41 
 
 109 
 24 
 
 45 
 23 
 
 80 
 
 165« 
 
 191 
 218 
 
 813,' 
 
 8 Sept, 
 
 .00, 
 
 9 Doc. 
 
 67.5, 
 3 Nor. 
 
 610, 
 20 Not. 
 
 6^9 
 *2 
 
 5^9 
 
 36 j 7 
 4 14 
 67 7 
 
 27 j 3 
 18 I 
 
 
 3 
 
 1 3 
 
 1 ! 
 
 8 11 
 5 19 
 
 1, 
 
 
 r 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •Ten 
 
 inoutha only. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 PHTHISIS IX NKW ZEALAND. 85 
 
 Tn a subsequent ]ia])f'r on tlie diseases of the New Zealanders, 
 contril)uted to the Afci/ico-Chintrf/ical Reviev, in 1854, he says : — ■ 
 " Diseases of the lungs are much more frequent among the New 
 Zealanders than the Englisli. The great prevalence of diseases of the 
 lungs does not arise from the climate, but from causes peculiar to the 
 New Zealanders tliemselves. This I assume, from the comparative 
 rarity of cough and consumption among the European population." I 
 have quoted Dv. Thomson's experience at some length, as the conditions 
 he observed are not likely to occur again, and the results among .soldiers, 
 presumably of the same average tendency to disease, in various parts 
 of the world, ai^e valuable for comparison. The main facts as to the 
 climate of New Zealand are, that there is everywhere an absence of 
 extremes of heat or cold ; that nearly every part of both islands is freely 
 swept by the ocean winds ; that malarial conditions do not exist ; that 
 rain is abundant enough, but not excessive ; that the drainage by rivers 
 is good, and swampy districts are few. There are five meteorological 
 Stations in New Zealand, namely, at Auckland, Rotorua, Wellington, 
 Lincoln in Canterbury, and Dunedin. With the excei)tion of Rotorua, 
 none of these, however, give a just representation of the climate of 
 New Zealand away from the coa.st. The annexed table (VII.), from the 
 Government Blue Book, shows the results of observations at the various 
 stations during the year 1886. 
 
 The inland climates tlifFer in many respects from those of the coast, 
 but exact observations have yet to be made on the subject. Much of 
 the country occupied by settlers is from 1000 to 2000 feet above sea 
 level. The air is drier than about the coast ; there is less rain ; and the 
 temperature is higher generally in summer, and lower in winter, than 
 nearer the sea. Along the range of moiiutains in the South Island, the 
 climate is that of similar districts elsewhere in like latitudes. The air 
 is fresh and exhilarating ; there are magnificent lakes, rivers, and 
 glaciers to be explored ; but, as the country is little settled in many 
 places, much of it is not avai]al)le for invalids. 
 
 The table given re[)resents fairly the climate of the coast, but many 
 important points must be left out in such records. Places which are 
 sheltered from the south-west gales are much warmer than exposed 
 places in the same or higher latitudes, and there are many important 
 local varieties of climate in each district. Thus, for instance, the 
 northern part of Stewart Island is warmer in latitude 47° in 
 winter, than Christchurch in latitude 44°. Nelson, Blenheim, and 
 Napier are places whose climates are not represented by any of the 
 statistics as to Wellington, Auckland, »i'c. The west coast of the 
 South Island is only settled in a few places, but there is every reason 
 to believe that the rainfall all along that coast is greater than elsewhere 
 in New Zealand. It is inqwssible in this paper to deal with all the 
 local varieties of climate, but this can be said of every part of New 
 Zealand — that the clii.iate is favoui-able to out-door work and recreation 
 of all kinds, at all seasons of the year; and all kinds of out-door sports 
 are much in favoiu" with all classes. 
 
 Another factor favourable to health generally, and which tends to 
 reduce the mortality from phthisis especially, is the absence of large 
 towns. The largest population in any one centre does not exceed 50,000 ;
 
 SQ INTERCOLONIAL MEDICAL COXGKESS OF AUSTRALASIA. 
 
 even in tlie largest towns, Auckland and Dunedin, there is very little 
 overcrowding. The houses are, many of them, built of wood, and well 
 ventilated ; often of one story only, and with abundance of open spaces 
 either round about them, or in the vicinity. The drainage is in many 
 cases defective, but on the whole, the conditions ai-e vastly more 
 favourable to human life — as shown by that most delicate test, a low 
 infant mortality — than in the towns and villages of the old world. 
 
 The social condition of the people must also count as an important 
 favourable item. Good food is abundant and cheap. There is nowhere 
 the grinding jioverty that is to be found in the larger centres of 
 population. Wages, even in depressed times, are high enough to assure, 
 to every man who can work, good food and clothing, and lodging for 
 himself and those dependent on him. Probably, as a consequence of 
 this, drunkenness, and the evils that spring from it, are on the decrease. 
 The nati\e-born New Zealander very rarely drinks to excess, or, indeed, 
 cares much for alcoholic stimulants of any kind. He plays football and 
 cricket, and is interested in all athletic contests ; in tliis, resembling his 
 brother colonists in other parts of Australasia. 
 
 The occupations of the people must also have an important part to 
 play in their tendencies to disease. In a paper read before the Otago 
 Branch of the New Zealand Institute, by Professor Mainwaring Brown, 
 of Dunedin, in 1888, the number of hands engaged in manufactories is 
 given as 22,102, or 3"8 per cent, of the total population. The total 
 producing population he estimates to be about 101,000, including those 
 engaged in agricultural and pastoral pursuits and mining. In addition, 
 lie estimates t)ther industrial classes, consisting of those engaged in the 
 building trade, labourers, distributors, and others, as about 48,000, 
 
 As, however, none of the manufacturing indi;stries are conducted 
 under the bad hygienic influences that prevail in large communities, 
 they can hardly be properly compared with those of older countries. 
 The large j^roportion of people engaged in agricidtural and i)astoral 
 work, along with those depending on them, are little disposed to 
 ]ihthisis. But observation of cases seen in practice shows that in New 
 Zealand, as elsewhere, jjhthisis is often produced i]i the workshop, the 
 compositors' room, and in coal and other mines. 
 
 The settlers, as a rule, were drawn from a healthy class. This may 
 be said to be counterbalanced by the fact, that the Colony has also 
 attracted a large number of families predisposed to tubei'culosis ; and 
 also, that along with the good colonists, many of another stamp have 
 been introduced, by unwise innnigration laws and other influences. 
 
 TJie main practical deductions that I would make from the facts 
 stated are, that the native-born ])opulation of European blood of New 
 Zealand, and the imnngrants of Europe;in birth living in New Zealand, 
 are less subject to phthisis than their fathers, or than those who are 
 born in or settled in other Australasian Colonies, and that the causes 
 of this are mixed, but are mainly that the population, as a whole, is 
 well fed, well cared for, and has abundance of i)ure air to breathe. 
 
 The curious fact that the JNIaoris and half-castes are s]jecially 
 vulnerable to tuberculosis, is cajjable of explanation by several lines of 
 facts. In the first i)lace, all the .South Sea natives, brought into contact 
 with Europeans, seem to ac(]uire tuberculosis and infectious diseases 
 easily and viiulently. This is also noticeable among the aboriginals of
 
 TKEATMENT OF IMITIIISIS liV CLIMATK. 87 
 
 Australia. It is, doubtless, due to the fact that tuberculosis is, to a 
 certain extent, an infectious or bacillary disease. 
 
 The altered habits of the natives, their dirty habits, their prolonged 
 idleness, and csjiecially their custom of congregating in large nund)ers 
 in close, ill-ventilated huts, where they breathe the same air over and 
 over again, are among the most imjjurtant jjredisposing causes. Dr. 
 Hocken, of J)unedin, who has had a lai-ge and exceptional experience 
 of New Zealand, informs uie that he is of opinion that the adoption of 
 European blankets and European clothes, instead of the native flax mat, 
 is a ])Owerful predisposing cause. The native gets overheated in the 
 unaccustomed garments, throws them otF, and becomes chilled and 
 depressed in consei^uence. It seems to me not unlikely, too, that the 
 fact that tuberculosis is a new disease among them, may account partly 
 for its fatal etiect. European populations have been fighting this and other 
 infectious and constitutional diseases for centuries, and are, to a certain 
 extent, protected iigainst them. There has been no such contest among 
 the inhabitants of the Oceanic Islands, until comparatively recently 
 isolated from the outside world, and consequently there has been no 
 such protection as Eui'opean populations have acquired. 
 
 It is no part of the scope of this jmper to discuss either the pathology 
 oi" the treatment of consumption. [ believe that the part, played by the 
 bacillus of Koch, is analogous to that taken Ijy the torula in yeast 
 fermentation. It needs, like the yeast torula, certain conditions for its 
 development, and these conditions have been hitherto called, and I 
 think justly, the causes of consumption. That many of these conditions 
 are absent in New Zealand is, I chink, the chief reason for the smaller 
 mortality from consum})tion in tiiese islands. It cannot be too strongly 
 urged, that there is no specific in the New Zealand climate which will 
 cure advanced cases of phthisis. The range of climatic treatment is 
 limited here as elsewhere, and I will only add my ])rotest, to that of 
 others, against the crUelty and uselessness of recommending a sea voyage, 
 and residence in the Colonies, for a very large number of the cases of 
 consumption which come under the notice of physicians at Home and 
 elsewhere. 
 
 TREATMENT OF PHTHISIS BY CLIMATE. 
 
 By DuxcAX Turner L.B.C.S. Ed., L.R.C.P. Loxd. 
 
 Within th(j last twelve montlis, I have seen a number of patients 
 who had resided, some of them in winter and some in summer, 
 in the higher jjarts of the Alps, chiefly St. Moritz. They were 
 unanimous as to the benefits tliey had dei-ived from their sojourn 
 there. 31any of them had visited other resorts, but they all gave the 
 jneference to the high altitude stations. The })rincipal drawback, with 
 respect to Aljiine health retreats, is the expense. It is not a treatment 
 that any poor man, or even a ])erson with a moderate income, can adopt. 
 And many jjoor jjeople, or those of limited mean.s, find their way to our 
 .shores in tJie hojje (alas! too often delusive) that they can regain 
 liealth, and at the same time earn a livelihood in our genial climate.
 
 88 IXTEKCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 The oliject of this paper is to refer shortly to the Australian 
 climates suitable to consumptive invalids. In order to bhorten as 
 much as possible my remarks, I will sketch briefly the necessary 
 information. The inhabited ]iortion of settled Australia may be 
 divided mainly into three divisions — the littoral, or shore division, 
 which is at present the most populous ; the great mountain chain, 
 commonly called the Dividing Eange ; and the great inland plains 
 beyond. The first of thes-e may be dismissed at once, as it is 
 generally acknowledged that, with the exception of a few sheltered 
 nooks on the coast, it is entirely unsuited to the phthisical invalid. 
 The mountain chain is of more interest to us, although, so far, a great 
 deal of it is practically so little known that we can only speak of a few 
 mountain localities where real settlement has taken place. In comparing 
 our mountain regions with those of Europe, Asia or America, we are at 
 once struck with the fact that our mountains are generally so restricted 
 in height, that the high altitude treatment can never be carried out here 
 in its entirety. • But, taking them for what they are, I believe that they 
 have been strangely overlooked by medical men in this country. In 
 recommending to patients, Avho cannot take a sea voyage, a suitable 
 residence in summer, where can we send them to, unless it is to the 
 mountains 1 Unfortunately, the accommodation at most of our 
 mountain resorts is entirely inadequate to the wants of an invalid 
 patient. Also, our information res^pecting the climates of the most 
 elevated, is meagre and unsatisfactoiy. For some time past, I have been 
 making inquiries in this direction. The highest settled parts of 
 Australia are, the Blue Mountains, near Sydney, and Mount Macedon, 
 near Melbourne. Tliese places have not, as yet, been specially 
 recommended to chest sufferers, but I may mention that I have myself 
 known several patients to be much benefited by residence there. And 
 in, at least, two cases there was apparently perfect restoration. 
 
 With the exception of a few towns in New South Wales, there are 
 no settled districts in any of the colonies at a sufficient elevation to 
 afford relial)le data on the question of the immunity of the inhabitants 
 from phthisis. To the practitioners of these towns, however, I addressed 
 some time ago a few questions. The majority of the communications 
 were obligingly responded to, and 1 will now give a brief .sketch of the 
 replies. 
 
 From Bathurst, 2153 feet above sea level, Dr. Basset writes: — ''In 
 a practice of twenty-five years, I have only seen about six cases of 
 phtliisis originating here. In this nundjer, I don't include aboriginals." 
 
 From Crookwell, near Goulburn, 3000 feet above sea level, Dr. 
 A. E. Fitzpatrick writes : — " In a practice of over four years in this 
 neighboiirhocd I have not seen a single case of phthisis, nor haA'e I 
 heard of one." 
 
 From Bowenfels, close on 3000 feet above the sea, Dr. Asher writes : — 
 " I have seen but one case of jihthisis that originated here, and in that 
 case the ))atient recovered." 
 
 From Armidale, New England, 3300 feet above sea level, Dr. INlallam 
 writes : — " I do not know of any case of phthisis originating in our 
 tow}i or neighbourhood. My colleague. Dr. Wigan. who has been 
 l>ractising heie for thirteen oi- fourteen years, says he has never seen a 
 native-born New Englander develo{)ing i>hthisis."
 
 TlilCATMKXT OF PHTHISIS ISV CLIMATK. 89 
 
 From Walclia, another town of New England, 3300 feet above sea 
 level, Dr. Boodle writes : — " In nine years' pi-actice I have seen but one 
 case of jththisis, in a yellow boy, and he recovered." 
 
 I might give you more of these extracts, but they are all much alike, 
 and go f:ir to prove that in this country, as well as Euroi)e and Amei'ica, 
 the inhabitants of high altitudes have a remarkiil)le immunity from 
 phthisis. 
 
 As yet, no attempt has been made to found a mountain sanatorium 
 in Australia. Toowoomba, in the Darling Downs, Queensland, has the 
 nearest approach to one. Its winter climate is delightful, but the 
 altitude (barely 2000 feet) is insutiicient for rarefaction of atmosphere. 
 In the Australian Alps, however, tliere are several elevations equal to 
 that of Davos Platz, or St. Moritz, in Switzerland ; but, as yet, there is 
 no accommodation for invalids. This time last year I spent a week at 
 the Hospice, near Mount Hotham, in the Australian Alps, in Victoria. 
 The old man who ke])t the house of accommodation for travellers had 
 lived there, I think, 20 years. His })owers of observation concerning 
 tlie weather were not of a high order, but, from what I could gather, 
 there are several months of winter there, especially if the weather 
 happens to be dry, that are very much like the weather recorded in the 
 celebi-ated DaA'os Platz. The altitude is exactly the same as that of the 
 famous Swiss resort. tTnder any circumstances, this would be a delight- 
 fully cool place for invalids during the summer months. Rarefaction 
 and sunlight would be the same as at .similarly situated stations in the 
 Swiss Alps, which are proved to be highly beneficial. It is to be hoped 
 that ere long Victorian enterprise will })rovide adequate accommodation 
 in this beautiful spot, which, I have no doubt, would be soon largely 
 patronised. I have merely given this sketch in order to direct the 
 attention of Australian practitioners to the advantages of mountain 
 climate — advantages which, so far as I am aware, have not been touched 
 U[ion as yet by any local medical writer. 
 
 The last climate I will refer to in this paper is that of the great inland 
 plains of Australia. This climate is so well-known to most of you, that 
 it will not be necessary for me to enlarge on its properties. Briefly, it 
 may be described as something between the climate of the Riviera and 
 that of Egypt, dryer than the former, but not quite so dry as the latter. 
 Its chief recommendations to the chest invalid are — dryness, plenty of 
 sunshine, and moderate temperature, thus enabling a patient to pass a 
 great deal of his time in the open air, a most important i)art of treatment 
 in phthisical cases. That hundreds have recovered from passing two or 
 three winters in Riverina, I have no doubt. I have myself known 
 several instances, and other Melbourne practitioners have done the 
 same. The great plains are so much alike, that there is no need to 
 mention any [jarticular locality. In Victoria, we send our patients to 
 Echuca or Deniliquin for the wintcn-. If the rain maps can be depended 
 on. the districts of Swan Hill and Wentworth are the driest of the 
 Riverina district, and possilily a sanatorium may start up at one |tlace 
 or the other at some future time. 
 
 In giving a brief resunu' to this pa))er, I may state that I consider the 
 ocean cliuiate the best. After that, the high altitude climate at or above 
 3000 feet. Thirdly, comes the climate of the great inland plains. 
 Lastlv, there is the climate of the marine resorts.
 
 90 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 THE r)PEN-ATPt TREATMENT OF PHTHISIS. 
 By James- P. Ryan, 3I.K.Q.(J.P.I., L.R.C.S.I. 
 
 Chevalier of tlie Legion of Honour. 
 
 Graves says: " It is of great im})ortanee to know liov/ to make a man 
 plitliisical, as, by pursuing an opposite line of conduct, we shall be able 
 to prevent it," and, I may add, to cure it. 
 
 Xow, what are the conditions of living which tend to produce phthisis 'i 
 They are mainly such as cause an impaii*ed condition of general health, 
 and a l.owered vitality. Amongst these, ovtrcrou'Jiny and impiii-e air 
 hold the most important positions. We know that men may be subjected 
 to great hardships, such as exposure to wet and cold, want of food and 
 rest, fatigue, etc., without running the same chance of falling victims to 
 phthisis, as if they were huddled together in a confined space, and, 
 though supplied with a sufficienc}' of wholesome food, were deprived of 
 fresh air and exercise. And this applies not only to man, but very 
 largely also to the animal kingdom. Villemin, in the course of his 
 experiments, found tliat guinea pigs which were kept crowded together 
 had less power of resisting tuberculosis than those Avhich were allowed 
 more space and air. Aifections of the respiratory organs are far moi-e 
 prevalent amongst stabled horses, than amongst those that are running 
 out. 
 
 Experience, from all time and in all places, goes to show that those 
 who lead an outdoor life are more robust, and less prone to lung diseases, 
 than those whose occupations confine them within doors. I am informed 
 by those who knew the Australian aboriginals well, that phthisis used 
 to be very uncommon amongst the wild or half-civilised ones. Those 
 who adopt the customs of the white man, easil\- fall victims to it. The 
 Araucanian Indians, whose country — a level plateau some hundreds of 
 feet above the sea — lies in the southern part of the Sjtanish-American 
 Republic of Chili, are seldom affected with phthisis. I believe I am 
 correct in this statement. I lived close to their frontier for some years, 
 and my information was obtained by personal observation, as well as by 
 incjuiry. On the other hand, amongst their neighbours across the 
 border, the Chilenos, the disease is widely prevalent ; and markedly so, of 
 course, amongst the dwellers in towns. I attribute this to the fact that 
 the Chilenos are morbidly sensitive to cold — almost every ill that flesh is 
 heir to being jiut down to an " aire " or draught ; and air, being thus 
 looked upon as an enemy, is carefidly excluded. Hirsch says that 
 " phthisis is tmknown among nomad tribes, such as the Kirghiz of the 
 Central Asian Steppes, or the Bedouins of Arabia,, until these ])eopl(' 
 settle in towns." The same imu) unity from phthisis is observed in the 
 dwellers on high mountains, due, without doubt, to the sparse population, 
 and the active outdoor life which they lead, as well as to the purity of 
 the atmosphere which they breathe. As soon as they congregate together 
 in towns, the iunnunity is lost, and the disease is found to prevail at 
 (^uito, Cuzco, and Potosi, which are resjiectively 10,000, 11,000, and 
 13,000 feet above the level of the sea. 
 
 Dr. Guy found that of lOi comjjositors who worked in rooms having 
 less than ."'(.)(j cubic feet of air s})ace for each person, 12 jjer cent, had
 
 THE OPEX-AIll THKATMKXT OF PHTHISIS. 91 
 
 had blood-spitting. In 100 who worked in rooms having a capacity of 
 more than GOO cubic feet for eacli person, only 2 per cent, suffered in 
 this way. Dr. Eansome, in his paper on " Tubercular Infective Areas," 
 read before the Epidemiological Society in 1887, referiing to Salford, 
 says :— " In certain streets and courts, consisting of back to back houses, 
 unfurnished with through ventilation, tubercular disease was much more 
 common than in other jjarts of the same town ; and such disease occurred 
 again and again in the same houses." And this w^as subsequently fully 
 confirmed by a report made to the Local (lovernment Board by Dr. 
 F. W. Barry and Mr. Gordon Smith. 
 
 The day has passed when physicians pinned their faith to medicines 
 in the treatment of this disease ; and of the numerous remedies, from the 
 hypo])hosphites to Bergeon's gaseous enemata, which have been vaunted 
 as specifics for consumption, not one, excepting perhaps cod liver oil, 
 has enjoyed anything beyond an ephemeral reputation. Instead of 
 concentrating the attention on the local symptoms, as was formerly too 
 much the custom, the modern physician addresses himself to repairing 
 and strengthening the constitution of his patient, by sending him to the 
 country and telling him to eat well, and be as much as possible in 
 the open air. The few lucky ones who can afford the expense arc 
 recommended to try the mountains of Switzerland, or the high lands 
 of the Cape, or they are ordered u})on a long sea voyage ; and, without 
 doubt, the "mountain" and the "sea" cure, as they are called, have 
 often been attended by the happiest results. In the early part of the 
 present year, Dr. Theodore AVilliams gave the results of the treatment 
 of 141 cases of phthisis in his practice, by residence in high altitudes, 
 5000 to 9000 feet above the sea, and in 70 per cent, great improvement 
 took place, whilst in 30 per cent, there was complete .irrest of the 
 disease. Many are relieved, and their lives are prolonged, if they are 
 not cuved, by a residence on the table-lands of South Africa, or in the 
 Australian bush. 
 
 What then is it which has so beneficial an etiect upon the consumptive 
 patient, and which is found upon the mountain top, on the sea, and in 
 the desert ? Without any doubt, it is pure air. 
 
 The number of bacteria in a given (juantity of air is the best test of 
 its impurity ; and in this light, the following table is interesting, as 
 showing the result of observations made by Miquel on the Swiss 
 Mountains and in Paris : — 
 
 At an elevation of from 2000 to 1000 
 metres, in 10 cubic metres of air 
 
 On the Lake of Thun, 560 metres 
 
 Near Hotel Bellevue, Thun, 560 metres . 
 
 In a room of the same hotel 
 
 In the Park of Montsouris, near Paris 
 
 In Ptue de Eivoli, Paris 
 It would be intere.sting to know the result of an examination of the 
 air of a house in that street. And so, also, the atmospliere above the 
 ocean, in forests, and in the desert, as gauged by this test is nearly, 
 if not quite, pure. 
 
 Tlie tssential condition for success in the treatment of consumption is, 
 that the patient be kept constantly surrounded by the purest possible 
 
 <J bacteria 
 
 o 
 
 25 
 
 
 600 
 
 !) 
 
 7,600 
 
 5> 
 
 55,000 
 
 •)
 
 92 INTERCOLOXIAL MEDICAL COXGRESS OF AUSTRALASIA. 
 
 atmosphere. In tlieoiy, this is perhaps admitted by a hwge numl)er of 
 medical men, but in practice I am quite sure tliat the principle is not 
 carried out sufficiently far. Dr. Russell Reynolds, in his " System of 
 Medicine," gives sensil)le advice about diet, exercise, bathing, &c., and 
 speaking of a pure atmosphere, says : — " The grmt end he (the 
 physician) should aim at is, to surround his patients with as much pure 
 air as possible, consistent with warmth and absence of draughts. In 
 summer, [lood ventilation should be secured by letting down the windows 
 an inch or so at the top." I presume he means the bedroom windows at 
 night-time, though he does not say so, and he is silent about ventilation 
 in ii'inter. Coming from such an authority, this may, I presume, be 
 taken as a fair example of the prevalent idea held by medical men, or, 
 at all events, by many of them, of surrounding a phthisical patient with 
 pure air. Cthers suppose that, by keeping the window^s w^ell opened 
 during the day, they secure a supply of fresh air for tlie night ; a mere 
 delusion, I need hardly say, though it is better than excluding the air 
 both by day and by night. The patient should be constantly surrounded 
 by ])ure air. This is the ideal, but it is scarcely attainable in practice, 
 though, under favourable conditions, we may come near to it. 
 
 Conjure u]i for a moment the actual surroundings of an ordinary 
 phthisical })atieiit. He is in a chair, or in bed, in an apartment which 
 is at the same time his sitting-room and bed chamber. Even in fine 
 weather he wears an unnecessary amount of clothing, including two or 
 three shirts, which are not too frequently changed, and a chest protector 
 of wool or chamois leather. His bed coverings ixre soaked in foul- 
 smelling sweat, the windows are closed, the chimney stopped up, and he is 
 inhaling, during the greater part of the twenty -four hours, an atmosphere 
 reeking with impurities. I ask you, is it reasonable to expect 
 favourable results from any mode of treatment in a patient with such 
 surroundings 1 
 
 The first necessity, then, is that the consumptive be constantly, both 
 by day and by night, in the purest possible atmosphere. Where it is 
 feasible, send him to the mountains, to the desert, or on a long sea voyage ; 
 but tell him that, in oi'der to obtain the greatest amomit of benefit under 
 such favourable conditions, the air which he breathes during the long 
 hours of the night should be nearly, if not quite, as pui'e as the 
 atmosjihere by which he is surrounded during the day. 
 
 Unfortunately, by far the largest number of those suffering from 
 jihthisis are debarred, by want of means, from resoi-ting to the mountain 
 or sea "cure." But many might live in the country, instead of in town; 
 or in a suburb, instead of in the midst of a crowded population ; and 
 even the condition of the denizens of the lanes and alleys may be 
 improved, and they may be helped on towards recovery by imi)roving 
 their surroundings. The fear of air, and paiticularly of night air and 
 cold, entertained by the patient and by his friends, is groundless, and 
 must be coni])ated. Many i)hthisical patients are morbidly sensitive to 
 the slightest cold air or wind ; but this is ])roduced in some, and in all 
 greatly j\ggriivated, by over-clothing, and remaining indoors in a close 
 atmosphere. This hyper-sensitiveness of the skin and bronchial mucous 
 membrane is surely and rapidly lessened by te})id or cold ablutions, 
 followed by frictions with a rough towel or brush, and 1y being in the 
 open air.
 
 PNEUMATIC THERAPEUTICS RY MEANS OF P0UTA15LE APPMJATUS. \j'., 
 
 Not 80 very long ago, I was opposed to the establisliment of special 
 liospitals for the treatment of consum])tives, but I have come to recognise 
 the hopelessness of their condition, as patients in a general hospital. 
 They enter such, not to get better, but to die. But even our general 
 licspitals miglit be so improved as to be made more suitable for such 
 patients, by the addition to them of wide verandahs, where those who 
 could not walk about, or sit in the gardens (I assume the existence of 
 such), might lie in the air all day long, and all night long in fine weather, 
 as is the custom in the Augusta Hospital at Berlin ; or else tents, or 
 summer houses of light porous material, should be erected in the grounds, 
 which might be occupied during the sunnner months, if not all the 
 year round. Time will not permit of my entering into details of the most 
 suitable sites for, and the best mode of construction of, special institutions 
 for the treatment of phthisical patients. In Victoria, the sea-side 
 lias many advantages, not the least of which is the possession of a 
 tolerably equable temperature throughout the year, and a background 
 of wholesome scrub or forest country. The arrangements in such an 
 institution as the National Hospital for Consumption at Ventnor, 
 England, particularly in the new part of the buildings, are, on the whole, 
 excellent. It consists of blocks, each to accommodate 12 patients, each 
 patient having a separate sleeping apartment. Then there are sitting 
 and dining rooms, large balconies, and a system of ventilation partly 
 natural, partly artificial, by which 5000 cubic feet of fresh air, at a 
 temperature of 62^ Fahr., is supplied to each patient per hour. Of 
 course, all this means the expenditure of very large sums of money ; ami 
 yet it is exceedingly probable that Ijetter results might be obtained from 
 housing the patients in tents, huts, or in other light iMiildings constructed 
 of porous material. Whatever objections, on the score of coldness, 
 may be made to tliem in the countries of Northern Europe, where the 
 winters are long and severe, such objections cannot be valid here in 
 Victoria, where, by comparison, they are short and mild. But in 
 reality there is no difficulty whatever in warming the interior of such 
 constructions by means of open fire-places, stoves, and other appliances, 
 which may be utilised without taxing too severely the ingenuity of the 
 architect or the medical man. 
 
 ON PNEUMATIC THERAPEUTICS BY MEANS OF THE 
 PORTABLE APPARATUS. 
 
 By V. Mar AND, M.D., K.C.L 
 
 Consulting Surgeon to the Sycluey Benevolent Asylum, etc. 
 
 The article which first drew to this subject the attention of the 
 Australian pi-ofession, if I am correctly informed, was ])ublished by ma 
 in the Australasian Medical Gazette for September 1886. It made no 
 pretensions to completeness, and was written with the ho))e of 
 encouraging the adoption of a partially, if not wholly, neglected inode 
 of treatment. 
 
 My remarks, on the present occasion, are intended to apply i)rinci]>ally 
 to aero-therapeutics — that is to say, to the mechanical treatment of
 
 94 INTERCOLONIAL MEDICAL COXGRESS OF AUSTRALASIA. 
 
 certain affections of the resi)ii-atorv organs by means of alteration in 
 the jiressure and composition of atmospheric air, applied liy ajiparatuf. 
 that will act on the pulmonary surface only, or on this and on the 
 general surface of the whole body at the same time. The a]>paratus 
 used for carrying out the above principles are various. Later on I will 
 mention those used by me, and among the veiy many others, I will make 
 S])ecial mention of the one used by the American ]ihysicians, called by 
 them the difterentiator, and its action pneumatic differentiation, which is 
 thus descriljcd b}- its inventor, Dr. H. F. Williams, of Brooklyn : — ■" It 
 consists in immersing a patient in a partial vacuum, thereby removing 
 to a sufficient degi'ee the external pressure of the atmosphere, and at 
 the same time supplying the lungs with air at its normal pressure, and to 
 a greater or less extent impregnated with the substance which it is desired 
 to administer." Though at tirst siglit different, yet is the differentiator 
 the same in its effects as the administration of compressed air, the 
 superiority of the apjiaratus being the facility and thoroughness with 
 ■which remedies can be carried into the lungs. The Atmiometer of 
 Professor Jacobelli is an apparatus quite different from all others, and 
 almost perfect, with which we can carry out this mode of treatment 
 according to our most advanced knowledge. It is very comi>lex ; in 
 fact, is a combination of different apparatus, each having special purpose, 
 while all harmonise to form medicated atmospheres, and convey in 
 definite (quantities into the different organic cavities, normal or patho- 
 logical, any drug in the shape of spray, of varying fineness, or of 
 impalpable powders and solutions, having as menstruum the air 
 compressed or rarefied, or water for those cavities that tolerate it. 
 
 By whichever apparatus compressed air is received into the lungs, ue 
 have — First, a greater pressure acting on the superficies of them than 
 the one acting on the superficies of the body. This high-pressure air 
 will comi)letel3^ distend the lungs and expand the thorax. 8econd, this 
 positive pressure on the pulmonary surface will aid the action of the 
 inspiratory muscles, and so facilitate inspiration itself. The effect of 
 in.spiration, under these conditions, is a greater dilatation of the lungs 
 anil thorax than can be brought about even with the deepest natural 
 inspiration. Waldenburg has proved by expei'iments that a sti'ong 
 healthy man. after the deepest inspiration of atmospheric air, measured 
 across the chest 98 centimetres. After inspiration of air comjiressed to 
 + -^yX) atmosphere, the measurement was 100 centimetres, and when the 
 air Was compressed to -F J- atmosphere, it was 101 "5 centimetres. Then, 
 again, it has been calculated that the quantity of compressed air, which 
 can l>e forced into the lungs, may amount to 1000 centimetres more than 
 the quantity taken under the normal atmospheric pressure. The ultimate 
 results of the two factors mentioned, viz., increased intra-pidmonary 
 ]iressure, and increase of respiratory air, will be an increase of the vital 
 capacity of the lungs. Again, the respiratory air, in consequence of its 
 greater volume and tension, offers a greater resistance to the elastic 
 tissues of the pulmonary cells and to the expiratory muscles — hence, a 
 niore copious removal of the resi)iratory air, and an increased activity of 
 tlie ventilation of the lungs; that, of course, is if the pressure of the 
 condensed air is not so great as to overcome the natural elasticity of the 
 lungs, and cause emphysema.
 
 PXEUMATIO THHKAPKUTICS BY MKAX.S OF POiri'AlU.K APPAIJATL'S. 95 
 
 On tlie otluT hand, l>y expiration into rarefied uir, we can olitain the 
 following eftects : — Removal of larger qnantities of air fr.ont the lunos 
 than in ordinary expiration (from a few hundred to 10(tO cubic centi- 
 metres) ; an acceleration of the exchange of gases, hy the pumpin" out 
 of a considerable portion of the residual air, charged with carbonic acid, 
 and the admission of a largei- quantity of atmospheric air, charged with 
 oxygen ; diminution of the circinnference of the thorax, the retraction of 
 the lungs, the increase of the inspiratory and expiratory force, the 
 augmentation of the vital capacity of the lungs (Oertel). So by this 
 method we can remove dyspnrea, which is the result of expiratory 
 insutiiciency, as is the case with emphjsematous })atients, who at once 
 feel a progressive relief, and leave the apjmratus without a trace of 
 dyspna?a. 
 
 Of the effects on the circulation, as well as of the chemical effects of 
 acro-therapeutics, I will simjily say that the former are the same as in 
 normal respiration, only altered in jjroportion to the extent of 
 condensation of the air, and the mechanical force brought into play by 
 it ; and the latter by the quantity of ox\'gen absorbed, which will 
 produce a more active state of nutrition. These are effects apart from 
 those caused by the action of the remedy, with which the air may be 
 charged. From what precedes, it is easy to see that this method has a 
 large range of a[>plication, in the treatment of the various diseases of the 
 lungs. 
 
 Out of the whole number of cases (about GO) treated l)y me with this 
 method, I had written the history of 36, which 1 at first intended to 
 read as an appendix to this paper j but this being already lengthy, 
 I am unable to do so. Twenty, however, of the 36 cases were, with 
 description of apjjaratus used, etc., published in the Austrdlasian Medical 
 Gtndte for November 1887. The remarks that follow are based chiefly 
 on the clinical results obtained in those 36 cases, which are thus 
 divided : — 
 
 Asthma ... ... ... ... 4 
 
 Acute bronchitis ... ... ... 3 
 
 Chronic l^ronchitis ... ... ... 4 
 
 Premonitory and fii^st stage of phthisis ... 10 
 
 Chronic phthisis ... ... ... 
 
 Acute phthisis ... ... ... 1 
 
 Chronic pharyngo-laryngitis ... ... 2 
 
 Chronic Ehinorrhcea ... ... ... 1 
 
 Acute exudative pleurisy- ... ... 1 
 
 Pleuritis adhesiva clironica ... ... 1 
 
 36 
 Of the four cases of asthma recorded, one did not tolerate the 
 mechanical treatment, the other three received the most marked benefit 
 from it. Case No. .^» found relief from all the painful symptoms of 
 dyspncea only by the use of compressed air, the usual remedies having 
 failed to do so. In this, as well as in case No. 31, the inspiration of 
 compressed air was directed against the mechanical processes arising out 
 of the occlusion of the bronchi, and the asthnui was cut short by forcing- 
 air behind the stenosed parts of the lungs, and thus renewing tlie
 
 06 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 arrested exchange of gases, and preventing the inflation of the air 
 cells by preventing the i-arefaction of the air within them. No. 2'J 
 l)ad been a martyr to the disease for nearly ten years, and it is needless 
 to state that all known remedies had been used by him. Before the 
 treatment was commenced, the ap})roach of a storm, a change in the 
 weather, would have invariably brought on an attack. After dinner 
 he would be obliged to sit quiet for a couple of hours, was unable to 
 carry on his ministerial duties, and was unable to walk any distance, 
 ttc. After the treatment had been continued for a few days, he showed 
 signs of improvement, and now he can go out in any weather, conduct 
 two services in one day, go about his business, and, but for an occasional 
 approach of an attack, he would consider himself (juite cured. In this 
 case, rarefied air was not tolerated, though there was slight emphysema. 
 In this case, the compressed air was medicated with menthol, 1 in GO of 
 alcohol ; in the other two, witli ol. jjini silv. 
 
 Of the effects of aero-therapeutics in bronchitis, my ex)>erience confirms 
 the statement reported in my first paper, viz., that all cases could be 
 easily cured by this method ; that the moderate expansion of the 
 lungs relieves the constriction complained of in this disease, and 
 expectoration is soon rendered easy without the aid of those disgusting 
 compounds known as cough mixtures, about which (expectorants) no 
 less an authority than Prof, Aust. Flint writes (" Flint's Practice of 
 Medicine," p. 221) : — '• They are of doubtful eflicacy, and if not useful, 
 are less or more harmful. Squills, ipecac, syrups and opiates belong to 
 the relics of bygone daj's." The effects obtained in case No. 28 were 
 surprising. He was almost cyanotic when he first came to my rooms, 
 the cough was sim]»ly disti'essing, and he was almost exhausted from 
 want of sleej) and food. He improved rapidly, and was able to leave 
 town after a fortnight, feeling "as he had never done for the last ten 
 years." The chief Ijenefit to be derived by the systematic treatment 
 of bronchitis with this method is, the expansion of the pai'tially collapsed 
 cells, generally left by the disease, the collapse leading to subsequent 
 attacks, and often becoming the advanced agent of phthisis. 
 
 Against which last-named disease, aei'O-therapeutics is the most potent 
 agent which we possess. It is hardly necessary for me here to state, 
 that consumption (laryngeal or pulmonary) in all its stages, is curable, 
 this proposition being now beyond the argumentative stage. In the 
 Jjntish Medical Journal for Novemlter 17tli last, .Sir JNIorell Mackenzie 
 writes : — " I, who have also been of ojnnion that laryngeal phthisis w^as 
 in point of fact incurable, must now admit that the 2)0ssi!)ility of cure, 
 even in unfavourable cases, has been fully established." If tubercle is 
 curable in the larynx, why should it not be when in the lungs, the lesion 
 ])eing in both cases the efl'ect of the same virus, i.e., tubercle bacilli ? 
 Antiseptics are the therapeutic agents that cure laryngeal tuljerculosis, 
 antiseptics must be the chief remedies that eventually will be found to 
 cure the other manifestations of the bacilli tuberculosis on the respiratory 
 organs. I do not believe in being an enthusiast in matters relating to 
 therapeutic investigations, yet I cannot approve of an exaggerated 
 sce])ticism, as it will only lead to nihilism. Let the idea become 
 ])revalent that phthisis is incurable, and nobody will ever think of 
 excogitating a means to relieve the unhapi)y suflx;rers from this fell 
 disease;.
 
 PNEUMATIC THERAPEUTICS BY MEANS OP POKTAELE APPAKATUS. 97 
 
 Natural!}-, the treatment for consumption of the huigs cannot be so 
 efl&cient as that for tubercle of the laiynx, as we are unable, in the 
 former, to avail ourselves, with antiseptics, of surgical operations in 
 removing the causa riiorbi. This effect we may obtain in phthisis by 
 means that will destroy the germs of tlie disease directly, ancl by others 
 that will do so indirectly — tliat is to say, by antiseptics, and by raisin'^ 
 the general standard of nutrition, and otherwise renderino' the lunf 
 tissues sterile, or unlit for the ])roliferation of the said germs ; or stronjr 
 to isolate those parts already destroyed, and render them innocuous to 
 the adjoining tissites. Aero-therapentics is the only means, in the 
 present state of our knowledge, by which we can carry out the above 
 princi])les of treatment most efficiently. 
 
 It is certainly the best substitute for the climatic treatment ; in fact, 
 I do believe that this will ])rove curative only when the density of tlie 
 air is so changed as to induce the effects above mentioned in the 
 respiratory organs. Permit me to very briefly relate the following 
 history of a case, which bears on this point : — ^E. F., 29, ironmon^-er 
 ■with history of consumption in his family, and with short cough, loss of 
 weight, energy, and strength, consulted me in 188G. Had sul>crepitant 
 rales anteriorly and posteriorly over left apex. The ordinary treatment 
 ■was ordered, tvifh chcin<je of residence to the amntry. There were no 
 means of increasing his weight (10 st.), or making a marked improve- 
 ment ill his condition. On April 16th, 1888, he was ordered to take 
 two hours' exercise daily in this wise — viz., by ascending a hill slowly, 
 keeping his right arm compressed against the same side of his chest, 
 making deep and regular inspirations, itc. The only medicine given 
 was troch. acid carbol. six to ten a day, a liberal use of milk, and some 
 rum. On November 18, 1888, his weight had increased to eleven stone, 
 and no physical signs were left. Now, to my mind, the only agent that 
 brought about this change was the forced expansion of the left apex, 
 and the other physiological effects of the forced inspirations. 
 
 We have not found yet an antisei)tic agent which will destrov the 
 bacilli, and cure the organic lesions caused by them, as quinine does for 
 intermittent fever, and its sequehe. But we certainly possess antiseptics 
 that prove of great advantage, and the pneumatic apparatus is the most 
 efficient means for carrying these disinfectants into the lungs. And 
 here let me say that medicinal substances, in any form whatever, can 
 be brought into contact with the mucous membrane of every part of the 
 respiratory organs, by blending them with the inspired aii-, when proper 
 precautions are taken. 1 must refer you, however, to the sj»ecial works 
 on this sultject. 
 
 In all the cases treated by me by this method, the expectoration, no 
 matter how offensive, lost its bad smell after a few days' treatment. 
 The pus and muco-pus would disappear next, the expectorated matter 
 becoming pui'ely mucous. With the disappearance of these symptoms, 
 I have constantly found a great improvement, even in the most hopeless 
 cases, of all the sym])toms that accompany this stage of the disease, 
 especially the shortness of breath and the excessive perspiration. 
 
 It is true that several times I have administered atropine from the 
 beginning, V)ut I am now convinced that even without this drug, by 
 clearing out the lungs, the perspiration disappears. Case 27 is an 
 instance in point. I gave him ^-^ of a grain of atropine occasionally; 
 
 II
 
 98 INTERCOLONIAL MEDICAL CONGKESS OF AUSTRALASIA. 
 
 but one evening, having liad the pills prejtared by a new chemist, after 
 taking his usual pill, alarming symptoms of atropia poisoning set in. 
 He took no more atropia ; the perspiration returned a few days after- 
 wards, but gi'adually disappeared with the disapi)earance of the other 
 symptoms. Nos. 24-30 never took atropine, and the persjnration 
 disaj)peared. But we not only carry by this means antiseptic air into 
 every alveolus, and so carry out, as far as possible, the etiological 
 treatment, but also by it we indirectly destroy the bacilli, by placing the 
 lung tissue in the best condition for arresting their devastation, even in 
 an advanced stage of the disease. 
 
 In the earlier stages (in the premonitory and first stage), my practice 
 convinces me that consumi)tion can be arrested, viz., the physical signs 
 indicative of the phthisical process are brought to a standstill. The 
 weight of the body increases, the respiratory capacity augments, the 
 slight cough, the disturbed sleep, the careworn face, the want of energy 
 (amounting to lassitude on slight exertion), all disap})ear, and do not 
 return, so far as my experience enables me to state, even after 14 or 16 
 months. It can be said that the general remedial agents employed by 
 me may account for a good deal of the improvement ; but I doubt it 
 greatly, and for two reasons — First, that many, if not all, the patients 
 have been under the usual treatment previous to combining it with 
 aero-therapeutics, without the slightest benefit. Second, that of late I 
 prescribe hardly any medicine, except some simple one, as a mild 
 [lurgative, or the like. I take only great }>ains in directing the patient's 
 diet. 
 
 Even in cases where temporary relief only was ]3ossible, it has been a 
 substantial one, life having been continued for many months in comparative 
 comfort, when there seemed nothing but the release of death left at the 
 time they commenced treatment. 
 
 I have now only a few remarks to make aV)Out the use of compressed 
 air while hemoptysis is present. I have used it in all cases of moderate 
 severity — that is to say, whenever patients expectorated some blood 
 mixed with phlegm, or pure, in mouthfuls. I only adopt the precaution 
 of using moderate pressure at first, and few cylinders, the blood always 
 disappearing after a few days. 
 
 In my cases, you will find that I have used aero-thei'apeutics in many 
 more diseases of the respiratory oi-gans, even in a case of chronic 
 rhinorrhcea, in which it was employed with a view of relieving the large 
 bronchial tubes from their share in the affection, but it succeeded in 
 stoi)jnng the secretion from the nasal superficies of glairy nnicus which, 
 previous to the treatment, amounted to about two or three tumblerfuls 
 l)er day, but was soon reduced to one-third, the bronchial symptoms 
 disappearing altogether. The air was medicated with menthol solu- 
 tion, 1-40. 
 
 1
 
 TIIR IMMKDIATK TUHATMENT OP PLEURISY WITH KFFUSIOX. 99 
 
 ON THE IMMEDIxVTE TREATMENT OF PLEURISY 
 WITH EFFUSION. 
 
 By S. DouGAN Bird, M.D. 
 
 Fonucrlj' Lecturer on Medicine in the University of Melbourne. 
 
 The subject of this short paper is limited to one pliase of the 
 trciitmeut of one morbid state. It is this — Given a patient, otherwise 
 normal, sutiering from that very common disorder, sudden intlammatory 
 eti'usiou into a ])leural cavity, is it not only ])Ossible and permissible, 
 but tlie soundest and best practice, to cure him at once, clto, tnto et 
 Jc.cioide, by drawing off the fluid, instead of waiting for Nature to 
 remove it by the tedious and somewhat uncertain process of a1)Sor[)tion 1 
 
 I contend that it is, and have so done for the last twenty-ti\e years, 
 with the result that I have never had to regret early tai)i)ing, but 
 .several times have bitterly regretted being over-persuaded to delay it. 
 
 It is hardly necessary to refer to the history of thoracentesis, which 
 the older writers, and indeed, some of more recent times, looked upon 
 with holy horror, as a last resource, somewhat on the same platform as 
 craniotomy, or the Ctesarian section in midwifery. Let us come down to 
 our own times. We may search all the special treatises and all the 
 dictionaries of medicine in all languages, and we will find nothing about 
 the immediate treatment of pleurisy with effusion, but only blisters, 
 iodine, mercury, strapping, even that refinement of cruelty, the " thirst 
 cure," and so on, for seveial pages, while the unluck}^ patient is losing 
 time, money, flesh, and faith in his doctor ; and it is not till the next 
 chapter, when losing all patience, he may be supposed, like a woman in 
 labour, to be begging for "something to be done," that the question of 
 this simple little procedure is entertained at all ! 
 
 But some may say. We now know that pleurisy is not the fatal 
 disease which our venesective ancestors supposed it to be ; therefore, 
 why interfere, when doubtless a large proportion of cases undergo 
 natural recovery 1 True ; not innnediately fatal, but left to itself, or 
 medically treated, it is often a prolific parent of e\il. How often do 
 \\G see hopelessly collapsed lungs tied down by old adhesions, which 
 \N ould have been prevented by early interference ? How many 
 phthisicals, who can trace back their illness to expectantly treated 
 pleurisy with eftusion, which not only kept their lower lobe squeezed 
 and useless till it was ho})elessly impermeable to air, but lowered their 
 general vitality so much by confinement and starvation, that the ever- 
 ready bacillus pounced on them as congenial homes'? Such ca.ses are 
 not so common now as they were twenty years ago, for obvious reasons ; 
 but they are by no means rare, especially in new arrivals from Europe 
 in search of health. 
 
 To my mind, the early drawing off of pleuritic eftusion, to sa\'e the 
 patient from after ill effects, is as sound treatment as the early division 
 of stricture in strangulated hernia, instead of waiting till the gut is on 
 the vei'ge of gangrene ; or the inunediate reduction of a dislocation, 
 instead of waiting till the head of the bone has contracted adhesions in 
 its new position. In each of these three morbid states, we have 
 inq)ortant organs displaced by sudden and unnatural conditions, which 
 are liable to do them permanent injury. Surely then, if these 
 
 II 2
 
 100 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 conditions can be removed by simple and liarmless means, as in our 
 present subject, the sooner this is done the better ; as the duration of 
 the iUness is reduced from weeks or months to days, the consequences 
 of prolonged pressure are avoided ; and last, not least, the chances of the 
 degeneration of the fluid into pus are reduced to a minimum. If the 
 object of sound medical and surgical treatment be to assist Nature 
 towards natural cure, surely immediate tajjping with a small trocar 
 (provided that meddlesome and dangerous apparatus, tlie aspirator, is 
 not superadded) exactly does so in these cases, and does it quickly, 
 safely, and with no more pain tlian that of a pincli or the pi'ick of a pin. 
 
 By immediate tapping, I mean rather so in comparison with the old 
 plan of unnecessary and even blameful delay. We do not often have a 
 chance of seeing a case of pleurisy from its very inception ; but there 
 can be no doubt that when the aoute pain ceases suddenly with the 
 friction sound, this is directly caused by effusion separating the inflamed 
 surfaces. So far, so good. If this effusion were always limited to a 
 layer of fluid just sufficient to prevent friction, it would, no doubt, be 
 rapidly absorbed, and is so in many cases that never seek medical 
 advice. But in a considerable percentage this does not happen, and the 
 efi'usion goes on. 
 
 However heretical it may seem to philosopliers of the Paley school, it 
 is no uncommon thing for Nature's salutary ])rocesses not to stop when 
 they have done their work, but to go on blindly, so to speak, till they 
 push the original disease into the background, and become themselves 
 the leading feature in the case. This we often see in haemoptysis, 
 which, trying to relieve a gorged lung to the extent of a few ounces, 
 overdoes the matter to the extent of a few pints, and leaves the patient 
 bloodless, and at death's door. So again, in the critical discharges from 
 the great emunctories, at the turning-point of feveis and acute inflam- 
 mations, wlien the highest skill of the physician is called for to decide 
 whether he shall interfere, or hold his hand and stand by as a s])ectator. 
 
 So, in our present suliject. If absor|)tion rapidly takes place after pain 
 ceases, and the rested and blandly-cushioned surfaces of serous membrane 
 have had time to recover themselves, leave well alone by all means ; but 
 if by examination we And that the fluid is either stationary or increasing, 
 the time for interference has come. It is delay, and not action, that is 
 dangerous, and tapping should be i-esorted to at once. I have not found 
 that pyrexia need be a bar to this ; in fact, the temperature often falls on 
 removal of the fluid. 
 
 The next thing we have to consider, is the method of operating. To 
 begin Avith, any suction apparatus is not only useless, but liarmful, and 
 its use is as foolisli and unscientific as it would be for an engineer to 
 erect complicated and expensive pumping gear for the draining of a 
 mountain loch into the valley below, when ho need only cut a channel or 
 tunnel, and use the natural fall. Besides, the asi)irator acts too rapidly 
 and forcibly, and gives the lung no time to expand, and has been known 
 even to burst it, and cause pneumothorax. 
 
 A tolerably fine trochar shoidd be used, as the patient lies on his side 
 on the bed, or sofa, and on withdrawal of tlie stylet, a yard or so of 
 small-sized elastic tubing, armed with a nozzle, is at once fitted into the 
 canula. A natural syphon is thus formed, the fluid running into a 
 vessel on tlie floor. No air can enter, and the elaborate precautions of 
 
 1
 
 THE XEi:VOU.S SUBSTRATUM OF IXFLUKXZA. 101 
 
 IJowtlitcli are quite uncalled for. The \AeViVA gradual I >/ drains as the lung 
 expands, and probably an hour or two will elap.se before the flow ceases. 
 In these early tap|nngs, flakes of lynii)h, to obstruct the tube, are rarely 
 or never met with. 
 
 If the little ojjeration be done in this way, hurry, and any efforts to 
 forcibly assist the flow being, of all things, avoided, it is ])erfectly free from 
 danger, and the chances of recurrence or i)urulent degeneration are very 
 small indeed. Perfect rest on the affected side sliould be enjoined 
 afterwards, but I have not found strapping the chest do any particular 
 good. Treated in this Avay, an uncomplicated case, in an otherwise 
 healthy person, is usually perfectly well in four, or at the outside, five 
 days, as I have proved in a vast number of cases. Of course, it must 
 1)6 borne in mind that we do not always see the patient from the first. 
 If the effusion has existed some time, a different phase is entered on, 
 with which this paper does not deal. 
 
 A couple of cases particularly obtrude themselves on my memory as 
 illustrati\'e of the advantages of such ti-eatment. Some years ago a 
 well known acrol:)at and contortionist came to me. He had cauglit cold 
 on board ship shortly before, and his left pleura was full of fluid, with 
 heart di8{)]aceinent and great dyspncea. I sent him at once to his hotel 
 and tapped him as described, keeping him in bed on his side for 
 four days. He performed wonderful feats and antics in the evening of 
 the fourth day, and during the week, when he left for a tour in the 
 other colonies, expressing himself perfectly well. In six weeks he came 
 to me again, having got chilled while waiting for the mail steamer on 
 the pier at Adelaide. The 7'ight pleura was now distended with fluid. 
 Same treatment, same result. I examined him before he left for 
 America, and could discover no morbid signs. Another case was a 
 young tradesman just married, most anxious to fulfil a building contract, 
 but Tuial)Ie to work from dyspnoja and palpitation, caused by recent 
 pleurisy M-ith effusion. Tapped on Friday, at work on INIonday. I 
 examined him about a month afterwards, and found nothing abnormal 
 in his chest, and g^nei'al health perfect. We all know v/hat would have 
 happened if these cases had been treated medically and expectantly, or 
 if tapping had been delayed till pyrexia had ceased — probably^ but not 
 certainly, recovery in a fevj vxehs, with the risk of many untoward 
 sequelae, and a depressed state of general health from confinement, low 
 diet, lowering medicines, and worry at the loss of time and money. 
 
 THE XERVOUS SUBSTRATUM OF INFLUENZA. 
 
 By J. W. Springtiiorpe, M.A., M.D. Melb., M.R.C.P. Lond. 
 
 Physiciau to thj Melbo.uno Hospital. 
 
 Lecturer to tae University of Melbourne in Therapeutics, Dietetics and Hygiene. 
 
 In the Australian Medical Journal for October 18S5 is an account, by 
 the writer of the present paper, containing such information as was then 
 ]>rocurable, upon the great epidemic of influenza which had visited 
 Australasia during that year, and which was locally known amongst
 
 102 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 our public as " fog fever." It was therein shown that influenza had 
 reappeared, after many years of comparative absence, in a severe and 
 widely epidemic form ; that, beginning in May, it reached its acme in 
 August, prevailed over a large portion of Australasia, attacking a very 
 large percentage of the population in Victoria at any rate, and apparently 
 singling out those individuals who were daily much in the open air. A 
 comparison of the features of the epidemic with the excellent description 
 of that in 1847, given by Peacock, in " Quain's Dictionary of Medicine," 
 showed how closely our epidemic followed the three main types therein 
 difterentiated, viz., simple influenza, influenza with ])ulmonary complica- 
 tions, and influenza with gastro-intestinal complications ; whilst the 
 existence of an apparently new feature — the occurrence of cases witli 
 well-marked cardiac symptoms — was commented upon, particulars of 
 which are given in the record referred to. 
 
 The present paper is in continuance of the investigation then originated, 
 and aims at the explanation of the disease upon the basis of some specific 
 virus depressing the pneumogastric and sym]iathetic nerves. The 
 recurrence of the epidemic, the nature of external cause, and other 
 points interesting from a differential diagnosis point of view, ai'e also 
 incidentally touched upon as they have come into prominence, and 
 been disclosed during this enquiry. 
 
 1. The Recurrence of the Epidemic. 
 
 Observation has shown, that a disease with the same general 
 characters as that already described, has returned each autumn and 
 winter since 1885, and has been specially well marked during this late 
 winter. In ray own practice, both hosj)ital and private, a very large 
 proportion of my cases, from June until lately, have been distinctly 
 influenzal in type. Anomalous cases, also, which seem explicable upon 
 no other hypothesis than that which is hei"e advanced, have not been 
 uncommon. 
 
 2. Causation. 
 
 Little fresh light has been thrown upon the ccmsa causans. The 
 late winter was as dry, as that of 1885 was wet and foggy — hence, the 
 "fog" element, then insisted upon, is found, as elsewhere, to be non- 
 essential. Variations of temperature, and of wind, liowever, have seemed 
 very frequently to have had great influence in producing relajjses, if not 
 in originating fresh cases. Again, from the mode of infection, the rapid 
 onset, the wide range, the repeated relapses following atmospheric changes, 
 the effect of change of air upon the course of disease, as well as from 
 the practically constant presence of a naso-pharyngeal catarrh, it seems 
 certain that tlie poison attacks the system thi'ough the medium of the air 
 — though whether the matert'es viorbi be a specific microbe, or a peculiar 
 atmospheric condition, remains problematic as ever. But, whichever it 
 be, the incubation stage generally seems to have been extremely short. 
 From some cases noted, in which i)rior infection seemed very unlikely, 
 less than twenty-four hours elapsed. Throughout, relapses were the 
 almost invariable rule. Lastly, the course of disease suggests the 
 operation of a long-continued series of de])ressants.
 
 THE NERVOUS SUHSTJiATUM OF INFLUEXZA. 
 
 103 
 
 3. The Substratum Attacked. 
 
 This paper is largely written to express the winter's conviction that 
 the causa c((H.'<ans produces its results almost, if not entirely, through the 
 medium of the nervous system ; that, in fact, the symptomatology of 
 influenza rests upon a nervous substratum ; that all its clinical i)henoniena 
 may be explained ujion such an hypothesis, and that no other hypothesis 
 explains tliem to the same extent. Taking it for granted that the 
 medium of attack is the atmosphere, the point of impact is necessarily 
 the naso-pharynx, radiating upwards to the frontal sinuses and middle 
 ear, and downwards along both gastro-intestinal and pulmonary mucous 
 membranes. What, then, is the nervous supply of the naso-pharynx, 
 and what are the results which physiology and pathology show us, to 
 follow from severe repeated dei)ression of tlie nerves ending therein 1 
 
 These may be arranged in the following table : — 
 
 Xerve Sltply. 
 
 Endiiigs of cervical 
 pymiiathetic. 
 
 FUXCTIOXS. 
 
 Euilings of 2:)ueu- 
 mogastric. 
 
 Trophic and secretoi-y changes 
 ill the mucous membranes 
 and associated glands ; 
 vaso-motor influences to 
 the body in general, and 
 Lead and neck in particular. 
 
 Accelerator of heart rhythm. 
 
 Inhibitory nerve of heart ; 
 chief afferent nerve to heat 
 centre, respiratory centre, 
 and vaso-motor centre ; 
 sensory nerve to stomach 
 and cesophagus. 
 
 The pnenmogastiic 
 reflexly. 
 
 Motor nerve to pharynx, 
 larynx, cesophagus, sto- 
 mach, and partly to intes- 
 tme ; trophic nerve of the 
 lungs ; co-ordination of 
 functions of organic life ; 
 connections with other cra- 
 nial nerves, cerebrum and 
 cerebellum. 
 
 Result of Depressiox — 
 Severe and Contixued. 
 
 Aggravated, inti'actable, naso- 
 pharyngeal catarrh, with 
 considerable secretion, se- 
 vere frontal headache, 
 local injeciion of mem- 
 branes, with possible ulce- 
 ration and sloughing; and 
 swellings of glands ; pro- 
 fuse sweating of head and 
 neck, or body generally. 
 
 Heart's action irregular, 
 extremely rapid, inter- 
 mittence, syncope. Chills, 
 flushes, and jDyrexial at- 
 tacks of every degree, with 
 unaccountable alterations 
 in temperature, now very 
 high, now sub-normal ; 
 dysphonia, disturbed res- 
 piration up to Cheyne- 
 Stokes' respiration, sweat- 
 ing anorexia, epigastric 
 pains. 
 
 Cough, vomiting, constipa- 
 tion, disturbed bowels ; 
 pneumonic processes, tend- 
 ing to phthisis ; marked 
 general prostration, both 
 mental and bodily ; de- 
 lirium, insomnia, vertigo, 
 nem-algic attacks of tlie 
 flftli nerve, and pains, es- 
 pecially in the neck. 
 
 Such, then, are the possibilities which might be predicated from a 
 series of depressants, acting upon the symjuithetic and pneumogastric 
 nerves in the naso-jihaiynx.
 
 104 IXTERCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. . 
 
 The glossopharyngeal is so bound u]) with the pneumogastric, that 
 the two in this locality are practicall}^ insepai-able. The only symptom 
 added by its implication would be disorder of taste, and this was almost 
 constantly present. Further, in addition to the local and reflex symptoms, 
 the catarrhal condition might extend by direct continiiity into both lungs 
 and intestines. 
 
 Now^, to compare these with clinical phenomena actually observed. 
 Naso-pharyngeal catarrh of an inveterate character, and with the usual 
 sym[)toms characteristic of an influenzal origin, has been found to prevail 
 extensively under the following main asjiects. Numerous illustrations 
 might be adduced, and are procurable, but it has been thought unnecessary 
 to introduce them here : — 
 
 (a) Siui])le recurrent naso-pharyngeal catarrh, attended with transient 
 depression, and sometimes with transient rise in temperature. 
 
 (b) Such catarrh, with sudden pyrexial attacks of varying severity, 
 attended with great exhaustion, profuse sweating, and even rapid 
 emaciation, with the usual concomitants of pyrexia added. 
 
 In a large number of cases other symptoms were present, in addition 
 to those just mentioned. Thus : 
 
 (c) In those wherein the respiratory system was vulnerable or 
 invaded — Bronchitic, broncho-pneumonic, and pleuro-pneumonic attacks, 
 associated with [b), and characterised by running very abnormal courses. 
 
 (d) In tlie hepatic. — " Rheumatic" pains, profuse sweating, continued 
 fever, al^dominal disturbances ; often phenomenal prostration ; the cases 
 simulating now acute rheumatism, now typhoid fever, or leading to severe 
 congestion of the liver, or aggravated renal irritation, but with the local 
 throat lesion, &c., in addition. 
 
 (e) Where the heart was vulnerable. — Extremely ra];)id ])ulse, often 
 intermittent, with cardiac dyspnoea and svncopal attacks. 
 
 In long-continued cases, which were generally of class (c) or (J), phthisis 
 or tuberculosis supervened in many instances. 
 
 More exceptional cases have been those in which middle ear mischief 
 followed pharyngeal sloughing (3) ; whei'e Cheyne-Stokes respiration 
 and n)arked cardiac alterations occurred (1); wherein it was almost 
 impossible to distinguish from typhoid fever (3); wherein acute diabetes 
 was re-established (1); and wherein malnutrition of the bowel occurred, 
 to the extent of sloughing of the intestinal mucous membrane (2). 
 
 A com])arison of these clinical pictures, with the table of results which 
 should follow the continued depression of the vagus and cervical sympa- 
 thetic will make apparent a very close agreement. The writer has been 
 driven to the conclusion that the symptoms, noted under the class name 
 of Influenza, are thus explicate, both in their diversity and in their 
 totality, upon this hypothesis, and, it apjiears to him, upon this hypothesis 
 alone. 
 
 4. Features of Interest from a Clinical Point of View. 
 
 This investigation has also disclosed some features of great interest : — 
 {(i) Tlie nature of the throat aftection. — Quite a number of cases 
 have been sent into the hospital as cases of diphtheria, which car(>ful 
 examination has led the writer to regard as influenzal. The difi"erential 
 diagnosis is discussed in some remarks in the Throat Section of the 
 Congress in the discussion upon Diphtheria. The difference is maintained
 
 THE XEuvous sui!sti;atu.m of influenza. 105 
 
 to be essential, even though tlie virus of diphtheria seems to attack the 
 same nerves in a soiuewliat .similar way. 
 
 (fi) The gastro-intestinal form of influenza, confused with typhoid 
 fever. — So far as the writer is aware, one outcome of this enquiry has 
 been the discovery of a form of continued fever amongst ourselves, 
 which is mistakable foi-, and has been mistaken for, typhoid fever, 
 whilst really influenzal in origin. The difterential diagnosis between 
 the two is entered into in the general discussion upon Typhoid Fever at 
 the present Congress. 
 
 (c) Another very important point elucidated has been the great 
 number of cases of more or less acute phthisis, and even of acute 
 tuberculosis, which have dated their origin to attacks of influenza, a 
 result readily explicable, when we remember the extreme prostration 
 and the pulmonic com]ilications of the disease, and the great influence 
 which the pneumogastric exerts over the nutrition of the lungs and of 
 the body generally. 
 
 ((/) Lastly, the cardiac status produced by influenza in cases of heart 
 weakness, is apparently a new point in symptomatology, and one of 
 considerable importance. To the cases already adduced in the p)revious 
 paper, others could be added. Only one extreme case, however, will be 
 here given : — 
 
 Mrs. C, jet. 2o, married, one healthy child ; father died of heart 
 disease ; self and mother both hepatic ; patient always neurotic, often 
 hysterical ; several times an^emic ; suffered from tyj)hoid fever with 
 bronchitis thirteen years ago ; no syphilis, rheumatism, scarlet fever 
 or chorea ; six years ago suffered from cardiac irregularity, the result, 
 apparently, of dyspepsia and tea-drinking. Since marriage has worried 
 very mucli. In lu85 had influenza, and a nasal catarrh each winter 
 since. AVjout May last a fresh attack, with cardiac irregularity ; pulse 
 uncountable, but no redema anywhere, though generally prostrate. 
 Child born in August ; relapse soon after, with cardiac dyspnoea, 
 swelling of feet, and all the appearance of serious heart disease ; twice 
 seen by two medical men of standing, and told that she could not 
 possibly live. When the writer saw her, seven weeks ago, she had 
 orthopncea, oedema of feet and legs, paroxysms of Cheyne-Stokes 
 respiration, with slight temi)erature, great weakness, anaemia, sweating, 
 and marked p)ost-nasal catarrh. The lungs were sound, the pulse 160, 
 and the ffrst sound accompanied by a bruit. After very careful 
 examination, the opinion was given that anaemia, great excitement 
 (patient, believing she was dying, had said " good-bye " to over twenty 
 friends on the previous day), and influenza, would account for all her 
 symptoms, and a less grave ])rognosis was gradually advanced. At 
 present, with heart still beating i-apidly, and a bruit accompanying the 
 ffrst sound, patient eats well, sleeps lying down, breathes naturally, 
 takes gentle exercise daily without any oedema, is convalescing rapidly, 
 and requires to follow only the ordinary cautions necessary in cases of 
 vulnerable heart. 
 
 [Six months have elapsed since the foregoing was written, and duiing 
 that time diphtheria, influenza, and typhoid have been epidemic. This 
 extended experience has remarkaljly verified the conclusions here 
 advanced. The case mentioned above has required no treatment for four 
 months.]
 
 106 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 ON WANT OF PROPORTION IN THE SIGNS AND 
 SYMPTOMS OF DISEASES OF THE HEART AND 
 GREAT VESSELS. 
 
 By James Jamieson, M.D. 
 
 Lecturer on Medicine at the Melbourne University, and Physician to the Alfred 
 
 Hospital. 
 
 It is an oft-repeated, and perhaps ratlier trite observation, that in the 
 knowledge, and even the ability to make good use of the modern 
 i-efinements in j^hysical diagnosis, there may not be an unmixed gain. 
 There is certainly a tendency — pardonable perhaps, but still eironeous 
 • — to lay undue stress on them, to the extent of reckoning that when we 
 have inspected and ])alpated, percussed and auscultated the chest, we 
 have done almost all that is I'eally essential for diagnosis, and for the 
 treatment based on it. Most of us, perhaps, need to be reminded of the 
 truths so strongly insisted on by Dr. Stokes, in the preface to his work 
 on " Diseases of the Chest " : — " It cannot be too often repeated that 
 physical signs only reveal mechanical conditions, which may proceed 
 from the most ditferent causes ; and that the latter are to be determined 
 by a process of reasoning on their connection and succession, on their 
 relation to time, and their association with si/mptoms. It is in this that 
 the medical mind is seen. Without this power, I have no hesitation in 
 saying that it would be safer to wholly neglect the physical signs, and 
 to trust in ))ractice to symptoms alone." Even with all our improve- 
 ments in physical diagnosis — and tliese have been considerable, even 
 since Dr. Stokes published his great work — this is still good doctrine, 
 though it may be good doctrine pushed to its extreme consequences. 
 For, doubtless, there may also be error in allowing the conclusions based 
 on symptoms to override those derived from a consideration of physical 
 signs. 
 
 It is with the view of illustrating and emphasising tlie truth, so well 
 stated in the iirst part of the quotation just given, that I have thought 
 it worth narrating the following cases, which have come under my 
 observation at the Alfred Hospital. They are intended to show the 
 benefit to be derived from using all available he]j)s in diagnosis ; and to 
 indicate, further, how great is the difficulty which may be experienced 
 in arriving at correct conclusions about tlie extent and severity of 
 organic disease of the heart and great vessels, and how one may be led 
 astray to regard that severity as greater or less tlian it really is. 
 
 The first case was that of a man, T. D., a sailor, aged oO, admitted 
 to the Alfred Hospital on 16th August, 1888. He stated that, till a 
 month before admission, he had been well, and able to do a full day's 
 work at full current wages. When working in water, he caught cold, 
 getting a dry cough, and suffering from dyspnoea, with some swelling of 
 the belly. A week after, the legs began to swell, though this swelling 
 for a time disappeared, and the dyspncsa was not marked, when lie had 
 been lying down. Two or tla'ee times he coughed up a little bright 
 red frothy blood. Had scurvy eleven years before, but had never 
 suffered from rheumatism. All his peojjle had been healthy, as he had 
 been himself.
 
 WANT OP PUOI'ORTION IN SYMPTOMS OF JIKART DISEASES. 107 
 
 On iulmission, tlie legs and belly were much swollen, and there vvas 
 slight cedema of the chest-wall. He had a markedly cyanosed look 
 about the face, and he suffered so much from dyspnciea, that he was 
 unable to lie down. The superficial veins of the neck were distended, 
 the ])rouunence being most marked on the right side. He had a 
 troublesome short cough, but no expectoration. 
 
 Examination of the lungs revealed nothing more than harsh breath 
 sounds anteriorly ; but at both bases, ])OsteriorIy, there was slight 
 dulness with crej)itation, but no increase of vocal resonance. 
 
 The examination of the heart showed that the apex beat was displaced 
 downward, and to the left ; and a double blowing sound was heard 
 there, and was transmitted to the left. Over the tricuspid area, there 
 was heard a loud systolic murmur ; and the second pulmonary sound 
 was accentuated, and had quite a ringing character. The aortic sounds 
 were not altered in character. The pulse was 100, regular, but 
 compressible. 
 
 It appeared, therefore, that we had to do with a case of mitral 
 disease, the signs being those of obstruction and incompetence combined. 
 It was further evident, from the sounds heard at the right apex and 
 base, that there was tricuspid incompetence ; this being also made plain 
 by the swollen condition of the veins of the neck, and the marked 
 cyanosis. 
 
 The treatment consisted in the use of the hosjiital stimulating 
 mixture, with m. xv. of tincture of digitalis. Under this he improved 
 for a time ; but when he became worse again, both Tinct. of strophanthus 
 and this same mixture were tried, without any appreciable good effect. 
 
 On the 20th, he was found to be in some respects much improved, 
 the dropsical symptoms having disai)peared, but he was not yet able 
 to lie down on account of the dyspnoea, and the veins of the neck were 
 still distended. The murmui's described had not altered. Pulse tracings 
 were taken on this day for the first time, with Dudgeon's sphygmograph, 
 with the condition here shown : — 
 
 Perhaps this did not show more than that the heart was supplying a 
 small amount of blood to the arteries at each systole ; but, at least, it 
 seemed to give some confirmation of the supposed state of things at the 
 mitral orifice. From this time there was continuous improvement in 
 the general condition, the breathing becoming much easier, and cj^anosis 
 to a great extent disappearing. There was evidence of improvement, 
 also, in the following pulse tracing, taken on the 28th : — 
 
 fW k iV. (W^ fv /V ^v /V k k A 
 
 But on the 30th, the whole as])ect of the case was found to have 
 changed for the worse. He was taken with increased difKculty of 
 breathing ; the cyanotic condition of the face again became fully apparent, 
 and he was seized with fits of coughing, when he spat up blood, not 
 much mixed with mucus. From this time, the course was steadily 
 downward ; the cough with bloody expectoration continuing, and pain 
 
 LIBRARY OF THE 
 
 LQ5 ANGLES COUNTY MEDICAL ASSOCIATION 
 
 634 SOUTH WE3TLAKF AWF.
 
 108 INTKRCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 in the chest, with pleuritic rubbing, helping to make it evident that 
 there was pulmonaiy embolism, with infarct formation, going on. The 
 breathing for some days had the Cheyne-Stokes character, and this 
 enabled us to make an interesting observation. Pain was complained 
 of on the left side, at the base of the heart ; and, when i-espiration was 
 deep, there was a distinct friction sound, synchronous with the chest 
 movements ; but when respiration almost ceased for a short period, the 
 rubbing sound was synchronous with the cardiac contractions. 
 
 Deatii occurred on September 12th. On post-mortem examination, 
 both sides of the heart contained clots, which in the auricles had in 
 part an ante-mortem character. The left ventricle was dilated and 
 hypertrophied, the only distinctly morbid condition at the mitral orifice 
 being, that one of the valves was slightly shortened, so that closure was 
 not perfect. There was no constriction of the opening, and careful 
 examination revealed nothing more than a slight roughness on the 
 surface of the valves, which, but for the fact of a murmur having been 
 lieard, accompanying the auricular systole, might readily have been 
 overlooked. The right ventricle was dilated, and the tricuspid opening 
 rather enlarged. There was an increase in th.e amount of pericardial 
 fluid, but no roughness of the surfaces. There was, however, fibrinous 
 deposit, causing roughness of the pleural surfaces at the base of the 
 heart, its situation accoimting for the fact that the heart was capable, 
 by its movement, of causing the friction sound, synchronous with its 
 contractions and easily heard when respiration tempoi-arily ceased. 
 Both lungs contained several infarcts, and both showed some consolidation 
 at the bases ; the kidneys were slightly granular ; the liver was congested, 
 and showed indications of the nutmeg condition. 
 
 This case had several points of interest about it. It was not easily 
 apparent, how such severe cardiac S3-mptorns should have come about so 
 suddenly in a man previously healtJiy ; and it can hai'dly be said that 
 the post-mortem examination helped much toward a clearer explanation. 
 Till careful investigation was made, it did not appear that there was any 
 disease of the mitral valves at all ; and there was certainly nothing in 
 their state, incompatible with the continuance of life for some years, 
 with at least fair health. Up to August 29th, indeed, he seemed to 
 1)6 in a fair way of recovery, the supervention of severe symptoms then 
 being due to the pulmonaiy embolism. It might even be suspected 
 that the strengthened action of the heax't, which led to such general 
 imjn-ovement, had the counterbalancing disadvantage, that more vigorous 
 contraction favoured the detachment of clots, which had been deposited 
 in the right heai't, at the time when it was much dilated and weak. It 
 may safely be said that the mode of production of such severe heart 
 symptoms was unusual. In some chronic lung conditions, and notably 
 in emphysema, it is well known that the right ventricle becomes 
 hypertrophied, with consecutive dilatation and incompetence, followed 
 by venous stagnation and dropsy. Could the same state of things have 
 come about here quickly, as the result of some acute obstruction to the 
 circulation through the lungs'? If we assume the occurrence of tricuspid 
 incompetence, with consequent stagnation in the systemic venous system, 
 we can understand further that the increased work thrown on the left 
 ventricle, by this stagnation working backwaixl into the arteries, caiised 
 the slight mitral aftection to acquire importance. In this way the
 
 WANT OF PllOPORTION IN SYMPTOMS OF HEART DISEASES. 109 
 
 vicious circle would be luiule complete, though in an order the reverse 
 of that most frequently observed. 
 
 The second case was, in some respects, the counterpart of that just 
 related. The patient, S.D., a butcher, aged 38, was admitted to the 
 hospital on 18th July, 1888, having previously attended as an 
 out-patient. He stated that he had had an attack of rheumatism six 
 years previously, and liad suffered from slight shortness of breathino- 
 ever after. On the whole, he had enjoyed good health, and followed his 
 occupation till November 1887, when, after lifting carcases of shf,'ep, he 
 felt an aching pain in the left side. Since that time, he had suffered 
 more or less from pain of a throbbing or aching character. He was not 
 aware of having strained himself, and certainly had no symi^toms of an 
 acute nature. For the previous three months he had been Avorse, the 
 pain extending to the left groin and the loin, and being sutiicient to 
 make his sleep broken. There had never been swelling of the feet, or 
 any distinct pulmonary symptoms. 
 
 On examination, the first thing remarked was the distinctness of the 
 apex beat, seen and felt in the fourth or fifth intercostal space, according 
 as the chest was in inspiration or expiration. As he lay in bed, his 
 breathing was quiet and regular, and no abnormality of the lungs could 
 be detected. Auscultation revealed a slight systolic sound at the apex, 
 not communicated to the left. There was a double bruit, heard loudest 
 to the right of the sternixm, over the aortic orifice, but transmitted rather 
 widely to the base of the heart, toward the right clavicle, and down the 
 whole length of the sternum. The diastolic murmur was very loud and 
 long drawn. In the epigastrium, and as far down as the umbilicus, 
 there was a faint systolic sound heard. On examining the chest 
 posteriorly, there was found a spot on the left side, between the eleventh 
 and twelfth ribs, where there was tenderness on })ressure, and distinct 
 heaving pulsation. At the seat of pulsation, there was heard a faint 
 bruit, about equal in intensity, and similar in character, to that noticed 
 just above the umbilicus. There was no abnormal pulsation to be felt 
 in the corresponding part of the lumbar region anteriorly, though it liad 
 been distinctly noticed in that situation when he was first seen in the 
 out-patient room Ijy Dr. Maudsley. He liad then, and previously, 
 complained of pain and throbbing, extending from the margin of the ribs 
 to the groin, on the left side. After admission, not only had this 
 pulsation entirely disappeared, but it was easy to define the abdominal 
 aorta, to all appearance normal on palpation, along the greater part of 
 its course. 
 
 The supi)osition was, that he had double aortic mischief, the character 
 and localisation of tlie murmurs jiointing distinctly to that defect, but it 
 was not at all clear what was the cause of pulsation in the lumbar 
 region. 8j)hygmographic tracings were taken, for the purpose of getting 
 whatever light might thus be obtainable, and they were found to be tliQ 
 same on both sides. 
 
 The tracing shown, thougli not that of a typically normal i)ulse, 
 certainly has not the special characteristics either of aortic stenosis or 
 regui'gitation. It has not the sloping rise and rounded top of the first,
 
 110 IXTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 and just as little does it exhibit the sudden and deep fall of the other. 
 In so far, therefore, as the sphygmographic indication went, it was only 
 in taking away any marked significance from the murmurs heard over 
 the aortic area. Some roughness there probably Avas at the aortic 
 entrance, causing the systolic murmur, and the loud and long diastolic 
 bruit could hardly be accounted for on any other supposition than that 
 of reflux from the aorta into the ventricle. But if such regurgitation 
 tliere was, it certainly must have been small in amount, and going on 
 through a very small opening. That the disturbance of the blood 
 current in either direction, in the neighbourhood of the heart, was 
 slight, was also shown by the fact that the man steadily improved under 
 the influence of rest, losing the pain he first complained of, and never 
 experiencing difficulty of breathing ; in fact, he expres.sed his ability and 
 willingness to go to work again. There was still little appreciable change 
 in the murmurs described, or in the pulsation in the loin. On the 7th 
 August however, there was slight pulsation noticed for the first time, 
 in the second intercostal space, close to the right sternal border. This 
 became more marked, and was easily distinguished on the ISth, just 
 before he was discharged at his own request, promising to return and 
 report himself. 
 
 This case was a very interesting one, the physical signs being so 
 obtrusive, and the general symptoms comparatively slight. The most 
 probable supposition, perhaps, is that there had been effusion of blood 
 into the sheath of the descending aorta, without much, if any, injury to 
 the proper aortic wall, so that recovery by absorption was possible. But, 
 independently of this assumed accidental condition, it seems certain that 
 there existed dilatation of the aorta, which was undergoing slow but 
 progressive development, and was making itself more apparent at last, 
 by ](ulsation to the right of the sternum. 
 
 After this was written, the man presented himself again for 
 examination on 20th December, four months after his discharge. He 
 had been losing weight, biit had continued at work, and declined 
 re-admission. The murmurs heai-d about the aortic area wei'e not much 
 altered, but the ]>ulsation on the right side was more distinct, being 
 easily seen and felt in the second intercostal space, and less so in the 
 third, about an inch and a half from the sternum. The pulsation in the 
 left loin was just the same, but the blowing sound seemed to be rather 
 louder, and also heard further up along the left side of the spine. 
 
 Pulse tracings were again taken, right and left radials being found 
 similar. Those here given are from the left radial, the first taken in the 
 recumbent, the second in the sitting posture, and it cannot be said that 
 they give any assistance in diagnosing the exact nature of the severe 
 condition undoubtedly present. 
 
 I 
 
 A third case may be shortly narrated, in which, with very marked 
 implication of the heart and great vessels, there was relatively but a
 
 WAXT OF PHOPOKTIOX tX SYMPTOMS OF HEAHT DISKASKS. Ill 
 
 sljglit ainouiit of general di.sturbance. The patient, F. G., aged 54, by 
 occupation a hodcarrier, was admitted to the hospital on 8tli October, 
 1888. He stated that he had always been well, and tit for hard work, 
 till six months previously, when, having got drunk, he lay in wet 
 clothes all night. Soon after, lie was seized with a severe oough, which 
 was harsh in character, though not attended with pain. His voice also 
 became hoarse, so that for a time he could scarcely make himself under- 
 stood. Gradually, his breathing became rather difticult on exertion, 
 though it was all right so long as he was quiet. He had never been 
 troubled with giddiness, and for some time he had slept well. Just 
 al)0ut the time of admission, he had begun to feel shooting pains in the 
 left shoulder, and a feeling of weight in the epigastrium. A week 
 previous to admission, he spat up a small quantity of blood. 
 
 On admission, it was noticed that his voice was harsh in tone, and 
 that he had a loud brassy cough ; but nothing abnoi'mal was discovered 
 about the vocal cords. Inspection of the chest revealed very marked 
 deviations from the normal condition. The upper part of the left side 
 was covered with large veins, some crossing the sternum to the right. 
 There was also a swollen condition of the veins of the left upper arm. 
 The supra-clavicular space was also more filled out on the left than on 
 the right. As he lay in bed, there was no sign of cardiac impulse to be 
 seen or felt in the usual situation, but there was marked pulsation, 
 resembling a good deal that of the cardiac apex, to be seen and felt in 
 the second intercostal space on the light side, about two inches from the 
 sternum. To the touch, it was a sharp stroke, re-duplicated in character. 
 "When he stood up, a centre of pulsation could be made out on the left 
 side, behind the cartilages of the ribs, on a level with the tip of the 
 ensiform cartilage ; but even then there was no distinct apex-beat to be 
 felt am^vhere. On percussion, there was dulness on the right side, 
 down to the level of the third rib, and on the left to the upper border 
 of the fourth rib. The cardiac sounds could only be faintly heard on 
 the left side when he lay quiet, but became louder and more distinct 
 when he stood it}» ; and were heard best low down, behind the combined 
 costal cartilages. They were heard most loudly over the seat of pulsation 
 on the right side, when he was lying, and even when he stood up, they 
 were at least as loud as over what corresponded with the cardiac area. 
 In neither situation were the sounds accompanied or displaced by a 
 bruit. The only thing that could be called a murmur was heard, and 
 that only occasionally and faintly, behind the cartilage of the sixth i-ib 
 on the right side. Posteriorly, there was nothing abnormal discovered 
 on the right side, except unusual distinctness of the heart sounds ; but 
 on the left, there was dulness on percussion, down almost to the angle 
 of the scapula, and there, as in the infra-clavicular region in front, the 
 breath and voice-sounds were faint. The case had very striking features, 
 therefore. There was evidently a tumour, occupying or compressing 
 the upper lobe of the left lung, and pressing on the left subclavian vein. 
 The heart was considerably disj)laced, and at first, indeed, it almost 
 seemed as if it had in some way got jnished completely up l)eneath the 
 right clavicle, both pulsation and cardiac sounds being so distinct there. 
 That idea could not be held, however, for there was no unusual dulness 
 behind the middle of the sternum, and it was impossible to understand 
 how any tuuiour, in the upper part of the left thorax, could have pushed
 
 112 
 
 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA, 
 
 the lieai't up beneath the riglit clavicle with its apex still downwards. 
 It was also made aj^parent, in time, that the heart had been actually 
 pushed down, so that its pulsations were hidden behind the conjoined 
 cartilages. It had further to be assumed that the pulsation on the right 
 side was caused by the aorta, tliough it was difficult to account for its 
 position, so far to the right and high up, when the heart w^as at the 
 same time driven down. Of course an aneurismal dilatation of the 
 ascending aorta might extend far to the right ; but the pulsation was 
 very distinct and shai']), and not at all a distensile heave. And besides, 
 there was not the dulness on percussion behind the sternum, which 
 might have been expected in the case of a large aneurism of the tir.st 
 part of the aorta ; and there was no blowing sound to be heard at or 
 near the seat of jjulsation. S})hygmogra[)hic tracings of both radial 
 pulses were taken, and were found to be similar in character ; and as 
 will be seen, not much help was got from this source, the curves not 
 differing materially from those commonly enough got in healthy persons. 
 
 N K N 
 
 In spite, too, of the marked local signs, the man was not long in the 
 hos])ital before he began to say that he had no pain ; that he ate and 
 slept well ; and was fit to undertake a light job, which he knew he could 
 get. He certainly exhibited very little in the way of distress, or any 
 general illness, and was at last allowed to go out, with the request that 
 he would report himself in a short time, and at least return if he became 
 worse. 
 
 It may be regarded as certain that there was some dilatation of tlie 
 aorta in its first part, though tlie pulsation was a distinct double beat, 
 and some of the most characteristic signs of aneurism were lacking. 
 This was confirmed by the fact that, a few days before he was discharged, 
 it was noticed that there was a little bulging of the second intercostal 
 space, and of the third rib, even though the pulsation remained the same 
 in character, and no 1)ruit could be heard at its seat. 
 
 The only attempt at active treatment consisted in the introduction of 
 an ex])loring needle at tlie second left intercostal space, in the hope that 
 the tumour might be of hydatid nature. The needle was introduced to 
 the depth of two inches, entering easily, l)ut no fluid was got, not even 
 blood. The result Avas, therefore, purely negative.
 
 A CASE OF CEREBELLAR DISEASE. 113 
 
 A CASE OF CEREBELLAR DISEASE, IN WHICH AN 
 EXPLORATORY TREPHINING AND REMOVAL OF 
 DISEASED BRxVIN SUBSTANCE WAS FOLLOWED BY 
 GOOD RESULTS. 
 
 By Hexhv Maudsley, M.D. 
 
 The .surgical treatment of intracranial tumour.s, and other conditions 
 of the brain which are diagnosed, not by any deformity of the skull, 
 nor by any history of injury, but by the symptoms general and focal 
 they give rise to, being still in its infancy, it is our duty to report all 
 such cases, wliether successful or not. Only in that way is progress 
 likely to be made, and it is to be borne in mind that the reports of 
 unsuccessful as well as successful cases are likely to advance our 
 knowledge. This must be my apology for reading before such an 
 assembly an account of a single case. 
 
 On January 9th, 1888, I saw, with Dr. Davenport, H. C, a gentleman 
 '^0 years of age. He gave us the following history : — 
 
 He had never been out of Australia, had travelled much in the bush, 
 and had enjoyed good health until the onset of the present illness. 
 There was no history of syphilis, of head injury, or of disease of the 
 middle ear. He had been temperate in all things. There was no 
 liLstory of tvxbercle, of cancer, or of tumour of any kind in his family. 
 
 In September 1886 (sixteen months before I saw him), he began to 
 suffer from headache. The headache was severe, more or less constant, 
 l)ut paroxysmally wor.se. It was referred to occipital region, and 
 radiated towards the vertex. Since that date his headache has continued, 
 occasionally a week elapsing without pain ; latterly, the paroxysmal pain 
 has become worse. 
 
 In December 1886 (three months after the onset), he began to sutler 
 from attacks of vomiting, independent of any errors of diet. The 
 attacks would last one to three days, and rarely a week elap,sed without 
 an attack. During the attacks, the pain in the head was " agonising." 
 These attacks have not diminished in frequency or sevei'ity, liut, on the 
 contrary, have inci'eased. 
 
 In July 1887, he began to suff'er from giddiness, and his gait liecame 
 affected. He .staggered like a drunken man, and had a tendeiicy to fall 
 forwards and to the left. 
 
 In Augu.st 1887, dimness of vision came on fir.st in the left eye, and 
 in the course of a month he l>ecame completely blind, Ijeing unable 
 to see the Ijrightest light. Before the onset of blindness, he would 
 occasionally see double. Deafness in the left ear came on aljout the 
 same time, and seemed to have a gradual onset. 
 
 Since September 1887, lie has had some difficulty in walking, 
 independent of his blindness, the left arm and leg being awkward in 
 their movements. Since the same date thei'e has been asymmetry of 
 the face. There is no history of convulsions, or of loss of consciousneiss. 
 
 On January 9th, his condition was as follows : — He is a tall, stout 
 man, complaining of lieadache, vomiting, blindness, and deafness 
 on the left side. On testing his cranial nerves, we tind a complete 
 
 I
 
 114 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 absence of the sense of smell, complete blindness, and deafness on the 
 left side. There is slight paresis in all the muscles (the upper and 
 lower groups), supplied by the facial nerve. There is no ati'ection of 
 the ocular muscles or of those of mastication. The pupils are unequal, 
 the right widely dilated, the left of medium size. Neitlier pupil reacts 
 to light ; the left reacts in accommodation, the right is sluggish. There 
 is no nystagmus. 
 
 Examination of the fundus oculi reveals a white hlled-in disc, the 
 arteries ai'e small, and obscured by white inilammatoiy deposits. There 
 are numerous wliite patches around the margin, suggestive of old 
 hfemon'hages. The apj)earances are indicative of white atrophy, 
 conseciitive to neuritis, and the blindness is no doubt due to this 
 cause. The non-reaction of the pupils to light, their reaction on 
 convergence of tlie eyeballs, is further evidence of this atrophy being 
 the cause of the blindness. There is no actual motor paralysis of 
 the limbs, but the movements of the left liand arm and leg are more 
 awkward than natural. When supported by two persons, he has a 
 distinct tendency to fall to the left. There is no typical hemiplegic gait. 
 He complains of some numbness and tingling in both hands, but there 
 is no loss of sensibility to touch, pain, or temperature. The superficial 
 reflexes are normal. With regard to the deep reflexes, the knee-jerk 
 is obtained with difliculty on the right side ; on the left, its presence is 
 doubtful. Ankle clonus is not present on either side. His bladder 
 and rectal reflexes are normal, and his sexual condition is normal. He 
 gutters from constipation. 
 
 Examination of the skull reveals nothing abnormal. His heart, 
 lungs, liver and spleen are normal. There is no sign of hydatid, no 
 evidence of syphilis, old or recent, and no evidence of ear mischief. 
 Tlie urine is free fx'om sugar or albumen. 
 
 Such being the condition of the patient, witli such a previous history, 
 there was very little doubt that he was suffering from organic brain 
 disease, and little more doubt that the disease was either an intracranial 
 tumour in its widest sense, or an abscess of the brain. The exact 
 nature of the tumour, its size, and its position, were not so clear. With 
 regard to the position, the slow onset of the disease, the genei'al 
 symptoms having existed a year before any focal symptoms appeared, 
 the character of his gait, the probable simultaneous occurrence of left 
 facial paresis witli deafness on the left side, tlie diminution of the knee- 
 jerk on the right side, and its doubtful presence on the left, seemed to 
 point distinctly to some lesion involving tlie left auditory and left facial, 
 where these are in contiguity, and to some attection of the left lobe of 
 the cerebellum. An absence of any distinct paralysis, motor or sensory ; 
 an absence of any convulsions, the position of the headache, and the 
 severity of the vomiting, also favoured the view of the lesion being in the 
 cerebellum. Deafness occurring alone, is of little value in localising 
 a lesion, for liajmorrhage into the nerve or its nucleus, or into the end 
 organ, is not unfrequently a cause of sudden deafness; but deafness on 
 tlie same side as a facial palsy, and not dependent on disease of the 
 middle ear, points strongly to one lesion involving both nerves near 
 their entrance into the internal auditory foi'amen. 
 
 That the lesion causing the deafness in the left ear, was not in the 
 right temporo-sphenoidal lobe, in the pcrcepti^'e centre for hearing, may
 
 A CASK OF CKJtKBELLAK DISKASK. 115 
 
 be dismissed, as in lesion of one temporo-sphenoidtd lobe tlie deafness is 
 only temporary, the same being the case in experimental lesions in the 
 monkey. From these considerations, one lesion in the left lobe of tlie 
 cere))ellum, about the amygdala, causing pressure on the neighbouring 
 left facial and left auditory, seemed highly probable. 
 
 With regard to the pathological diagnosis, abscess may be dismissed 
 .at once, as thei'e was no ear mischief, and never had been any, and no 
 liistory of a blow, and there was an absence of fever. 
 
 Syphilis and tubercle may he dismissed, as he had been treated by 
 mercury and iodide of potassium some months before, by Dr. 
 Springthorpe. There was no evidence of tubercle elsewhere in the 
 body, and no family histoiy. 
 
 The diagnosis seemed to lie between hydatid and a sarcoma or glioma 
 of the cerebellum, or some tumour growing from the temporal bone, 
 about the internal auditoiy foramen, and pressing on the cerebelknu. 
 Against its being a hydatid, was the absence of any signs of hydatids in 
 other organs, and the site (cei-ebellum or base of the skull) is not one 
 favoured Ijy hydatids, the majority occurring within the cranium being 
 in the cerebral hemispheres. Dr. Thomas' valuable paper, at the last 
 meeting of the Congress, showed that out of 97 cases of intra-cranial 
 liydatids, in 1 1 there were hydatids elsewhere, chiefly (5 of them) in the 
 liver, and of these 97, only i were in the cerebellum, so tliat the chances 
 of tliis being a hydatid were not very great. 
 
 The pathological diagnosis, then, remained doubtful. The pati(?nt 
 and friends, having heard of tlie successful cases of brain surgery, were 
 in liopes that something might be done. However, when they were told 
 that any operation would he an exploratory one — that the result of it 
 was very doubtful ; that the two cases of attempts to remove a cerebellar 
 tumour had ended fatally ; that if the tumour were safely removed 
 his eyesight would not return — the friends were vmwilling to have 
 any operation. During the next thi'ee months, the patient made no 
 improvement. His headache became worse, and his attacks of vomiting 
 were more frequent, the patient and his friends were now anxious 
 that an exploratory operation should be pei-formed. 
 
 On April 8th, I saw the patient with Mr. FitzGerald. The symptoms 
 were the same as in January, except that he had gradually become 
 deaf on the right side. Mr. FitzGerald agreed with me, that there was 
 probably a tumour in the left lobe of the cerebellum, and that consecutive 
 to tliis was a distension of the ventricles, from inflammatory thickening 
 of the meninges about the base. He considered an exploratory operation 
 quite justifl able. The deafness on the right side somewhat complicated 
 the case ; upon tlie whole, I was of opinion that it was caused Ijy 
 neui'itis of the right auditory nerve. Dr. Springthorpe, who had seen 
 the patient before any localising symptoms appeared, saw liim, and was 
 present at the operation. He was of opinion that there might be a 
 tumour in the left lobe of the cerebellum. Dr. Davenport, who had 
 watclied the case for .some time, concurred in the diagnosis. 
 
 On April 20th, the head having been shaved and the scalp waslied 
 with jether, and kept in a carbolic towel for twenty-four Jiours, Mr. 
 FitzGerald made an incision from the occipital protubei'ance outwards 
 along the left superior curved line, and another downwards from a 
 point midway lietween mastoid and the protuberance at right angles to 
 
 1 2
 
 IIG INTERCOLOXIAL MEDICAL CONCiRESS OF AUSTliALASIA. 
 
 the tirst, and reflected the soft parts. He then trephined below the 
 line of the lateral sinus. The bone was thin ; on removal, the dura 
 mater bulged above the level of the opening, and presented a cyst-like 
 appearance. On inti-oducing a needle, no fluid escaped. The dura 
 mater was incised. The cerebellum bulged out, and was so soft that a 
 quantity ran away. There was no pulsation. A needle introduced in 
 a direction towards the petrous portion of the temporal, brought away 
 jio fluid. Mv. FitzGerald introduced his flnger, and found the brain 
 substixnce Aery soft, and came on what seemed to him to be a solid 
 nodular growth fixed to temporal bone, under the tent in proximity to the 
 temporal bone. The brain substance was decidedly softer than normal 
 cerebellar substance. It was decided not to proceed further. Mr. 
 Fitzgerald then, having seen advantage in a previous case from tapping 
 the ventricles in a case of hydrocephalus, trephined over the temporo- 
 occipital region of the skull with a small trephine, and passed a small 
 hollow needle in the direction of the venti'icle. No fluid escaped. The 
 bone was at once replaced, and the wound stitched. The flaps over the 
 cerebellar wound were stitched, and a drainage tube introduced. The 
 wounds Avere dressed Avith salicylic wool. 
 
 Dr. DaAenport gaA-e the chloroform, after liaA ing administered ^ grain 
 of morphia hypodermically. There Avas Aery little l)leeding from the 
 brain substance. The patient did not sufler so much from shock ; his 
 temperature Avas normal ; liis pulse aljout 100. The pupils contracted 
 under the influence of morphia. 
 
 The trephine Avound OA'er the Aault healed by flrst intention, the bone 
 adhering at once. Within three Aveeks, the occipital Avound was reduced 
 to a superficial granulating sore. 
 
 The patient conA'alesced rapidly. AMien he Avoke up from the 
 chloroform, his old pain had left him. C)n the third or fourth day, he 
 had noises in the right ear, and by the seventh he could hear sounds ; 
 by the fourteenth, he could hear Avords spoken sloAvly in a loud Aoice ; 
 and l)y the end of the month, he could listen to his nurse reading the 
 morning paper. He had subjecti^■e flashes of light, Ijut he Avas quite 
 blind. 
 
 Since the operation, there has been no return of the pain, no attack 
 of A'omiting, and his gait is now that of a blind man, there being no 
 tendency to fall to the right. He is deaf on the left side, partially on 
 the right, and he is quite blind, the optic discs being in a condition of 
 Avliite atrophy. He eats and sleeps Mell, but at times he is much 
 depressed, OAving to his blindness. 
 
 What the exact lesion was, remains doubtful. Was the left lobe of 
 the cerebellum the seat of a soft glioma? Or is thei'e a tumour in 
 connection Avith the temporal bone or the tent, which has ceased to 
 groAv since tlie operation ? 
 
 The extreme Inilging of tlie cerebellum into the opening, and the 
 softened condition of the cerel)ellar tissue, seem to make it probable 
 that tlie left lolje of the cerebellum was the seat of a soft glioma. 
 Unfortunately, none of the brain substance Avliich came away Avas 
 examined undei- tlie microscope. 
 
 Note on July 12, 1889. — The patient still continues in good health. 
 There has been no return of the lieadache or of the attacks of Aomiting. 
 ][e is deaf on the left side, and his sense of hearing is deficient on the
 
 A CASE OF IXJUKY TO 'niK FKOXTAL IJECilON OP THE BRAIX. 117 
 
 riglit; but he cun comei'se with liis fiiends, and can hear wlien spoken 
 to. He is completely blind. Evidently there is no recurrence of any 
 growtli, so that tlie probability of there having been a glioma in the 
 cerebellum is not great. 
 
 CEREBELLAR DISEASE. 
 
 Dr. Verco related a case lie has seen in consultation, in which there 
 were ditiiise, distant symptoms pointing to possible existence of cerebellar 
 disease, but not sufficient to justify operative interference. A short 
 time afterwards the patient came into the hospital, and died in about 
 two days with typhoid symptoms. On autopsy, there was found a cyst 
 on the under surface of the cerebellum, about its centre, but hollowing 
 out one lobe. It apparently originated in the pia-mater, had no limiting 
 membrane, and no hydatid cyst. The substance of the cerebellum was 
 somewhat softened. In this case, had operation been undertaken, the 
 cyst might have easily been opened, and recovery resulted. This 
 suggests that Dr. INIaudsley's case might have been such a sub-cerebellar 
 cyst, with some degenerative softening of the left cerebellar lobe. On 
 opei'ation, the lobe might have presented, and the linger liave been 
 passed into and through tlie softened organ, and into the simple cyst, 
 the contents of which might have been allowed to flow out without 
 notice. Gliomata are, as a rule, soft, non-encapsuled infiltrating growths, 
 and it is somewhat difficult to understand so complete a removal of 
 them by simple breaking down with the linger, as to prevent recurrence. 
 
 A CASE OF INJURY TO THE FROXTAL REGION OF 
 
 THE BRAIN. 
 
 By D. CoLQUHOux, M.D. Lond., M.R.C.P. Lond. 
 
 On August 5th, 1S87, I was called to see Mr. H. A. B., aged 24: 
 years, who was suflering from violent epileptic tits. When I saw him 
 he was unconscious, and breathing heavily, but there were no signs of 
 paralysis. He had for the next four days very few periods of remission, 
 fit following lit in ra2:)id succession. On the 7th of August, tliere was 
 a brief interval of consciousness, lasting for an hour or so, in which he 
 recognised those about him. This was followed by severe fits. On the 
 8th August, he became comatose between the fits, urine and tWces 
 escaped into the bed, cystitis set in, and on 9th August he died. 
 
 The fits came on in a manner common to many cases of epilepsy. 
 He gave a sudden cry, the head became extended, and violent general 
 convulsions came on. Tlie right hand and arm, however, seemed to me
 
 118 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 to have little intrinsic movement, but to be moved mainly by the general 
 tremor of the trunk. I made an examination of the body next day. In 
 physical structure there was nothing noteworthy. The body was small, 
 but normal. In the centre of the forehead, near the anterior limit of 
 the hair, an elevation about as big as a horse bean covdd be felt. It was 
 smooth and hai'd, and felt like callus. On removing the scalp, this was 
 found to be a bony growth at the seat of an old fracture. In the right 
 temple there was an opening into the skull, covered in by dense fibrous 
 tissue. On removing the calvarium, tliis aperture was seen to be the 
 beginning of an old fracture, which led to the centre of the frontal bone. 
 There, corresponding to the external boss, was a flattened and ragged 
 pistol bullet, embedded firmly in the inner table. The brain and dura 
 mater were here so firmly attached to the skull, that they had to be 
 removed in part with the calvarium. The veins on the siirface of the 
 brain were distended with blood, and the lateral ventricles contained 
 excess of fluid. 
 
 Dr. Scott, Professor of Anatomy at Otago University, who kindly 
 examined the brain, gave the following account of it : — 
 
 " The bullet seems to have first come in contact with the brain at the 
 posterior end of the lowest horizontal frontal convolution of the right side. 
 The entire length of this convolution was degenerated, and adherent 
 to the skull ; indeed, came away with the skull-cap when it wjis 
 removed. The external convolution, on the orbital face of the frontal 
 lobe, was also in the same condition. The anterior half of the middle 
 horizontal convolution, and the anteiior third of the superior, were like- 
 wise destroyed and adherent. The bullet finally lodged against the 
 superior frontal convolution of the left side, which was indented and 
 narrowed." 
 
 As I had been informed that the wound Avas originally inflicted in 
 Exeter, I wrote to the hospital there, and Dr. A. G. Blomfield, 
 Physician to the Exeter Dispensary, very kindly obtained the following- 
 details for me. He wrote as follows : — " The case was not under 
 treatment in the Exeter Hospital, but at the Torbay. Dr. Braufoot, 
 who was House Surgeon there at the time, writes me as follows : — ' I 
 recollect very well the case of poor Mr. B., and some interesting points 
 were published in the British Medical Journal, probably in August 
 1883. The lad was bi'ought in from Daddy Hole Plain with a bullet 
 wound in the right temple. The bullet had evidently impinged near 
 the mid-line on the inner surface, smashing the cranial bones ; and there 
 was a discussion at the time as to the bullet being felt beneath the 
 integument in one of the crevices. The lad was stupid and dazed on 
 admission, and somewhat collapsed, but in three or four hours answered 
 queries as to name, address and profession of his father, and a few 
 details about the deed, and his reasons for the last. Subsequently, he 
 had pyrexia and synq_)toms of inllannnatory reaction in the cranium, 
 and Ijecame gradually more and more stupid, but in ten days' time all 
 fever subsided, his mental faculties began to re-awaken, and he made 
 an uninterrupted recovery. He was soon tired by attention to books, 
 or reading for a long time, and occasionally became excited and 
 emotional. When admitted, no local palsy of any kind was discovered, 
 but subsetjuently he lost power in the left hand and arm, and the lower 
 part of the left side of the face was paralysed as far as volitional
 
 A CASE OF INJURY TO THE FRONTAL REGION OF THE BRAIN. 119 
 
 nioveiuent went, but for ordinary purposes of expression, of motion, and 
 eating, his facial and mouth muscles seemed to act normally. As far 
 as I recollect, this weakness of the side of the face and limb developed 
 subsequently, or coincidently with the iniiammatory reaction of the 
 wound in the head. When seen at the Exeter Assize, though his look 
 was unsteady and wild, and he gave one the idea of want of steady 
 attention, yet he talked of the future (viz., that he was going to study 
 medicine in Edinburgh) quite rationally, and he expressed his gratitude 
 for what had been done. There was no other paralysis but the 
 one mentioned.'" Dr. Blomfield adds that he had been unable to 
 discover if the patient had been epileptic before the attempt to commit 
 suicide, or his mental condition before that. I have not been able to 
 find the case rej^orted in the Journal, so that I can only speak of his 
 mental state as I had been able to observe it since he came to New 
 Zealand. He called on me soon after he arrived in New Zealand, about 
 three years ago. He had made a proposal for life assurance, and told 
 me, in the course of my inquiries, that he had tried to commit suicide, 
 and that a pistol bullet was lying somewhere in his brain. He also 
 informed me that he was subject to attacks of epilepsy, but I cannot 
 recollect if these attacks had come on before the attempted suicide, or 
 afterwards. I advised him not to go on with the proposal for insuring 
 I lis life, and he immediately agreed, asking me not to mention what he 
 liad told me, as he was anxious that his antecedents should not be 
 known in the colony. Afterwards, I found he had made similar 
 confidences to nearly all his acquaintances. I saw him occasionally 
 during the next three years, but never professionally until during his 
 last illness, but he spoke freely about his attacks. Fits occurred seldom, 
 1)ut when they came on they were very severe. On one occasion I met 
 him in the street, and he told me " he had, he thought, beaten the record, 
 having had about 300 tits in two days." He fell into the hands of an 
 American advertising quack early in 1887, who promised to cure him, 
 and received a relatively high fee from him. A somewhat long interval 
 of freedom from fits was followed by the last fatal attack. He had 
 spent a year or so in studying medicine at Edinburgh, and was 
 intelligently intei'ested in medical matters. A few weeks before his 
 death, he spoke to my surgical colleague, Dr. Brown, about the 
 advisability of submitting to the operation of trephining, for the 
 removal of the bullet. Dr. Brown approved of the operation, but Mr. B. 
 did not again pi-esent himself. In business he was not very successful. 
 He entered one of the banks as a junior clerk, and remained there for a 
 few months. He was apparently not tit for sustained work, and was 
 very forgetful. He tried several kinds of work, and finally bought a 
 small business, in which he lost the little capital he had possessed at 
 starting. He was not without shrewdness in money matters, but 
 was easily moved, by anyone who was in his company, to do 
 extravagant and foolish things. His tastes were in many ways 
 elevated and refined. He was fond of music, poetry and pictures. He 
 was, on the other hand, intensely erotic, and quite unal)le to restrain 
 his passions. At one time he was weeping and praying about his sins, 
 and attending a Ritualist Church, and in a few weeks he had become 
 a sceptic, and was cynical about human vii-tue. He was lialile to gusts 
 of fury, often set up by mere trifles. These would pass off as quickly
 
 120 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 as tliey had come on, and he would then apologise humljly for what lie 
 had said or done. He was, on the wlioie, kindly and well disposed. 
 He was emphatically a creature of impulse, but his impulse, as a rule, 
 was towards good ; but if it happened to be towards evil, he had no 
 power to check it by any restraint of will. The case is mainly interesting 
 as a contribution towards the localisation of the cerebral functions. In 
 connection with it, I may cite a case I'eported by Dr. S. K. Towle, and 
 quoted in the fifth volume of " Pepper's System of Medicine." 
 
 Dr. Towle says: — "The man had been a lieutenant in a volunteer 
 regiment, and I gave him rather more privileges (in the Soldier's Home 
 at Milwaukee) on that account ; but after a time I found that he was 
 more nearly an example of total depravity than I had ever seen. There 
 was no truth in him, and he was intelligent enough to make his lies 
 often seem plausible to me, as well as to others. By his wi'iting and 
 talking, and conduct generally, he kept the patients and their friends 
 in a ferment, and gave me more trouble than the whole hospital besides. 
 He had a small scar about the middle of the forehead, which he 
 said was due to a slight flesh wound from a glancing ball in 
 battle. While he was under my care, an older brother came to 
 see him, and he told me that, up to the time his brother (my 
 patient) entered the army, he was almost a model young man — 
 amiable and affectionate, the pet of the whole family and intimate 
 friends ; but, said he, ever since he came back he has been possessed of 
 a devil if ever anyone has. In a few months he quite suddenly died. 
 In sawing open the skull, at the point of the small scar on his forehead, 
 the saw came directly upon the butt end of a conical bullet, two-thirds 
 of which projected through the skull, piercing the membranes, and into 
 the brain. The internal table of the skull had been considerably 
 splintered by the ball, the pieces not being entirely separated, and there 
 was evidence of severe chi'onic inflammation all around, and quite a 
 collection of pus in the brain where the ball projected into. Here was 
 the devil that possessed the poor fellow." 
 
 Dr. Towle does not indicate precisely the anatomical lesions in this 
 case, but it was the injury done, as in the case reported aboAe, in the 
 frontal convolutions of the cerebrum, in the part assigned by Terrier 
 and others, to the organs of the moral and intellectual faculties. I am 
 not aware of many recorded cases of moral insanity due to definite 
 ascertained lesions of the cerebrum, but I have little doubt that in both 
 these patients, their erratic moral course was directly due to the 
 destruction or irritation of cei'tain definite regions in the brain, the 
 functions of wliich exact investigation has yet to determine.
 
 CASES ILLUSTRATINC; LOCALISATION IN NERVOUS DISEASES. 121 
 
 A SERIES OF CASES ILLUSTRATING LOCALISATION IN 
 NERVOUS DISEASES. 
 
 By J. W. Springthoupe, M.A., M.D. Melb., M.R.C.P. Lend. 
 Physician to the Melbourne Ho^ipital and Lecturer to the University of Melbourne. 
 
 The following series of cases is brought forward as typical of many 
 interesting features of nerve diseases, as a record of careful work in the 
 department of neurology, and as further evidence of the degree to which 
 localisation may be carried in such department. Age and etiology are 
 also noted, since they are frequently inseparably connected with the 
 nature of the lesion, but questions of prognosis and treatment are 
 untouched, as being likely to complicate what is intended to be kept 
 simple. 
 
 Cases 1 and 2 illustrate some of the finer points in the localisation of 
 spinal lesions. It was thought unnecessary to include cases illustrating 
 the ordinary diseases of the text-books. Lesions in the internal capsule 
 are then illustrated, both of the right capsule and of the left ; both of 
 rupture and of occlusion ; both of the lenticulo-striate and lenticulo- 
 oi)tic arteries, and of both combined. In all these, the symptoms and 
 causation may be said to present their typical features. A case is added 
 (Case 7) in which a cortical branch of the middle cerebral artery may 
 have been the seat of the occlusion. 
 
 Coming to the cortex itself, cases are recorded of probable implication 
 of the arm centre, and of certain injury to the leg centres, as well as of 
 lesions, irritative and otherwise, of the ascending frontal and parietal 
 convolutions, and of the lateral and inferior regions of the cortex. 
 Cases 20 and 21 are also presented as illustrating weakness of the brain 
 area as a whole. 
 
 Some typical brain tumours are also described and localised — one of 
 the pons, one of the fourth ventricle, and two of the cerebellum. In the 
 first three, a post-mortem examination disclosed the nature and site of 
 the lesion ; in the fourth an operation was performed, which gave relief 
 from some pressure symptoms. In all, the details showing the advance 
 of the tumour, the fresh symptoms produced, and the time required to 
 jiroduce them, may be accepted as strictly accurate. 
 
 Lastly, two cases are jiresented,, in which localisation was diagnosed 
 as probable, once by myself, once by others. In the former, i)eripheral 
 irritation, ovarian in origin, in a person with a local brain instability, 
 was found to be the actual cause ; in the latter, operation showed the case 
 to be one of chronic hydrocephalus and not hydatid cyst of the left 
 frontal lobe. 
 
 Appended are the Tables of Cases : —
 
 122 
 
 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 03 
 (S 
 
 -a 
 P. 
 
 The interferences with sensation and 
 motion as found by myself, and the 
 site of the injury, as verified upon the 
 patient, exactly correspond with the 
 experimental results obtained by Ferrier. 
 Tlius, the ilio-psoas, adductors sartorius, 
 the extensor femoris, and peronei, which 
 are regulated by the third and fourth 
 lumbar nerves, were uiiaff'ccted. 
 
 Ferrier found that the fourth and fifth 
 cervical were the motor spinal roots for 
 the Deltoid, Romhoids, spinati, biceps, 
 bracliialis anticus, supinator, longus, the 
 exten.sor and serrate muscles ; none of 
 these were aijpreciably affected. 
 
 The si.xth presides over movement and 
 nutrition in the latissimus dorsi pecto- 
 rales, triceps and pronators. The seventh 
 over some of these, the teres, sub- 
 scapularis and hand flexors. The eighth 
 over the flexors of wiLst, fingers, ai d 
 hand, the extensor of t!ie wrist and 
 triceps. And the fiist dorsal over the 
 thenar, hypothenar, and interosseal 
 muscles. Most, if not, exactly all of these 
 were found affected. 
 
 Patient had been treated foraoute rheuma- 
 tism for the first five weeks. 
 
 The arm and face fibres of the internal 
 capsule probably implicated simi)ly l>y 
 pressure, the rupture being behind" the 
 knee of the capsule. 
 
 IK 
 
 Contusion of the spine 
 implicating the exit 
 of the fifth lumbar, 
 and first and second 
 sacral nerves of the 
 right side. 
 
 Poliomyelitis anterior 
 acuta,commencing in 
 the right lower lum- 
 bar and first sacral 
 regions, implicating 
 mainly, bi-laterally, 
 the anterior zones 
 between the sixth 
 cervical and the first 
 dorsal. 
 
 °2 
 |l 
 
 
 After the injury, walked home ; complained of girdle 
 pain round lower waist, with tenderue.ss of right 
 side of upper sacral and lower lumbar vertebra;, 
 weak from the knee down. Pains in leg, especially 
 the iiibtep, stitfness of the part ; no reflex to tickling 
 within a week Weak in the following movements- 
 flexing the leg on the thigh, raising the os calcis, 
 walking, moving the ankle laterally and up and 
 down ; could not move tlie foot or flex the big toe. 
 (Gradually impiwed. In three weeks, sensation 
 normal, but foot dragged, and big toe not properly 
 flexed. 
 
 Suddenly pain and stiffness in right calf, and in right 
 side generally. Fourteen days pyrexia, with pro- 
 fu.se unpleasant sweating, then pains hi Lateral and 
 confined to the arms. Paresis and paralysis followed, 
 with atrophy ; both fairly symmetrical. 
 
 Two months later, slight wasting in right calf and 
 thigh. Flexion still weak. Forearms semi-flexed, 
 semi-prone ; fingers extended and abducted. Can- 
 not extend the elbow, flex the fingers, or rotate the 
 wrist. Shoulder movable, but cannot touch the 
 occiput. Electricity detected wasting in the ]>ccto- 
 rales, latissimus dorsi and triceps, in the flexor 
 muscles of the fore.arni, the thumb and interossei, 
 posteriorly, with little or none in the radial aspect 
 and supinator longus. 
 
 Later on, the flexor and thumb muscles, the interossei, 
 the abductor minimi digiti especially wasted, with 
 local coldness, lividity, and denuded aspect, but 
 flexion, rotation, abduction, &c., returning. Some 
 slight atrophy remaining in right leg. 
 
 Right liemiplegia. No unconsciousness, headache, or 
 dizziness. Leg affected more than arm, bluer, colder, 
 but no hemi-ani«thesia. Still, increased knee jerk, 
 ankle clonus, leg dragged; aim almost normal. No 
 deviation of mouth or tongue on attack, though 
 speech thick for two months, and whistling im- 
 possible. 
 
 O 
 
 Railway Accident — 
 a blunt fragment 
 of wood striking 
 him on the right 
 side. 
 
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 Rupture of small 
 tense artery three 
 months ago. 
 
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 CASKS ILLUSTRATIXr; LOCALISATIOX IN NERVOUS DISEASES. 
 
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 126 
 
 INTEKCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 s 
 
 In eight months, this tumour seems to 
 have grown from a size simply irritating 
 the pons to that mentioned. Its pro- 
 gress may be traced in the symptoms 
 The locality of the headache, again, 
 is noteworthy. The neuroparalytic 
 ophthalmia occurred oidy when i>ressure 
 on the Casseiiau ganglion had becimie 
 possible by the extension of the tumour. 
 
 Another case of localised lesion, in which 
 the extension of the tumour can be 
 traced in the symptoms as they arose. 
 
 
 
 Tumour the size of a 
 small orange resting 
 on left pons, impli- 
 cating the left 
 seventh, eighth, sixth 
 and fifth cranial 
 nerves in the order 
 named. 
 
 TiTmonr of the fourth 
 ventricle, pre.ssing 
 first ou the spinal 
 accessory and vagus, 
 sjireading forwards 
 to the right side, and 
 pressing on the right 
 sixth and eighth, the 
 facial and hypoglossal 
 nuclei, being deeper 
 seated, escaping. The 
 fifth somewhat im- 
 plicated, also the 
 valve of Vieussens, 
 the third and fourth, 
 and finally, the cor- 
 pora quadrigemina. 
 Considerable serosity 
 of the plexus, and 
 
 ■- }iS 
 
 1|£ 
 
 .S 5 3 
 
 O 
 
 Five months pieviously, left hemiparesis without 
 hemi-ana3.sthesia ; also paresis of right arm, and 
 severe right parietal headaches. Now, paralysis of 
 left seventh and eighth nerve; added, and marked 
 choreiform movements of all limbs, esiiecially the 
 right arm, with ulceration of left soft palate. In 
 sixteen days, diplopia an<l weakness of left ex- 
 ternal rectus, the headaches spi-eading to frontal 
 area, and embracing the whole head ; legs much 
 weaker, especially the right. In thirty-five, spasm 
 of massoteis, ami tenderness of scalp ; then double 
 optic neuritis aud giddiness. In sixty-five, right liand, 
 twenty with dynamometer, left hand nil. In eighty, 
 restlessness, doliiiuni, stujior, aiul iioTiro-paralytic 
 ophthalmia of the left eye, the headaches being very 
 severe and general. On the ninety-second day, died. 
 Throughout, no vomiting-. 
 
 Five weeks i)revious]y, .suddeidy severe vomiting, in- 
 cessant occipital headache, staggering gait. Now, 
 double optic neuritis, retiacting the heall with rigid 
 neck muscles, more on the left side, but disappearing 
 within ten days. Frequent yawning, and altered 
 heart rhythm. Within the week, deafness in right 
 ear, and about the .same time the right sixth paralysed. 
 Three weeks later, sight affected, pu])ils immobile ; 
 finally, double ptosis. All were on the right side. 
 Mind becoming gradually stupid ; drowsy, uncon- 
 scious, and comatose. Five weeks after admission, 
 no polyuria or polydipsia (said to accompany lesion 
 of isineal gland) ; no paralysis of facial or hypoglossal ; 
 no paralysis of limbs. Three weeks after admission, 
 sudden localised infiltrateii patch in mid upper 
 sacrum, dischai-ging pus from five apertures in two 
 days ; no choroidal atrophy, but opaque nerve-fibres 
 present. 
 
 
 a 
 
 M 
 
 o 
 
 H 
 
 O 
 
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 Probably syphilis. 
 Jliscarriage four 
 yeai's ago. Child 
 four months old 
 said to be suffering 
 from congenital 
 syphilis. 
 
 Syphilis, small pus- 
 tular rash ou body, 
 large symmetrical 
 scars on legs. Syphi- 
 litic i)laques found 
 on liver and spleen, 
 and a large gumma 
 breaking down in 
 the left kidney. 
 
 
 a 
 fa 
 
 Male. 22 
 
 
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 CASES ILLUSTRATING LOCALISATION IN NERVOUS DISEASES. 127 
 
 
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 localised tumour was fe 
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 ■essure-symptoms. 1 ma 
 
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 .tcruciatlng headaches, paroxysmal, at first 
 occiput, now advancing along the midline, 
 of vertigo, at first turning to the right, now 
 left (five months after the headaches). Ati 
 vomiting for six months, worse on empty s 
 with extreme straining and nausea. Extremi 
 
 optic neuritis, with scores of fiame coloured 
 rhages, and ai>pearances like albumenuric r 
 No kidney disease detectible. The hajmi 
 appeared suddenly, with sudden loss of he; 
 right ear. Right eye, vision almost gone. I 
 speech thick at times, and gait somewhat un: 
 
 n August 1SS7. Patient remained under my observation till 
 alising symptoms had appeared. His subsequent history is i 
 mcertainty as to the nature and site of the tumour. Little. 
 cuing through the occipital bone, some one-third of a teacup 
 c left .supero anteroparietal region, also with negative result 
 ve all erred in not locating the tumour there. The re.sult of 
 tary Section dollar nie from the ple;isnre of hearing Ur. Mau( 
 
 Somnambulism as a child. Congestive hea<Ia 
 stead of catamenia at monthly intervals, witli 
 and vomiting till htst twelve months. Tw 
 of both hanils for two years. Falling ou k 
 all, some fifty times during the liiat six i 
 Progressive failure of sight for five month 
 atrophy of each disc, and pigmentation. M 
 memory failing and obtuse, instead of q 
 pieviously. No epileptic attacks. No pa 
 Fulness of head iu ftoutal region, sugges 
 tumour. 
 
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 128 
 
 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 
 ffnse 
 with 
 
 Tlie 
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 aud 
 
 I re- 
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 one. 
 been 
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 iier.s, 
 the 
 esult 
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 illustrating a 1 
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 somewhat celeb 
 rent diagnoses 
 uterine or tissocii 
 
 found by skilled 
 suggested — ? abs 
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 ectiun. Eight m 
 largement of the 
 l1, and now, twe 
 iration, patient is 
 
 < 
 
 s illustrating 
 mstroke. Con 
 ity of cerebra! 
 latter is proba 
 nervous systei 
 ascular system. 
 
 
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 lilt from ] 
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 laiiy diffe 
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 aving been 
 he writer 
 iglittem])Oi 
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 I'as detectei 
 fter the ope 
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 effects of 
 the instal 
 site in th 
 within th 
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 ight ov.arian a: 
 tubal disease ; t 
 ovary half filiroi 
 half soft and friabl 
 tlie tube in a com 
 tion of well-inark 
 h.tmato-salipynx. 
 
 H* 
 
 -^ M =3 s e 
 
 
 olecular in 
 the brain i 
 with pro 
 manent v: 
 c n s e q 
 changes. 
 
 
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 « 1 
 
 
 ke of average 
 y unaffected ; 
 ued attention 
 re in the occi- 
 bloodshot, on 
 ; retina fairly 
 ntil the sun- 
 now unequal 
 
 aracter, more 
 occurring in 
 food, though 
 indescriliable 
 ,r. Symptoms 
 ,, with ajqiear- 
 Throbbings 
 of neck. No 
 alid from the 
 than eighteen 
 a seiiticemio 
 ee and a half 
 ily history of 
 ■en subject to 
 
 
 ras, siinstro 
 ice. Memor 
 y for contin 
 iression, mo 
 inful, and 
 Sight good ; 
 y upset ; u 
 igorous, but 
 
 bursting oh 
 ital regions, 
 staste for 
 g good, but 
 
 the right ea 
 halmic veins 
 in right eye, 
 1 right side 
 omplete inv 
 ins for more 
 ating from 
 placenta thi 
 was a fam: 
 d always be 
 
 ti 
 
 K 
 
 ivelve months ago in Mad 
 severity ; no paralyses sii 
 intellect keen, but capacit 
 almost nil. Feeling of op] 
 put, with eyes weak, pa 
 attempting steady work, 
 normal. Stomacli quickl 
 stroke, all the functions v: 
 to ordinary work. 
 
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 nbearable headaches of 
 in right parietal and ft 
 paroxysms. Extreme 
 seldom vomiting. Hear 
 noises almost constantly 
 of pressure mion both ojil 
 ance of incipient neuriti 
 in right jugular. Pains 
 spasms or paralyses. A 
 head and stomach symp 
 months, the symi)toms 
 attack following retainei 
 years iireviously. Tlieri 
 migraine, and patient 1 
 attacks herself. 
 
 
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 A CASE OF IIAYNAUD's DISEASE. 129 
 
 A CASE OF KAYNAUD'S DISEASE. 
 
 B}^ David Grant, M.A., M.D. Ediii. 
 
 Lecturer ou Materia Mcilica in the Uuiversity of Melbourne. 
 
 The condition which was lirst described, from its ultimate manifesta- 
 tion, as "symmetrical gangrene," and wliicli has since, according to the 
 stage which in nny given case was most cons{)icuons, been variously 
 recognised ;is "local syncope," "local asphyxia," "local ischa?mia," 
 "local cyanosis," will probably, and justly, take its place in nosologies 
 under the name of Kaynaud, who first collated the recorded cases, and 
 formulated a rational theory of its pathology. As it still ranks among 
 tlie rarer neuroses, a l)rief descrii)tion of a case which occurred recently 
 in my hospital practice, and which, through not absolutely typical, was 
 sufficiently well-marked, may be of some interest to the members of the 
 Congress ; and I therefore pro'.-eed, without further preface, to recount 
 its leading features. 
 
 History. 
 
 E. T., set. 38, married fourteen years, without children, engaged as a 
 seamstress, came under my treatment at the Melbourne Hospital in 
 July 1888. Her health had always been good ; she had had no acute 
 illness of any kind, but had sutiered from chilblains in girlhood. 
 
 Her pr(!sent illness began in the winter of 1885. iShe first noticed 
 that the terminal phalanges of the fingers became quite white and 
 painful, this condition lasting at first about a quarter of an hour, and 
 ceasing after friction or exposure to the heat of the fire. During the 
 winter it gradually extended upwards, and affected the second 
 phalanx ; and after exposure to sharp cold, the whiteness was followed 
 by a dark "blue-black" a])pearance, with severe pain. The left 
 fore-finger was particular atlected, and seems to have been treated as a 
 whitlow, the end being poulticed and incised, but no matter came, and 
 xcry little blood followed the incision. Soon after this, the nail dropped 
 of. 
 
 Improvement occurred during the summer, Ijut during the following 
 winter (1886) the condition became worse, and the nail of the left 
 middle finger was lost. The affection has been present more or less 
 continuously ever since, and as gradually become more painful. The 
 whiteness and deadness of tlie lingers occurred even during the warm 
 weather of the summer, but was especially produced by cold. 
 
 The pain has been greater during the present winter, and most of the 
 fingers have lately become red and swollen in the intervals between the 
 attacks ; but when the attacks come on, these red and swollen fingers 
 become quite white, cold, numb, and much smaller in size. 
 
 Causatiox. 
 
 On this i)oint, nothing definite can be ascertained, except that she had 
 much woriy and trouble before this ailment began. Hemicrania, 
 which is sometimes associated with the disease, is not known in her 
 family, nor is there a family history of any other neuro.ses. There are no 
 menstrual irregularities, and lier other organs and systems are normal, 
 
 K
 
 130 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 except (1) the digestive, which is occasionally painful. The tongue is 
 furred, and there is constipation. (2) The heart, where there is 
 evidence of aortic obstruction, in the presence of a faint systolic 
 murmur, loudest in the aortic area. 
 
 Local Appearances during Attack. 
 
 (1) Stage of Iscluemia. — Her condition last August was the follow- 
 ing : — Her hands are always more or less jiainful, and usually in a state 
 of redness and swelling. On first rising in the morning, the fingers, up 
 to the metacarpophalangeal joint, become perfectly white and dead, and 
 extremely painful. The bloodlessness of the fingers, quite symmetrical, 
 accompanied by extreme coldness and ]iainful antesthesia, and shar[)ly 
 and abrupitly marked off from the normal warmth and vascularity of the 
 metacar[)al region, was frequently seen by me, and pointed out to the 
 students. The extreme contrast and abrupt transition from absolute 
 cadaveric pallor to the natural glow was most striking, and totally 
 different fi'om the diffuse coldness and gradual transition to healthy 
 warmth of surface so commonly seen in those with weak circulation or 
 heart-lesions. This stage of iscluemia iisually lasted through the fore- 
 noon, and as the day became warmer, the whiteness was replaced by a 
 bluish-black appearance, which succeeded immediately to the maximum 
 whiteness. 
 
 (2) Stage of Cyanosis. — In this stage, which was rapidly develoj.ed, 
 and several times displayed itself while the patient was under 
 observation in the out-patient room, the cyanosis, or local asphyxia, was 
 extremely marked. The digits began to recover their warmth, and the 
 Avhiteness was rapidly replaced by a dee}» indigo hue, almost passing into 
 black. This stage was much shorter than the first (lasting usually from 
 five to ten minutes), and appeared to osve its existence to the fact that the 
 })rimary spasm, affecting both arteries and veins, disappeared first from 
 the latter, and permitted the regurgitation into the capillaries of venous 
 blood which had been detained for a considerable time in the smaller 
 veins. This state was immediately succeeded by a stage of eiythema, in 
 which the fingers became red and swollen, and the [lain was a little 
 diminished. 
 
 (3) Stage of Hypercemia. — Formerly, the |)ain ceased entirely at this 
 stage, l)ut now (i.e., in August 1888) the right forefinger and the left 
 little finger are permanently red and swollen. 
 
 (4) Gangrene. — On August 12th, I noted that " the left little finger 
 is red, swollen, and slightly tender ; there is a small cicatrix on its tip, 
 where a black patch formed some weeks ago, and a similar appearance 
 is extending under the nail, which threatens to separate. A similar dis- 
 colouration is visible on the dorsum, on the pidp of the last phalanx, and 
 under the nail of the right forefinger ; and a slight loss of skin on the 
 end of the right ring-finger, which was preceded by a black speck." 
 
 These losses of tissue in skin and nails were very small, but distinct 
 enough, iaivolving the loss of two entire nails, and of several small 
 j)ortions of skin. 
 
 None of the interesting nervous symptoms, such as aphasia, transient 
 blindness or deafness, were observed in this case; nor was there detected, 
 at any time, htematuria or albuminuria.
 
 A CASE OF RAYNAUD S DISE.\5E. 131 
 
 There were no cardiac symptoms. The aortic murmur was a very- 
 obscure one; and as ah-eady said, tlie local pallor was very different from 
 that sometimes seen in heart-disease. 
 
 The toes were symmetrically affected, but much less severely than the 
 fingers. 
 
 The intensity of the symptoms was always increased by cold, and as 
 the spring advanced they have gradually abated, until now there is only 
 a slight redness and fulness of the fingers, with scarcely any discomfort. 
 
 Treatment Practically Useless. 
 
 Treatment has been of little avail. It has been conducted on three 
 lines : — 
 
 (1) An attempt was made to remove the vascular spasm, jjartly by 
 acting directly on the arterioles l)y means of nitro-glycerine, partly b}' 
 diminishing undue excitability of vaso-motor centres by the agency of the 
 bromides. Tlie former, in one minim doses of the 1 per cent, solution, pro- 
 duced disagreeable physiological symptoms, without the least improvement 
 in the local disturbance, and was soon abandoned. The latter, alone or 
 combined with belladonna or valerian, were better tolerated, but equally 
 futile. In view of the cardiac lesion, although there were no signs of 
 defective compensation, digitalis had a fair trial, on the theory that it 
 might possibly overcome })eripheral resistance, but its action on the 
 arterioles I'endered this in theory almost a forlorn hope ; and, in fact, it 
 also was useless. Spirit of nitrous ether, as a vaso-dilator, was also 
 vainly tried. 
 
 (2) The changes were rung on the various vascular, blood, and 
 nervine tonics — chiefly iron, strychnia, and cod liver oil ; but in no case 
 did it appear that an}' beneficial effect was produced. 
 
 (3) Electricity, in the form of the descending stabile current, which 
 produces relaxation of the arterioles, hashad a pi'olonged trial, extending 
 over several months. The patient found that the attack was shortened 
 slightly by this ; the ischtemia passing into the stage of erythema some- 
 what sooner, but no permanent good was done. The spasm returned 
 with undiminished intensity on the following day, and the results of the 
 electrical treatment in this case hardly bear out the conclusions of 
 Raynaud himself as to its efticacy. 
 
 As minor details of treatment may be mentioned, the use of friction 
 and the wearing of warm gloves, which slightly palliated the severity of 
 the symptoms, but had no effect in preventing the recurrence of the 
 daily paroxysm. 
 
 Remarks. 
 
 The diagnosis in this case was based upon the presence of extreme 
 vaso-motor disturbance, characterised by three well-marked stages of 
 ischaemia, cyanosi.s, and erythema (or rather hypera^mia), affecting the 
 extremities symmetrically, excited or intensified by cold, and leading to 
 superficial necrosis of very small portions of nail and skin. The presence 
 of a valvular lesion of the heart, and the history of chilblains in child- 
 liood, caused at first some hesitation in diagnosis, but further observation 
 removed any doubt as to the existence of a true vaso-motor neurosis, 
 cattsing local disturbance of circulation, which could not be dependent 
 
 K 2
 
 132 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 either on back-working, or on defective cardiac power. In the descrij)- 
 tion of this disease, given by Dr. Allan Starr, in Pepper's " System of 
 Practical Medicine " (the only complete account to be found in any 
 systematic work), absence of cardiac disease is specified as a conditioir 
 of the diagnosis, but this appears to me to be an unnecessary require- 
 ment, inasmuch as the local phenomena are sufficiently characteristic 
 to be identified even in the presence of heart disease. 
 
 Another point of special interest in this case is the very short duration 
 of the attacks, and their daily recurrence— all the stages of the disease 
 being daily manifested. Pepper says that " the shortest duration of a 
 single attack has been ten days, the longest five months." But in this 
 case, a complete paroxysm was passed through every day, showing 
 typically — (1) local ischajmia ; (2) local cyanosis ; (3) local hyperajmia, 
 the first lasting a few hours, the second only a few^ minutes (not more 
 than 15), and the third being present in a varying degree until the 
 beginning of the next paroxysm. This daily recurrence of paroxysms 
 was a striking feature of the case. 
 
 Nature of the Disease.— Old Theory. 
 Until a few years ago, there were no post-mortem records of cases; and 
 the theory originally propounded by Raynaud, as a deduction from 
 clinical observations, viz., that the disease is a vaso-motor neurosis, was 
 universally accepted, the only difference of opinion being on the 
 question whether the vaso-motor irritation was in the vaso-motor centre 
 itself, or was excited by peripheral irritants. I find, however, in 
 Virchow and Hirsch's Jaliresbericht for 1888, an abstract of a paper by 
 Dr. Goldschmidt, in Revue de Medicine, entitled, "Gangrene Symmetrique 
 et Sclerodermic," in which he describes in detail a case of Raynaud's 
 Disease, " which was complicated with the appearances of an extensive 
 •scleroderma, in a woman cct. 43, previously healthy. . . . After five 
 years' existence of the disease, there finally appeared symptoms cardiac 
 and renal (albuminuria). The patient died suddenly in consequence of 
 cardiac failure (Herzinsufficienz). At the auto})sy, the essential feature 
 was a widespread endarteritis and endophlebitis terminalis, both in the 
 gangrenous and sclerosed parts; the same could be demonstrated in the ter- 
 minal arteries of the kidneys and lungs. It is noteworthy, that changes in 
 the peripheral nerves could not be demonstrated. Brain and spinal cord 
 were not examined. On the basis of the anatomical data, the author 
 regards it as certainly established, that in sclei-oderma, and in Raynaud's 
 disease, we have to do with the same pathological process in different 
 phases of development — an endarteritis terminalis, wuth regard to 
 which it must still remain doubtful whether it ow^es its origin to vaso- 
 motor disturbances, or is of micro-parasitic source." I translate this 
 abstract in full, because it is obvious that every post-mortem record of a 
 rather obscure disease is of importance as a possible source of light, and 
 I regret that I have no access to the original paper, to which reference 
 is made for the clinical details. The new theoiy here put forward is 
 totally at variance with that hitherto received, inasmuch as it takes the 
 disease out of the category of neuroses, and places it among chi"onic 
 degenerative affections of vessels. The two conditions maij have 
 coincided in Goldschmidt's case, for there is no incompatibility between 
 vascular s[)asm and vascular inflannnatiou. But endarteritis and
 
 A CASE OF Raynaud's disease. 133 
 
 emloplilebitis, j^er sc, appear to me to be totally inadequate to explain 
 the phenomena of Raynaud's Disease, for (1) its greatest frequency is 
 between the ages of 15 and 30, when endarteritis is rare : (2) only two 
 eases have been observed itx patients as old as 50, when endarteritis is 
 common ; (3) endarteritis is a chronic condition, leading to permanent 
 oi'ganic clianges, while Raynaud's Disease consists of definite attacks, 
 witli well-detined " stages," ending in recoveiy, and followed in a large 
 pro])ortiou of cases by recurrence ; (4) in my case the condition was 
 distinctly paroxysmal, and this character is also manifested by the 
 transitory aphasia, blindness, albuminuria, hematuria, and glycosuria, 
 which have been sometimes observed ; (5) endarteritis would scarcely 
 account for the precise symmetry of the local appearances, which is, on 
 the other hand, not only consistent with, but characteristic of, a purely 
 neurotic origin. This new theory may, therefore, 1 venture to think, be 
 set aside as insufficiently supported by positive evidence, inadequate in 
 itself, and inconsistent with clinical facts. 
 
 Reverting to the accepted theory, that the disease is a vaso-motor 
 neurosis, the question arises whether the vaso-motor irritation originates 
 in the centres themselves, or is reflected from the periphery. Raynaud 
 regarded it as central, mainly on the ground that "galvanisation of the 
 spinal cord modified the arterial spasm," and the partial benefit derived 
 from electrical treatment in the case here reported bears in the same 
 direction. Rut it would be rash to draw a positive conclusion from a 
 single piece of evidence wliich is still in want of confirmation, and it 
 appears that the good effects of galvanising the cord (assuming that they 
 are proved) may be due, not to the removal or suspension of morbid 
 changes in the vaso-motor centres themselves, but to a diminution of 
 their normal excitability, rendering them insusceptible to the action of 
 periphei-al irritants. 
 
 Stronger arguments, in favour of the centi'al seat of the primary 
 disturbance, appear to be found in the intensity and persistence of the 
 arterial S])asin, in the occasional paroxysmal character of tlie attacks, and 
 in a consideration of the alleged or suggested sources of reflex irritation. 
 The latter are all of a very general kind. Thus, " Wei.ss believes that 
 the condition may occur in response to irritation arising in the skin, in 
 the viscera, or in the brain " (Pepper, p. 1261). But cutaneous, visceral, 
 and cerebral irritations exist in hundreds of thousands of cases, without 
 producing symmetrical ischsemia and gangrene, and in any case in which 
 tJiey do, it becomes necessary to assume the existence of some undue 
 excitability of vaso-motor centres — in other words, to admit that the 
 essential condition is a central one. Here, we may refer to the analogy 
 of epilep.sy, where all sorts of peripheral irritants may come into j^lay as 
 exciting causes of the central dischai-ge. To this group of neuroses, 
 including epilepsy and hemicrania, Raynaud's Disease may most 
 reasonably be referred. 
 
 An additional item of evidence, in favour of a central change, is 
 furnished by the title of a paper which I find in ScJuniJfs J alirhuclter 
 for 1887 (Vol. 216, p. 310). The paper is by Marfan, and is entitled 
 " Syncope locale des extremites snperienrs a la suite d'une commotion 
 medullaire" [Arch Gen. 7 S. XX., p. 485, Oct.) Here again, I have no 
 access to the paper, and no abstract is given by Schmidt ; but the title 
 implies that the disease was consecutive to concussion of spinal centres.
 
 134 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 The existing evidence is not yet sufficient to justify a positive con- 
 clusion, but its weight is decidedly in favour of the tlieory that the 
 disease is of a central origin. 
 
 An attempt has been made to explain the symptoms of " Raynaud's 
 Disease," as the result of peripheral neuritis. Thus, in the British 
 Medical Journal for January 1887 (p. 57), Wiglesworth reports a case 
 under the title of " Peripheral Neuritis in Raynaud's Disease 
 (Symmetrical Gangrene)," and in the discussion on this paper at the 
 Pathological Society, reference was made to similar observations by 
 Bowlby, Pitres (2 cases), and INIountstein, of Strasburg. In Wigles- 
 worth's case, advanced chronic inflammatory changes were found in all 
 the nerve trunks of the limbs, but the clinical details of the report do 
 not appear to justify the diagnosis of Raynaud's Disease. The case was, 
 in fact, quite obviously one of peripheral neuritis, with epileptic 
 dementia, in which there was great atrophy of muscles, and in which 
 the gangrene (leading to the loss of fingers and toes) was the result, not 
 of deprivation of blood supply, but of injury to the tro))hic nerves. 
 There is no history given of vaso-motor phenomena, which are the 
 essential feature of Rajniaud's Disease ; and the value of the case is 
 further impaired by the fact, that advanced granular kidneys were also 
 found. Peripheral neuritis is as incapable as endarteritis of accounting 
 for the paroxysmal character of true Raynaud's Disease, and few 
 competent judges will be disposed to accept the conclusion of Dr. 
 Wiglesworth, that his observations " tend to take Raynaud's Disease out 
 of the category' of neuroses, by giving it a tangible material lesion to rest 
 upon." The obvious error in this case has arisen from the condition of 
 " symmetrical gangrene " having been identified with the lesion 
 described by Raynaud, and regarded as its essential phenomenon. As 
 a matter of fact, symmetrical gangrene is no necessary result of the vaso- 
 motor disturbance which constitutes the disease, and is much more likely 
 to be caused by trophic nerve lesions, either centi-al, or as in Wigles- 
 worth's case, peripheral. It is desirable to em.phasise the fact, that 
 symmetrical gangrene is a secondaiy result of various primary lesions, 
 and that it does not, ])e.r se, form a disease type. It would also be well if 
 the lesion now under consideration could receive a single descriptive 
 name, based on its pathological cause or chief clinical features. If I 
 were to describe my own case in this way, I should call it " paroxysmal 
 recurrent isclipemia;" but this name would probably be inadequate 
 in many cases, and as the clinical phenomena are variable, and the 
 essential pathological cause is still obscure, it seems advisable still to 
 retain the convenient title of " Raynaud's Disease." 
 
 Addendum. 
 Since the foregoing paper was read, I have just received the British 
 Medical Journal for December 8th, 1888, containing a paper by Dr. 
 Affleck, on Two Cases of Raynaud's Disease. For one of these the left 
 foot had to be amputated, and the internal plantar nerve was found to 
 " have suffered extensively from neuritis, and was undergoing degenera- 
 tive change, many of the bundles being entirely destroyed, and replaced 
 by fatty matter." The author remarks that, "it might, perhaps, be 
 urged that this was a secondary result to tlie tissues of tlie affected parts, 
 from the changes in them accompanying the gangrene;" and considering
 
 AORTIC INCOMPETENCE AND LOCOMOTOR ATAXIA. 135 
 
 tliat in this case the gangrene was extensive, involving the anterioi- half 
 of the foot, so that " it was evident that every tissue in this part had 
 perished," and considering that this condition had existed for nearly two 
 months before amputation, it seems more reasonable to regard the 
 degeneration of the nerve as a consequence, than as a cause, of the 
 gangrene. It may be remarked also, that the appearances described and 
 figured are those of simiile fntty degeneration (not, as in Wiglesworth's 
 case, including hyperplasia, and other results of inflanmiation), so that 
 there is the more justification for regarding them as indicative of 
 ascending degeneration, consecutive to the gangrene of the parts which 
 they sup})lied. 
 
 The repeated observations of neuritis, or changes similar to those of 
 neuritis, in cases of Raynaud's Disease, must be regarded as having an 
 important bearing upon its pathology, but that neuritis is the cause, or 
 even a necessary contributing cause, of the symmetrical gangrene, is not 
 yet established or rendered probable by hitherto recorded cases. On 
 this point, I would remark — (1) That the arrest of circulation in this 
 disease is sufficient to account for gangrene, without invoking the aid of 
 trophic nerve-lesion ; (2) tliat perii^heral neuritis is very common, and 
 Raynaud's Disease comparatively rare ; (3) that motor symptoms, usually 
 present in neuritis, are absent in Raynaud's Disease ; (4) that the 
 sensory symptoms are obviously dejiendent on, or explicable b}^, the 
 vascular disturbance ; (5) that mere neuritis cannot account for the 
 distinctly paroxysmal t3'pe of the disease ; (6) that the occasionally 
 associated aphasia, glycosuria, hfematuria, blindness, and deafness, all 
 transitory, are entirely consistent with the theory of a central vaso-raotor 
 disturbance, and entirely irrelevant to that of a neuritis. 
 
 AORTIC IXCOMPETEXCE AXD LOCOMOTOR ATAXIA. 
 By D. CoLQUHOUN, M.D. Lond., M. R.C.P. Lond., Dunedin. 
 
 About two and a half years ago, I had under my care a woman suffering 
 from mit.al incompetence, in whom there were marked symptoms of 
 inco-ordination of the lower limbs, with abolition of the patellar reflex. 
 Shortly afterwards, the first of the two cases, whose histories follow, 
 came under my care. The symptoms presented seemed clearly to be 
 those of locomotor ataxia, but on account of the heart lesion accompanjdng 
 them, it seemed to me to ]>e not unlikely that the deficiency in the 
 functional activit}' of the cord, in this and my previous case, was due 
 primarily to imjierfections of the circulation. In a little more than 
 twelve months, a similar case, also detailed in this pa])er, came under 
 notice in Dunedin Hospital, and I learned from the Medical News, of 
 Philadelphia, that the coincidence of aortic I'egurgitation and locomotor 
 ataxia had been already discussed in the Berliner KliniscJie Wochensdirift. 
 I take the following account of the discussion from the Medical News 
 of July 7, 1888 :— 
 
 " Bergerand Rosenbach, in 1879, called the attention of the profession, 
 in a brief notice in Berliner Kliuische Wochenschrift, to the association of
 
 13G INTERCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 aortic insufficiency witli locomotor ataxia. They published notes of 
 seven cases, without comment. In tlie following year, Angel, in an 
 article in the same journal, entitled, ' The Coincidence of Heart Lesions 
 with Tabes,' reported on a series of twelve patients suffering from 
 locomotor ataxia, five cases in which there was the sign of aortic 
 insufficiency, namely, a diastolic murmur, present however only after 
 muscular effort, and disappearing during prolonged rest. The murmur 
 was not heard at all in the morning, while the patient still remained in 
 bed. This observer regarded the murmur in question as due to abnormal 
 action of the heart muscle. 
 
 " Groedel, whose opportunities for the study of locomotor ataxia at 
 Bad-Nauheim have been very extensive, regards the occurrence of 
 cardiac affections in this disease as wholly accidental. In this view, he 
 concurs with Eulenburg and Ei'b. Between 1875 and 1879, namely, at 
 a time when his attention had not yet been especially called to the 
 subject, Groedel noted, in forty-three cases of ataxia, only two in which 
 the signs of valvular disease were present. Between 1880 and the close 
 of 1887, a period during which every case of locomotor ataxia was 
 studied wath especial reference to the condition of the heart, valvular 
 lesions were detected in only four out of one hundred and eight cases, 
 and in no instance was he able to recognise the murmur of aortic 
 insufficiency after muscular exertion, as described by Angel. Cardiac 
 phenomena of a diflerent kind were, however, very frequently observed. 
 These consisted of feeble action of the heart, increased frequency of the 
 contractions, small pulse, faintness of the sounds, manifestations not 
 oidy common in enfeebled subjects, buc also in those still well nourished 
 and strong. In only two instances were these symptoms associated with 
 the signs of dilatation of the right and left chambers of the heart." 
 
 It is evident that Groedel's observations were made on patients whose 
 primary disease was locomotor ataxia, and they can hardly be said to 
 negative the possible connection between some cases of aortic insufficiency 
 and the development of symptoms of locomotor ataxia. It seems to be 
 a point worthy of obsei'vation, whether valvular lesions, accompanied by 
 failing compensation, may not be frequently accompanied by symptoms 
 such as are met with in locomotor ataxia. Pi-obably too, the prolonged 
 action of this cause — failing compensation — may give rise to changes in 
 the posterior columns of the cord, which may remain Avhen the failure 
 has been partially recovered from. 
 
 Dr. Moxon, in his Croonian Lectures on the Influence of the Circu- 
 lation on the Nervous System, has pointed out that the blood supply of 
 the cord is so distributed as to make the lower part of the cord especially 
 liable to suffer from deficient force of the circulatory appai-atus. The 
 su))))ly from the vertebral arteries has to be sup]>lemented by a precarious 
 supply from below, the re-inforcing vessels reaching the cord along the 
 strands of the canda equina, at an exceedingly disadvantageons angle. 
 
 It seems hardly reasonable to dismiss such cases from consideration as 
 merely coincidence, when the causes assigned seem fairly to account for 
 the symptoms produced. I will now submit my two cases for your 
 consideration : — 
 
 A. H. S.,a gentleman, aged .55 years, consulted me first in Sej)tember 
 1880. He then complained chiefly of giddiness, especially on sudden 
 movements, and of loss of sight for a few seconds under the same cir-
 
 AORTIC IXCOMPETKNCK AXD LOCOMOTOK ATAXIA. 137 
 
 eurastances. He had not been well for months, but had intervals of 
 compai'ativc ease. For the greater ])art of his life, he had been a very 
 strong and healthy man. He was born in England, but left it as a boy, 
 and had worked as a digger in California, Victoria, and New Zealand, 
 leading a hard life. He was more tiian usually active for many years, 
 able to walk up hill, or run and .jump, with less distress than most men. 
 He had never any serious illness, was married, and the father of ten 
 children, all of whom were healthy. 
 
 For some months he had noticed that he staggered in the dark, and 
 that when he closed his eyes at the washhand basin, he could not balance 
 himself. On rising from a chair, he said he would often stagger as if 
 he had been drinking. Two years before, he had pains in his back and 
 round the body, but these had not lasted long, nor been intense. There 
 were no lightning or rheumatic pains in the limbs. He had for about 
 four or five months difficulty in retaining his urine ; it came from him 
 suddenly with some force. On examination, the urine was acid, specific 
 gravity 1018, not albuminous, and normal in quantity. 
 
 Both pupils were contracted, the right almost to a pin-point. His 
 sight was, and had been, good. The patellar reflex was absent in both 
 legs. He slept badly, di-eamed a great deal, and was drowsy all day. 
 Digestive power was only fair. He was often bilious, but had no 
 vomiting attacks. Bowels, as a rule, wei'e constipated. He was fairly 
 nourished, but said he had lost about sixteen pounds weight in the last 
 six or eight months. 
 
 There was visible pulsation in the great arteries of the neck, and in 
 the arteries of the arm, most marked when the arms were raised. The 
 area of cardiac dulness was considerably increased ; there was heaving, 
 diffused pulsation over the cardiac area, and the heart's apex could be 
 felt about three inches below the left nipple, and two and a-half inches 
 on its outer side. Tlie first and second sounds of the heart were replaced 
 by murmurs heard towards the base, and conducted to the apex. The 
 pulse was slow, about sixty to the minute, and presented the chai-acteristic 
 sphygmographic tracing of aortic regurgitation. 
 
 I have seen this patient at intervals since the above notes were taken. 
 He has had several angina-like attacks, but has been able to attend to 
 his business (that of a brewer) until within the last month (beginning of 
 November 1888). His present condition is that of marked failure of 
 comjjensation. There is a small amount of albumin in his urine, partly 
 due to pus from cystitis. He has oedema of the feet and legs, and some 
 ascites, and frequent and distressing attacks of dyspnoea, which are 
 controlled by small injections of morphia and digitalis. There is no 
 advance in the ataxic symptoms. 
 
 The following case was admitted into the Dunedin Hospital on 
 November 5, 1887, where he was under the care of Dr. De Zouche, and 
 afterwards of Dr. Stenhouse. I am indebted to those gentlemen for 
 permission to use their notes, and also for the opportunity of examining 
 the patient from time to time : — 
 
 James B., aged 45 years, a miller by occupation, complained on 
 admission to the hospital of numbness in the arms and legs, and almost 
 complete inability to walk. About a month before admission, he had 
 severe "rheumatic" pains all over the body, but especially in the legs, 
 from the lii{)s downwards. He was unable to pass urine ; desired to do
 
 138 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 SO often, but on making the attempt, felt great pain in tlie penis. lie 
 then came to the out-j^atient room, and Dr. Roberts drew off the urine 
 with a catheter. He had subsequently great pain in the I'egion of the 
 bladder for two or three hours, but was afterwards able to pass a little 
 urine for a few days. During all this time his legs felt tired, and the 
 left foot became numb. He has had shooting pains in the legs for years 
 past. Twelve or thirteen years ago he worked in water for a day or two 
 every week for some months. He has had no illness of any kind that 
 he knows of, and has always been a veiy temperate man. While at his 
 ordinary work, he was always a good deal exposed to cold. 
 
 His father is alive, aged 76 years, and has always been healthy. His 
 mother died in child-bed, and there is no history of any constitutional 
 weakness in liis family. 
 
 Patient is a tall, strongly-built man, very antemic and feeble-looking. 
 There is visible pulsation in the arteries of the neck and arms. The 
 pulse is full and bounding — the water-hammer pulse. The area of 
 cardiac dulness is increased, and the apex beat is some distance to the 
 left of and below the normal position. The first and second sounds of the 
 heart are replaced by well marked blowing sounds heard at the base, 
 mid-sternal region and apex. The pulse is 105, respirations 27, tempera- 
 ture normal. The tongue is transversely fissured and red, the bowels are 
 usually constipated, and digestive power is weak. There is deficient 
 control of the bladder ; the urine is normal in character and amount. 
 
 He cannot stand with his eyes shut ; patellar reflex is absent in both 
 legs, and his gait is weak and uncertain. Muscular power is good in both 
 legs. The joints are normal. He complains of feeling numbness over 
 the mid-dorsal region of the sj)ine for about three inches of its length, 
 and of a tender spot towards the lower end of the dorsal region, and 
 first lumbar vertebra. The flexors of the left leg respond only slightly to 
 the induced current, the flexors and extensors of the right leg res})ond 
 freely. The skin over both legs is somewhat anaesthetic. 
 
 Intelligence is good. He com])lains of occasional dimness of sight ; 
 but there is no record of ophthalmoscopic examination, or of the condition 
 of the pupils. 
 
 He had symptoms of failing compensation of the heart. Dyspntea on 
 exertion, &.e. After stajing for some months in the hospital, he left 
 somewhat improved in his general condition, but, of course, with the 
 special diseased organs unimproved. 
 
 In these two cases, the questions arise : Is the condition that of aortic 
 regurgitation, with failure of comjjensation, accompanied by locomotor 
 ataxia as an accidental conq:)lication 1 or, do the ataxic symptoms depend 
 on changes in the spinal cord, due to imperfect blood supply '? In both 
 cases there is an absence of syphilis, which we know is a potent agent in 
 ])roducing locomotor ataxia. In the first case, the patient was exposed 
 to cold and wet, which may have produced chronic inflammatory 
 changes in the cord ; but the second patient has been for years leading a 
 particularly quiet, regular life. In both, it was impossible to fix exactly 
 the date of appearance of the ataxic symptoms, but they seemed to be 
 nearly coincident with the first signs of failing compensation in the 
 heart. 
 
 Again, locomotor ataxia is usually a disease of many sym])toms — there 
 may be changes in the eye, in the muscles of the eye, gastric disorders,
 
 CLINICAL NOTES ON SOME CASES OF CEHEBRO-SPINAL FEVER. 139 
 
 skin troubles, joint atfections, lightning })ains, itc. In tliese two cases 
 tlie symptoms of locomotor ataxia were limited to the want of 
 co-ordination, wlien the eyes were shut or not available, the absence of 
 the patellar reflex, and want of control over the bladder, with a few 
 minor disorders of sensation. The nervous phenomena were such as 
 might result from passive congestion of the posterior columns of the 
 cord. In neither case was the disease markedly progressive, althougli 
 it must be noted that the time for observation has been limited. It 
 seems to me that these cases can be separated from ordinary cases of 
 ataxia. I should be inclined to describe them as cases of aortic 
 insufficiency, with ataxic symptoms. I think the evidence is decidedly 
 against the suggestion, that locomotor ataxia has anything to do with 
 producing aortic disease. But there is not sufficient evidence in the 
 meantime to pi'ove, or disprove, that cardiac incompetence may give rise 
 to symptoms of locomotor ataxia. It is with the hope that attention 
 may be directed to this point, that I venture to place these two cases on 
 record. 
 
 CLINICAL NOTES ON SOME CASES OF CEREBRO- 
 SPINAL FEVER. 
 
 By William Finlay, M.D., Bathurst, N.S.W. 
 
 Case I. 
 
 On the evening of the 16th April, 1887, I was called to see a young 
 man 21 years of age, a labourer, some fifteen miles distant. He had 
 always enjoyed good health until some eight days previously, when he 
 was suddenly seized with chills, vomiting, intense pain in the head, back 
 of the neck and spine, accompanied with great Aveakness of the lower 
 extremities. He was conveyed in this state to Bathurst, on two occa- 
 sions, to consult a medical practitioner. He gradually got worse, and I 
 was informed that he had taken " a fit " the previous evening, and force 
 had to be used to keep him in bed. During the da}-, he had been quieter, 
 but towards evening was srettinij: more delirious. 
 
 o o O 
 
 On examination, I found the tongue whitish, large, and fiabby ; the 
 skin cold and pallid ; hyi)erjesthesia well marked over the entire body, 
 and especially over the cardiac region ; photophobia and hyperiemia of 
 conjunctiva; temperature in axilla, 9G'' F. ; pulse 48, and rather full ; 
 respirations shallow and increased in frequency. The head was drawn back 
 to nearly a right angle, the back arched forwards, the thighs and legs 
 flexed and somewhat rigid, but could be easily moved. For a time he 
 would remain quiet, until a paroxysm of pain would seize him, when lie 
 would toss about, and uttering a piercing shriek, exclaim "Oh! my 
 liead!" requiring force to keep him in bed. He complained of pains all 
 ovei-, but worse in the head, back of the neck, and spine ; the paroxysmal 
 attacks, he said, felt like some one driving a nail into the ciown of liis 
 head.
 
 140 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 While I was present, he was seized with a tonic convulsion, and his 
 body bent like an arch. This convulsion lasted two or three minutes, 
 when he again resumed his former position. One drachm of the liquid 
 extract of opium, combined with ten minims of the tincture of digitalis, 
 was administered ; and a mixture, containing ten grains of the bromide 
 of sodium, thirty grains of the hydrate of chloral, fifteen minims of the 
 ordinary solution of the hydrochlorate of morphia, and ten minims of the 
 tincture of digitalis prescribed, to be given, well diluted in water, every 
 four hours, till the ])ain in the head was relieved. 
 
 On the following day, August 17th, I was informed that he had 
 several convulsions during the night. The temperature was 96° F., 
 pulse 60, respirations shallow and frequent. Still complains of his head, 
 and aches all over ; seems stu{)id and apathetic ; retraction of head and 
 aching of spine still present. A ^^apular eruption on forearms, consisting 
 of a few whitish raised spots, about one-eighth of an inch in diameter, and 
 feeling exactly like a split pea under the skin. Seemed much weaker. 
 
 During the next twenty-four hours, he was for the greater part of the 
 time delirious. The temperature in the axilla was 98° F., pulse 68, 
 i-espirations shallow and frequent, hypera^sthesia still present ; shrinks 
 when pressure applied to the skin. Papules on arms more numerous, 
 and now found on legs, with mottling of arms and legs, but only 
 extending as high as elbows and knees. 
 
 For the following three days the stupor became more profound, the 
 pulse inci'eased in frequency, the mottling on the arms and legs was of a 
 duskier hue, and on the ■22nd, I discovei'ed a large, irregular-shaped, 
 reddish patch on the left infra-dorsal region, extending in length about 
 four inches, and about two and a half inches in breadth. He remained 
 in the same condition till the 26th April, 1887, when the tongue was 
 found very much swollen, and almost black, and several reddish-black 
 spots had appeai'ed on the legs. 
 
 During the 27th and 28th, the si)ots on the legs had gradually 
 increased in size, and coalesced. He died early on the morning of the 
 29th, and in a few hours the whole body had become almost black. No 
 autopsj' allowed. 
 
 Case II. 
 
 Was that of a boy, seven years of age, who was just recovering from 
 an attack of enteric fever. I was asked to visit him on the evening of 
 the 13th May, 1887. He was vomiting, and complained of great pain 
 in the back of the neck, and every little while would cry out, " Oh ! my 
 head !" He was very irritable, and showed great aversion to anyone 
 approaching him. The face was flushed, the tongue white and flabb}', 
 the temperatui-e in axilla was 102° F.; pulse 130; respirations normal. 
 Prescribed a mixture containing four minims of the tinctui-e of aconite, 
 five minims of the compound tincture of cinchona, and two grains of 
 the iodide of sodium in each dose ; to be given, well diluted in water, 
 thrice daily. 
 
 During the following night, he was wildly delirious, and on the 14th 
 I found it im]>ossible to take the temperature or pulse, on account of 
 the ]iy])era'sthetic condition of the skin, and his attempting to strike, 
 kick or bite, if you approached him. The head was then retracted, with 
 photo2)hobia and suffusion of conjunctiva. He would lie quietly for a
 
 CLINICAL NOTES ON SOME CASES OP CEREBRO-S'PINAL FEVER. 141 
 
 few minutes with the eyes nearly closed, and turned away from the 
 light, till another exacerbation would set in, when, with a shriek, he 
 woiild coui])lain of his head. 
 
 On the loth, he was in a similar condition, and a gag had to be used 
 to administer food and medicine. 
 
 On the IGth, he was very weak, but still dared anyone to approach 
 him. In addition to the retraction of the head, the spine was now 
 arched forward, and the thighs and legs flexed. 
 
 On the 17th, a hard, shotty eruption appeared on the arms and legs ; 
 skin cold and pallid. The treatment was then altered, and fifteen grains 
 of the bromide of sodium, ten grains of the hydrate of chloral, and five 
 minims of the ordinary solution of the hydrochlorate of mor])hia were 
 given every four hours, well diluted in water. 
 
 On the 18th, he was much (piieter, but resists when you attem})t to 
 administer food or medicine. For the following three days he remained 
 in a state of stupor ; skin cold and pallid. During this period, the 
 mixture was administered thrice daily. 
 
 On the 22nd, he appeared to be able to recognise those around him, 
 but liis hearing was evidently affected. Eruption faded, leaving a slight 
 mottling of the skin ; hypera^sthesia less marked. The treatment was 
 again altered, and eight grains of the iodide of sodium, ten minims of the 
 B.P. solution of the perchloride of mercury, and five minims of the 
 compound tincture of cinchona was given, Avell diluted in water, three 
 times a day. 
 
 He steadily improved from the 22nd till the 28tli May, 1887, when 
 he again comjilained of a severe pain in the head and back of the neck, 
 l)ut the symptoms were quickly relieved by the administration of the 
 bromide of sodium mixture, given three or four times. On the 30th, he 
 was quite free from pain, and from this date onward the im])rovement 
 was permanent, and I last saw him on June 12th, 1887, when he seemed 
 quite recovered from the eftects of his illness. 
 
 Case III. 
 
 This was a young unmarried woman, of fine j)hysique and good family 
 history. She had been feeling out of sorts for seven or eight days, but 
 able to perform her usual domestic duties. On the evening of the 19tli 
 July, 1887, I was hastily summoned to visit her. While attending to 
 the household work, she was suddenly seized with an attack of vomiting, 
 intense pain in the head, and aches all over. The face was flushed, the 
 tongue whitish, large, and flabby ; the conjunctiva red and suffused, with 
 photophobia ; and the head thrown back. The temperature in the 
 axilla was lOU'F., and the pulse 84. 
 
 Treatment.— For the cerebral symptoms, forty-five grains of the 
 bromide of sodium, combined with thirty minims of the compound 
 tincture of cinchona, was given eveiy four hours, well diluted in water. 
 The vomiting was checked by giving thirty grains of the snbnitrate of 
 bismuth in milk every two hours ; and the i)atient's strength maintained 
 by administering a dessertspoonful of brandy in water every four hours ; 
 the diet restricted to boiled milk. The room was darkened, all noise 
 excluded, and the patient kept thoroughly quiet. 
 
 On the following day, the temperature was 99' F., pulse 82 ; and I 
 was informed that she had been delirious all night, but since morning
 
 142 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 had been quieter, with hicid intervals. When conscious, she was 
 extremely irritable, and complained of pain in the head, back of the 
 neck, and on movement along the spine. Muco-purulent discharge from 
 both eyes, lids tumefied, cornea clouded, and considerable uterine 
 liajmorrhage. At 1 1 p.m. a sleejiing draught containing thirty grains of 
 the hydrate of chloral, thirty minims of the ordinary solution of morphia, 
 and five minims of the tincture of digitalis was administered. 
 
 On the 21st, the temperature was 100° F,, pulse 80. She had slept 
 quietly till 2 a.m., was then very restless; cutaneous hyperesthesia 
 more marked over the region of the heart ; uterine haemorrhage still 
 continued. 
 
 On the 22nd, she slept till 5 a.m. Three dark-red irregular-shaped 
 purpuric patches along the spine, in the dorso-lumbar region ; uterine 
 haemorrhage less profuse. Now lies in a state of stupor, with head 
 retracted, and thighs and legs flexed. She remained in this state till 
 the 25th, at times becoming delirious, and with difficulty kept in bed, 
 and then again relapsing into a state of stupor. Treatment continued, 
 with the evening draught omitted. 
 
 On the 26th, the temperature was 98° F., pulse 64, and she could then 
 recognise those around her, but was very irritable and weak ; purpuric 
 j^atches faded, hypera^sthesia of skin and hypertemia of conjunctiva 
 disappearing. 
 
 Prescribed twenty grains of the iodide of sodium, ten grains of the 
 bromide of sodium, and twenty minims of the compound tincture of 
 cinchona; to be given thrice daily, well diluted in water. At 11 ]).m. 
 a draught was given for three nights, containing thirty grains of the 
 liydrate of chloral, and twenty minims of the ordinary solution of the 
 hydrochlorate of moi'phia. 
 
 Very slowly, but steadily, the patient improved in health, making an 
 uninterrupted recovery, and by the 18th of the following August, was 
 so far convalescent as to stand the strain of being removed to another 
 part of the colony for a change. 
 
 Case IV. 
 
 Was that of a strong, robust young man, 21 years of age, a brother of 
 the young woman, the history of whose illness I have just related. This 
 case presented features of unusual interest to me, as I was present when 
 he arrived home, to all api)earance with the picture of robust health ; 
 and within three hours I was called to see him, to find him in a 
 condition of extreme danger. 
 
 He had been employed on a station, seventeen miles distant, and, 
 hearing of his sister's illness, he rode over on the evening of the 26th 
 August, 1887, feeling in the best of health. Two hours after, he was 
 suddenly seized with diarrha>a, pain in the head, back of the neck, 
 si>ine, and lower extremities. The greater part of the time he had spent 
 in his sister's room, the curtains of the bed were drawn close to exclude 
 the light, and he had been caressing and hovering over her a good deal. 
 
 Before I arrived, he had been rcuKned to another house, a little way 
 distant. He was then in a state of collapse, skin cold and clammy ; 
 temperature 96° F., pulse 48, pupils dilated, the head thrown back, the 
 spine arched forward, the thighs and legs flexed, with considerable 
 rigidity of the limbs. He complained of pain in the back of the neck,
 
 CLIXICAL NOTES OX SOME CASES OF CEREBUO-SPIXAL FEVER. 143 
 
 iind, when the pain in the head became agonising, he woxiUl scream, 
 " Oh ! my head !" The jiaroxysm would last two or three minutes and 
 then abate, when he would lie and moan. 
 
 Treat ineni. — The diarrhtea was controlled by a mixture containing 
 bismuth, diluted sulphuric acid and morphia. For the cerebral and 
 spinal s\ m]>toms, forty-live grains of the bromide of sodium, coml)ined 
 with ten minims of the tincture of digitalis, were given, well diluted in 
 water, every four hours, and a tablespoonful of brandy in water thrice 
 daih". The room was darkened, all noise excluded, and the patient 
 restricted to a diet of boiled milk. 
 
 On the 27th, the })ain in the head was greatly relieved ; complained 
 of pain in the back of the neck, and, on movement, along the s[)ine. 
 Photophobia and suffusion of conjunctiva ; hypertesthesia of skin, more 
 marked over the cardiac region ; temperature 98° F., pulse 60. 
 
 On the 2Sth, I was told that he had been delirious all night. Com- 
 l)lained of pain in the back of the neck and limbs. Photophobia and 
 hyi)en>?sthesia still present. The temperature was 98-6'^ F., pulse GO. 
 Prescribed sleejiing draught, containing chloral and morphine. 
 
 On the 29th, he had slept till G a.m., quiet and apathetic; tempera- 
 ture 98'G° F., pulse 54. 
 
 On August 1st, he com[)lained of })ain only on moving ; temperature 
 98° F,, pulse 50. 
 
 On August 2nd, the pulse was 54, and on the 3rd was 60. On the 
 4th, a petechial rash appeared all over the body, with the exception of 
 the liead, hands and feet ; and on the forearms a few whitish, raised spots, 
 feeling hard and sliotty ; temperature 98° F., pulse 60. 
 
 This eruption remained till the 6th, then disajipeared within 24 
 hours. Prescribed thirty grains of the iodide of sodium, ten grains of 
 the bromide of sodium, and five minims of the tincture of digitalis, to 
 V)e given thrice daily, well diluted in water. 
 
 From this time onward, he rapidly increased in strength, and was 
 sufficiently recovered by the end of the month to perform light work. 
 
 Case V. 
 
 Was that of a young woman, 27 }ears of age, who consulted me on 
 the evening of the 20th December, 1888. She had always enjoyed fair 
 health, although never robust. On the })revious day, she was suddenly 
 seized with chills, vomiting and diarrhoea, severe lieadache, pain along 
 the spine, which was aggravated on movement, and aches all over ; so 
 much so, that she said she could hardly bear her clothes to touch her. 
 The temperature was 99° F. ; pulse 110; the tongue large and wliitish. 
 
 T'reatment. — Picst and quietness was advised, and thirty grains of tlie 
 bromide of sodium, combined with ten grains of antipyrin, were given, 
 well diluted in water, thrice daily. On the 21st, the i)ain had nearly 
 disappeared. The administration of the mixture was followed by free 
 diajihoresis, and she is now slowly recovering from the extreme 
 prostration produced by the illness. 
 
 PiEMARKS. 
 
 The last case may be cited as an example of a large number that have 
 occiu-red in my practice during the last fifteen months ; and I consider 
 they may be properly classified as aborted cases of cerebro-spinal fever.
 
 144 IXTERCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 The symptoms, as they appeared during tlie i)rogress of the disease, 
 may be briefly summarised as follows ; — 
 
 There is the sudden invasion, intense pain in the head and back of 
 the neck, generally I'adiating along the spine, and sometimes into the 
 limbs. The headache is constant, and greatly aggravated by light, sound, 
 or movement, whether active or passive. Then there is a chill, almost 
 immediately followed by retching and vomiting. The tongue is large, 
 white and flabby, later beconung brown ; then, in serious or lingering cases, 
 becoming swollen and black ; the temperature in the early stage rising to 
 102° F., and in a day or two falling and remaining below the normal 
 till convalescence sets in. The pulse and respiration varied considerably 
 in most of the cases. Delirium sometimes violent in character, and 
 iisually eventuating in stupor or coma. Tonic contraction of the muscles 
 of the neck and back. Hypera^sthesia of skin, generally more marked 
 over the cardiac and epigastric regions. A hard, shotty eruption on 
 arms and legs, only extending as high as the elbows and knees, 
 accompanied later on by a dusky mottling of the skin over the same 
 extent of surface. More rarely cutaneous and uterine haemorrhages. 
 In one case, a })etechial rash ajipeared over the whole body, with the 
 exception of the head, hands and feet. Neuralgic pains in thoracic and 
 abdominal cavities. In every case, there was great prostration. 
 
 The treatment adopted, I have already related to you. In future, I 
 would feel inclined to scimulate more freely from the commencement of 
 the attack, and I believe more favourable results will be obtained. As 
 to the cause or origin of the disease, I have no new theory to advance. 
 Wheu the first cases came under my observation, I was led to think 
 that inferior flour had something to do with its causation ; as, on enquiry, 
 I found that a considerable number of those attacked obtained their 
 bread from the one Ijaker ; but when we consider that in almost every 
 case, only one meniber of a family was attacked, we must grant that 
 this hypothesis is untenable. On the same grounds, we must exclude 
 the water supply. In many of the cases, the dwellings and drainage 
 were far from being models of sanitary science ; but, in others, little 
 fault could be found with the surroundings. 
 
 ON SOME FOEMS OF SUNSTROKE OBSERVED IN 
 CHILDREN. 
 
 By W. K. MacRoberts, jM.B., L.K.Q.C.P.I., Newcastle, N.S.W. 
 
 Late Physician to the Weutworth District Hospital. 
 
 The sul)ject of sunstroke — insolatio — heat apoplexy, ])ure and simjile, 
 lias always appeared to me to be peculiarly adapted for investigation by 
 Australian enquirers. So far, the authorities have been Indian entirely. 
 They have conjectured an etiology, including so many predisposing 
 causes, that obtain very rarely, if at all, in these colonies, and least of 
 all in the districts where sunstroke most prevails. The very complete 
 .symptomatology of the disease, contributed by Fayrer, MacLean, and 
 Moore, shows a type, materially different from the Australian type, at 
 least as far as my experience goes. And this has been borne home to me,
 
 SOME FOKMS OF SUX.STKOKE OBSERVED IN CIIILDKEN. 145 
 
 when seeking guidance iVom their works in many a perjilexing case. 
 As for the pathology, wliioh shonkl be the ultimate criterion of difference 
 or identity, it is, so far, so A^ague and unsatisfactory, that a German 
 observer, Arndt, discounts all the results of the Anglo-Indians, by the 
 tlieory that their post-mortem manipulations were unskilful — " a con- 
 clusion not very complimentary," as Dr. Moore observes. 
 
 Now, it seems to me that there are many good j^rimd facie reasons, 
 not only for variations of the Australian from the Intlian type, but also 
 for essential ditierences between them. Diversity of race, diet, and modes 
 of life; the omni[)resence of malaria in the one country, and its almost 
 total absence in the other, occur at once, on reflection. 
 
 The number of predisposing causes enumerated as factors in India, 
 as well as the nuniljer of varieties of the atfection described, lend colour 
 to the suspicion that many other febrile disturbances simulate, and some- 
 times actually "personate" — if I may use the term — the true cases of 
 sunstroke. Nay, it is admitted by the authors, that this is jirobably 
 often the case ; and Hilton Fagge i-emarks, " I should imagine that a 
 person, attacked on a very hot day in India with cerebral haemorrhage or 
 embolism, would lie exceedingly likely to have his case set down as one 
 of " insolatio," even by competent observers." 
 
 Of counse, it is quite jjossible for mistakes in diagnosis, or confusion 
 of types to occur here as well ; but I w^ould submit, that the chances of 
 other morbific influences intervening " to darken judgment," are not 
 nearly so many. In the flrst place, the reputation uf the Kiverina 
 district for instance, which I take as the Australian type for salubrity, 
 is a great contrast to the '" bad eminence " of Bengal, in the opposite 
 particular. Population is extremely scanty, there is no overcrowding, 
 and epidemics are, therefore, few and far between. Malaria is absent, 
 and the eucalyptus trees shed forth one nevei-failing antiseptic effluence 
 in the bright dry aii". When sunstroke occurs, it is sunstroke, a 
 veritable ictus so/is, from — 
 
 " The stress of tlie noontide — those sunbeams like swords!" 
 
 The stroke is swift and sudden and obvious, and jiredisposing causes 
 obtrude themselves very little on our notice. 
 
 For these and other reasons, I am inclined to think that the class of 
 nervous affection, due to the action of excessive solar heat in the 
 colonies, is more distinct, more clearly defined, and separate from 
 extraneous confusing influences, and, therefore, more open to accurate 
 scientific investigation, than the varieties hitherto descriVied and investi- 
 gated by the Anglo-Indian writers. 
 
 It is, however, in dealing with cases of sunstroke, in which the 
 sufferers are children, that the classical descriptions of the disease 
 appear most inapplicable. During the three hottest months of the 
 summer of 87-88, in Wentworth, in the Riverina, I encountered a 
 series of at least a dozen cases, in which the patients' ages varied from 
 two years to twelve. In no case was there room for doubt that 
 the action of the sun's rays was the actual ccmsa causans, though 
 hygienic and jjhysiological conditions undoubtedly caused variations in 
 the train of .symptoms. The variations, though great in degree, were 
 engrafted wpon a distinct and peculiar type— a type very inadequately 
 designated by the appellations of sun fever, ardent fever, or thermal 
 
 L
 
 146 INTERCOLONIAL MEDICAL COXGRESS OF AUSTRALASIA. 
 
 fever, and not to be accounted for on Murcliison's theory of all the 
 milder varieties of sunstroke being sini])ly cases of intermittent fever. 
 
 It would rather appear that the undeveloped, or only developing, 
 motor and special sense cerebral centres of children yield a different note 
 to the stroke of the sun from that of adults. That the action upon them 
 is at once more intense and more diffuse, as well as more lasting, as will 
 be seen from a recapitulation of a selection of the cases. They followed 
 each other with such rapidity in the very hot weather, as to suggest at 
 first the advent of an epidemic of typhus, typlioid, or cerebro-spinal 
 fever. However, I was able in each case to trace a history of prolonged 
 exposure to the sun, preceding the onset of the S3anptoms. In fact, the 
 sudden seizure after exposure was the only prominent featiire the cases 
 presented in common. Intense cephalic pain was also present in all, 
 and, in the fatal cases, coma preceded death. For the rest, as will be 
 seen in the detail of the cases, the symptoms varied on an ascending 
 scale : — Severe pain, with constipation and delirium at night ; cephalic 
 j^ain, with cerebral vomiting ; pain, with convulsions ; pain, with asphasia 
 and non-spastic hemiplegia ; intense j^ain, with spastic hemiplegia. 
 
 Case I. — 11. P., ?et. .5, presented a history of exposure to a hot sun, 
 without a hat, at a children's picnic. There followed immediately an 
 attack of cerebral vomiting, and severe occipital pain, and most obstinate 
 constipation, which continued all through tlie illness, though previously 
 the bowels had been free and regulai'. There was also considerable 
 delirium at night, and temperature lemained at 100° for four days. 
 Belief was afforded by te})id sponging, K. Br. in large doses, and the use 
 of injections. Recovery in about ten days. 
 
 Case II. — A. M., jet. 3, lived in the bush, exposed to afternoon sun, 
 and woke up in the morning with all the symptoms of infantile 
 paralysis. On examination, I found great loss of })Ower in lower 
 extremities, tenderness in legs, and all along the s})ine, on pressure ; 
 slight retraction of head, and complaint of pain in nape of neck. 
 Temperature 102° Fahr. Treated with strong counter-irritants along 
 spine, blister to occiput, followed by small doses of quinine. All the 
 symptoms disappeared in three days; but three weeks after this, there 
 was, unfortunately, another long exposure to the hot sun, an attack of 
 A'orniting, followed by convulsions, coma, and death. 
 
 Case III.— D. M'L., jet. 10, a child of full habit of body. History of 
 violent exertion — running up a hill on a hot day wdth hat off. A sudden 
 attack of com])lete aphasia and right hemiplegia, which lasted seven 
 days, and then began to disappear together. Treatment consisted in rest 
 in dark room ; blister over left half of cranium ; calomel in yVS^'^^"^ 
 doses every quarter of an hour, and gr. x of K. Br. at night. Improve- 
 ment began on the eighth day, and under quinine, strychnine, and 
 Faradism, a complete cure was efiected in 36 days. 
 
 Cases IV. and V. — Two children — sisters — jet. 4 and 5 respectively, 
 were suddenly attacked together with occipital pain and convulsions, 
 after wading in the river on a hot day. These cases ran a very rapid 
 course, death occurring on the fourth and fifth days, after convulsions 
 and coma. Calomel was given, as in Case III. The wet pack was tried, 
 and in each case brought dovvn the temperature from 104° to 103° Fahr. 
 on the first application, and after that had no effect. 
 
 I
 
 SOME FOUMS OF SUNSTROKE OBSERVED IX CHILDREN. 147 
 
 Case VI. — S. B., jet. 12, a resident at the irrigation colony of 
 Mildura, then in a very primitive state. She had been living in a tent, 
 and seems to have been badly nourished. She was decidedly overgrown ; 
 had been ailing with headache and feverishness for some days before I 
 saw her, after exposure to great heat. Having been consulted by her 
 father, I advised a continuous wet pack, which was not applied. She 
 was admitted to hospital subsequently in a hopeless condition ; tempera- 
 ture, 107\ Convulsions every five minutes, and between the fits x'igid 
 contraction of the muscles of the right side of the body. Intervals of 
 semi-consciousness, during which intense cephalic pain was evidently 
 present ; contracted ]iupils. Wet packing tried, and reduced temperature 
 2" Fahr., but only temporarily. Kectal irrigation with cold water also 
 tried, with no etFect. Counter-irritants were also ineffectual. Coma 
 supervened, and then deatli, in twenty-four hours after admission. 
 
 Such are the six cases I desire to present to your notice. I had 
 others, probably of the same nature, but I have omitted them, because 
 the history of exposure before the attack was not so clear and 
 unmistakable as in these. The cases unfortunately lack the essential 
 interest of a post-mortem; but the train of symptoms following a 
 sunstroke are sufficiently striking to draw attention to them. They 
 present few points of similarity to any of the varieties of insolatio in 
 adults. The convulsive and paralytic notes are here the dominant ones. 
 A comparative i>hysiology of children is wanted, to show how and to 
 what extent their heat-regulating and vaso-niotor centres react to 
 external impulse. Roughly speaking, I should say that the heat- 
 regulating centre of Naunyn, Quincke, and Ott was, in these cases, 
 directly and powerfully affected ; and that simultaneously other centres 
 lying in close proximity, and probably less disconnected from, and 
 independent of it, than in the adult, were excited to discharge their 
 influences by the same cause. Kussmaul and Tenner vouch for the 
 existence of a spasm centre, at the junction of pons and medulla, 
 extremely sensitive to the action of venalised blood, and to direct 
 stimulation of any sort. The action of a temperature of, say 110° Fahr. 
 in the shade, through the delicate cranium of a young child, upon its 
 cerebral vessels, would certainly amount to direct stimulation of a good 
 many cortical centres, and even medullary tissues. It is to this direct 
 action, rather than to that of venalised blood, I am inclined to ascribe 
 these cases ; and it is to some therapeutical method, promptl}' directed to 
 the heat-regulating centre, I would look for success in treatment. As 
 will have been seen, my treatment was empirical, and only moderately 
 successful, for want of reliable authorities to look to for guidance. It 
 was only in my last case (Case YI.) that I came, as I believe, on the 
 right track, and then it was too late. Even at the eleventh hour, 
 however, a 12-grain dose of antipyrin produced a fall of 2° Fahr., and a 
 slight and momentary cessation of symptoms. The earliest and the latest 
 experiments upon the action of this invaluable drug, alike point to the 
 conclusion, that its action is dii'cctly upon the heat-producing centre in 
 tlie corpora quadrigemina. Anyone who has made much use of it, be he 
 a physiologist or not, must come to the conclusion that it goes straight 
 to head quarters, wherever they may be, and does its work with 
 l>usiness-like jjromptitude. Here we have, I should think, the true and 
 reliable remedy ; and, except where heart failure is threatened, I now
 
 148 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 commence the treatment of any case presenting febrile and cerebi'al 
 symptoms combined, with an appropriate dose of antipyrin, by this 
 means, I consider, obtaining a decided vantage ground at the start, as 
 its action is as certain as clockwork. 
 
 However, here I leave my cases to your consideration, and earnestly 
 invite discussion and further investigation by Australian practitioners 
 of this peculiai'ly Austi-alian subject. As a lethal agency among the 
 children of our imperfectly acclimatised race in the hot districts of this 
 continent, I am confident that sunstroke in some form or other is almost 
 supreme. No effort has yet been made to follow the obviously useful 
 hygienic example of the Chinese and Hindoos, who shave their heads, 
 and by the iise of fans producing a cool current of air, can walk about 
 uncovered under the hottest sun. At any rate, European parents who, 
 in tera])eratures ranging to 110° in the shade, allow their children to go 
 about with heavy hats and long thick curls, may pei-haps soon learn 
 from the indigenous Asiatics, that safety lies in the opposite direction. 
 "Sun-bonnets," with which little girls are particularly liable to be afflicted, 
 are, I think, most objectionable. The best form is a light, well-ventilated 
 straw hat, which should serve until we reach, in process of evolution, the 
 shaven crown and palmetto fan. Why, too, our children in the 
 Riverina district are expected to sit in school all the hot summer after- 
 noon, and return home sometimes long distances at the very hottest 
 period of the day, while their little Anglo-Indian cousins think of 
 nothing but siesta after twelve o'clock till the evening cool, it is hard to 
 understand. At any rate, they are expected to do it, and this tyjie of 
 disease is one of the outcomes of the system. Acclimatisation is going 
 on, and it will not be entirely accomplished in one generation. As it is, 
 I have noticed a remarkable difference in the capacity for standing heat 
 between the children of Europeans and those of the colonial born, while 
 Chinese half-breeds seem to enjoy a happy immunity from adverse solar 
 influences. And here, perhaps, arises another question within the 
 Chinese problem, for the number of children of Chinese fathers and 
 European mothers already bears a high })roportion to the total juvenile 
 population in and around Wentworth, and I believe in AVilcannia also ; 
 whether they may not prove the " fittest " in the hard struggle for 
 existence in those districts, is an open but alarming question. 
 
 As an appendix to these notes, I would call attention, if it has not 
 already been done, to the great prevalence of a form of occipital head- 
 ache among adults in the Wentworth tlistriot. It is always regarded 
 by the sufferer as the remains of a "touch of the sun," and seems to be 
 really due to a congested condition of the occipital dura mater. It is 
 relieved by leeching over the sinuses ; and, by a long course of iodide of 
 potassium, is usually permanently cured. Sometimes intense i)ain is 
 complained of in this region, and in such a case, I have always found 
 tinct. cannabis indica^, in 30 minim doses, a certain means of relief.
 
 mSTOKY OF TYPHOID FKVER IX VICTORIA, AND ITS ETIOLOGY. 149 
 
 TYPHOID FEVER. 
 
 A General Meeting of the Congress was held in the Wilson Hall 
 on Friday, January 11th, 1889, at 2 p.m., the Honourable Dr. Taylor, 
 President of the Section of Medicine, occupying the chair. The 
 following papers were submitted concerning the history, etiology, 
 ]>athology and treatment of typhoid fever. A discussion followed, 
 which, on account of the limited time available, was restricted to the 
 subject of etiology. 
 
 HISTORY OF TYPHOID FEVER IN VICTORIA, AND ITS 
 
 ETIOLOGY. 
 
 By James Robertson, M.A., M.D. 
 
 rormerly Physician to the Melbourne Hospital, and Lecturer ou Medicine in the 
 University of Melbourne. 
 
 It will be readily allowed that typhoid fever is now endemic in 
 Victoria, and, I believe, throughout the Australian Colonies. The 
 ^[uestion naturally arises — is it identical with the form of fever formerly 
 (lesignated " Colonial 1 " In answering this question, I avail myself of 
 such information as is supplied by the writings of pioneer members of 
 our profession. In the early days of the colony, prior to the discovery 
 of gold, the prevailing fever was regarded as incidental to the climate, 
 a seasoning fever, and was thence designated "Colonial." Colonial 
 fever was described by one of the early medical pioneers (the late Dr. 
 David John Thomas), as " bilious remittent," with typhoid symptoms, 
 having no regular period of incubation, and running no regular course, 
 but usually terminating in a critical discharge of dark-coloured bilious 
 offensive matter. 
 
 The name " bilious remittent " suggests the idea that the so-called 
 •' Colonial fever" may have been due to malarial poison, emanating 
 from marshy or swampy soil, and its being regarded as a seasoning 
 fever tends to foster that idea. That such was not the case, however, 
 may be legitimately inferred from the absence of any form of inter- 
 mittent or malarial fever, originating in the Colony of Victoria. 
 
 Dr. Thomas afterwards stated that, on resuming practice in 1860, 
 after a prolonged visit to Eui'ope, he had not seen a genuine case of the 
 old Colonial fever, and that typhoid seemed to have taken its place. 
 The fever, prevalent on the diggings in 1854 and 1855, was described by 
 another writer in the Australian Medical Journal (Dr. Hunt), as "fever 
 associated with dysentery, not of the ordinary inflannnatory type, but of 
 a hsemorrhagic character — fever of the typhoid kind, which assumed a 
 less severe aspect, with the gradually ameliorating circumstances of the 
 digger's life." 
 
 My own recollection of the fever prevalent in Melboui-ne, extends to 
 the year 1853. It was certainly of a very low type, and not infrequently 
 attended with haemorrhage from the bowels, a feature which stamped it 
 as being true typhoid. The term " remittent " was doubtless used as
 
 150 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 expressing the more obvious symptoms, the occurrence of exacerbations 
 and remissions, for in those clays the temperature was not tested by the 
 thermometer. Typhoid often assumes a distinctly remittent form, in 
 which the evenino- exacerbations and mornincj remissions are well 
 marked. 
 
 A case of fever is reported in the Australian Medical .Journal, January 
 1856, xmder the heading, ''Autumnal Fever," by the late Dr. Tracy. 
 From the symptoms described — " tenderness in the right inguinal 
 region, hpemorrhage from the bowels"-— it was evidently a case of 
 typhoid fever. 
 
 According to Dr. Thomas, typhoid first appeared in the colony in 
 1842, being introduced by the ship Salsette. Three men from that vessel 
 were engaged as farm labourers at Heidelbei-g, and were attacked by 
 the fever. It proved fatal to two of them, and spread as from a centre, 
 attacking others in the neighbourhood. Other immigrants from the 
 same vessel, who went into the bush, were similarly attacked, and 
 communicated the disease to others. I would observe that in 1842 the 
 distinctive characteristics of typhus and of typhoid had not then been 
 recognised. They were regarded as identical in their nature, mere 
 varieties, due to the action of the same specific poison. Jenner had not 
 then shed a light on their obscure relations. From the highly contagious 
 character of the fever described, it may also be surmised that the form 
 of fever was typhiis, not typhoid. Typhus is found to be eminently 
 contagious, and to spread directly from the sick to the healthy, while 
 cases of typhoid may be treated in the wards of a general hospital, 
 without the disease spreading to the patients in the adjoining beds. 
 
 Prior to the year lS60, the fevers i)revalent in Victoria were known 
 or described under various terms, such as " Colonial," " continued," 
 "low," "bilious," "remittent," "bilious remittent" and "gastric." 
 The variety of names arose, no doubt, from the sudden influx of medical 
 men during the early period of the Victorian golden era, and the 
 employment by them of such terms as they considered best descriptive 
 of the nature of the fever met with. 
 
 (_)n my appointment as Physician to the Melbourne Hospital in 1 860, 
 I employed the opportunities presented, and found that the autopsies in 
 all fatal cases of fever revealed the same anatomical signs, according to the 
 stage of the disease. The tumefaction and ulceration of Peyer's patches, 
 and of the solitary glands, were found to be well marked in the lower part 
 of the ileum, particularly in the neighbourhood of the ileo-ca?cal valve. 
 Cases of fever were found to vary much in regard to severity and 
 duration, some being comparatively mild, and others very se\'ere and 
 protracted. The temperature was not always characteristic, the 
 abdominal and intestinal symptoms varied, the rose-coloured spots and 
 diarrhcea were often absent ; yet, when opportunity offered in cases 
 proving fatal by some complication, the intestinal lesions served to 
 confirm the true nature of the fever. 
 
 Before commencing to write a course of lectures on fever (in 1864) 
 for the Medical Students of the University, I had assured myself that, 
 however the fever might vary as regards its symptoms, severity and 
 duration, and by whatever names it might be designated, it was 
 essentially the same in type ; being, in fact, the true typhoid or enteric 
 fever so prevalent in Europe,
 
 HISTORY OF TYPHOID FEVER IX VICTORIA, AND ITS ETIOLOGY. 151 
 
 Ffoui tlie evidence adduced by Dr. William Budd, of Bristol, England, 
 and by other.s, I had also arrived at the oiiinion that it was connnuni- 
 cated by contagion. On referring to my notes, written at that time on 
 the causation of the fever, the first sentence runs thus : — " The weiglit of 
 evidence unmistakably proves, not only that this disease is contagious, 
 but that it is now only projiagated l)y contagion." There is no reason 
 to supj)0se that it was generated here, or that it existed among the 
 aborigines. Their nomadic habits would, I believe, preclude its 
 existence. 
 
 Typhoid fever has, at various periods within my own knowledge, 
 been imported into the Colony from British ports, and the conclusion 
 may be legitimately arrived at that it was originally so introduced, ancl 
 had become endemic at a very early period. 
 
 Soon after the year 1860, the nomenclature of fevei's gradually 
 underwent a change, and the term " Colonial " was supplanted by 
 "typhoid" or "enteric." In a letter under the heading "Hospital 
 Mortality," published in the February number of the Australian Medical 
 Journal, 1865, I wrote as follows: — -" The statistics of the Melbourne 
 Hospital are compiled by the Superintendent, and in classifying diseases, 
 he is guided by the Nosological Table published by the Registrar General 
 of the Colony, which certainly requires emendation before the fever 
 statistics can be employed as reliable data for the purpose of comparison. 
 The nomenclature adopted is faulty." All fevers were then classified 
 under two heads or forms — I. " Typhus and Infantile Fever ;" II. 
 "Remittent Fever." I further noticed "that no case of typhus, of 
 infantile, or of remittent fever, came under my care during 1863. The 
 type of fever prevailing then was typhoid, as it is now" (1865). 
 
 In the August number of the Australian Medical Journal, 1867, is 
 to be found a carefully- written jiaper by Dr. MacGillivray, of Sandhurst, 
 " On cases of Fever occurring in the Bendigo Hospital," with statistics 
 and temperatui'e-charts. He there states : — " An opinion is held by some 
 practitioners that, as well as enteric fever, we have here also a bilious 
 remittent, to which the name of ' Colonial ' is applied. So far as my 
 experience goes, I can only say that I have never seen such a fever 
 here." 
 
 There is now a general consensus of opinion, that typhoid is the 
 prevailing form of fever met with in this Colony. The history of 
 typhoid in A'^ictoria differs but little, if at all, from the record of that 
 disease in the other colonies, or in other countries. It prevails at 
 certain seasons and in certain localities, influenced by filthy and 
 unwholesome surroundings, but more esj)ecially by emanations from 
 decomj)Osirig excreta of typhoid patients. It varies from year to year, 
 as regards frequency and fatality, owing to meteorological changes, a 
 mild winter and moist autumn betokening a severe ty|)hoid season. A 
 reference to the tables of mortality issued by the Government Statist 
 shows that, while phthhsis is the first of all diseases in causation of 
 fatality, typhoid fever occupies the eighth ])hice. 
 
 The annual mortality from typhoid in Victoria has varied from 3*49 
 to 7-26 per 10,000 persons living, during the period extending from 
 1873 to 1886 inclusive (l-t years), the average being 5-23, exactly that 
 of New South Wales. In Queensland, the death-rate from typhoid is 
 much above that in Victoria ; while in South Australia, Tasmania, and
 
 152 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 New Zealand, it is lower ; and in England and Wales still lower, in the 
 five years ending with 1886. The mortality from typhoid in England 
 and Wales has been reduced from 4'30 to 249, and this has been 
 brought about by the adoption of general hygienic measures. The 
 adoption of similar measures in Yictoria would, without doubt, be 
 attended by equally beneficial results. 
 
 Etiology of Typhoid Feyer. 
 
 Typhoid is without doubt contagious, but not in the same way, or to 
 the same extent as typhus, small-pox, measles, or scarlatina. These are 
 highly contagious, and are readily conveyed from the sick to the healthy, 
 within a very limited area, at all times, and I might almost add, at 
 all seasons of the year, Avhen immunity is not conferred by a ])revious 
 attack. They are apparently conye3'ed by emanations or exhalations 
 from the bodies of the sick. It is not so with typhoid. Seldom, if ever, 
 is it communicated directly to patients in the adjoining beds in the 
 wards of a general hospital. The conditions which tend to its spread 
 are doubtful, or not yet fully understood. It is not conveyed im- 
 mediately from the sick to the healthy. The exhalations from the lungs 
 and skin, and even from the fresh discharges from the bowels, are only 
 yery slightly, if at all, contagious, otherwise more direct and satisfactory 
 evidence of contagion would be available, such as is found in typhus 
 fever, itc. Fresh or recent typhoid dejections are not regarded as con- 
 tagious, but become so by exposure, or during the process of j^utrefac- 
 tion, or fermentation. In proof of the innocuous character of fresh 
 typhoid dejections, I may notice the fact, on the authority of Murchison, 
 that the disease was not ti-ansmitted by feeding a pig on such dejecta, 
 mixed with barley meal ; on the contrary, the pig throve and waxed fat. 
 It is otherwise, when pigs are fed with tubercular matter, or milk from 
 tuberculous cows — they are said to fall victims to tuberculosis. 
 Although fresh typhoid eyacuations are not considered contagious, the 
 exhalations from privies, cessj)Ools, di-ains, and sewers, to which the 
 discharges from typhoid patients have found access, are regarded as 
 highly contagious. It has been found that water, from wells contaminated 
 by percolation from such sources, has proved the carrier of contagion. 
 Milk appears to have some special atfinity for the contagion of typhoid, 
 and to prove a very suitable medium for spreading the disease. 
 
 It is now generally accejited as proved, that contagious diseases ai-e 
 caused by the introduction of certain specific organisms or microbes into 
 the bodies of those susceptible of contagion. 
 
 Bacilli have been detected by so many observers in typhoid cases, 
 that their presence is now assured. They are found in the intestinal 
 canal, in the lymphatics, mesenteric glands, spleen, liver, kidneys, ifec, in 
 small masses. They have been cultivated external to the body in stiff' 
 gelatine, but are confined to the spots where they have been implanted. 
 A very important question still awaits solution — Have bacilli an in- 
 dependent existence external to the body 1 They are said to form spores 
 at certain high temperatures (86° to 108° Fahr.) It may therefore be 
 reasonably supposed that they meet with conditions favourable to their 
 development in warm climates, and this may account for the prevalence 
 of typhoid in warm countries.
 
 HISTORY OF TYPHOID FEVER IX VICTORIA, AXD ITS ETIOLOGY. 153 
 
 It is only under certain conilitions or circumstances tliat typhoid 
 appears to be transmissible. 
 
 What are the conditions, local and personal, that induce typhoid? 
 There is, it appears, a local or endemic influence, called into action more 
 e.specially at a particular season of the year, and also a constitutional 
 factoi', rendering some more susceptil)le than others. 
 
 Ill this colony, typhoid is more rife in the autumn months, in that 
 respect corresponding with that prevalent in Europ)e. In winter, with 
 a low temperature, it is absent; on the return of summei', sporadic cases 
 occur and become more and more numerous on the approach of autumn. 
 It is about the end of autumn that the fever becomes most prevalent, 
 particularly during the months of March,, April, and May. The number 
 of cases appears to be diminished in dry hot weather, and increased by 
 heat and moisture. I have observed that after a rain-fall, cases of 
 typhoid become more numerous. The contagia, be they bacilli or 
 spores, then meet with certain conditions that render them active, or 
 tend to their growth and multiplication. The season, favouring decay and 
 putrefactive changes, is that in which typhoid flourishes. 
 
 Statistics prove that lieat and moisture combined are followed by an 
 increase of fever. 
 
 A tabular statement of climatic conditions, compiled by Mr. C. 
 Moerlin, at the Melbourne Observatory, compared with one showing the 
 number of deaths from typhoid prepared by the Government Statist, 
 ])ublished by the late William Thomson, F.R.C.S., in his work on 
 Typhoid Fever 1878, proves that the deaths from typhoid fever were 
 especially numerous in the months of Mai'ch, April, and May, from the 
 year 1874 to 1878, inclusive, more so in those months when rain had 
 fallen copiously. In making this observation, I am aware that the con- 
 clusion arrived at is somewhat at variance with that drawn by the 
 author from the same data. The figures admit of the inference that 
 warm damj) weather contributed to an increase of the number of cases 
 of typhoid fever, or at all events, to an increase of the number of deaths 
 from that disease. 
 
 Many years ago, I expi-essed the opinion " that the frequent occurrence 
 of typhoid fever in the autumn season, was mainly attributable to the 
 facts, that heat and moisture favoured putrefaction, and that the atmos- 
 phere thereby became impregnated with emanations from decomposing 
 excreta." This view would be more in accordance ^yith the advanced 
 pathology of the pi'esent day. if the word '' bacilli" was substituted for 
 " emanations." 
 
 Outbi-eaks of typhoid fever have not infrequently followed the open- 
 ing up of offensive drains ; but all exposed to the exhalations have not 
 Vjecome the victims of fever. This brings me to notice the pt'sonal or 
 constitutional factor in causation. 
 
 Assuming that bacilli are extensively scattered over a large area, or 
 rather areas, in the typhoid season, as only a few persons become 
 affected, it is evident that some predisposing cause or causes are in 
 operation. For the germination and growth of a plant, we know that 
 not only is the gei-m or seed necessary, but the soil tit for its reception, 
 and other conditions, as regards tem])erature, moisture, tfec. 
 
 We have found that the season of the year greatly influences the 
 prevalence of fever. We find also that certain localities are more
 
 154 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 particularly liable to its invasion, owing to local insanitary conditions. 
 Whether these conditions operate by favouring the growth, multiplica- 
 tion, and greater activity of the bacilli, or by impairing the bodily 
 health, and inducing some personal or constitutional susceptibility, are 
 questions yet to be determined. 
 
 Age, without doubt, is a predisposing cause of typhoid fever ; children 
 under one year do not appear to be liable to it, and even under five they 
 do not readily contract it. From five to ten, and from ten to twenty, 
 the fever becomes more and more i^revalent with advancing years ; it 
 reaches its climax, in point of frequency and severity, at adult age, and 
 does not greatly decrease until after the age of thirty. It is a remark- 
 able fact, that delicate persons are not so liable to fall victims to it as 
 the apparently vigorous. One attack of the fever gives immunity to 
 another, as a rule; typhoid, in this respect, following the general law of 
 eruptive fevers. This may explain, to some extent, the less frequency 
 of its occurrence in advanced years, many having passed through the 
 fever in early life. How far the changes that take place in Peyer's 
 glands may contribute to that exemption, is a subject for inquiry. 
 
 What constitutes the personal or constitutional predisposition to 
 fever? This is a point to be solved, nodus vindice dignus. It may 
 be argued that the bodily functions have become impaired by the 
 prolonged heat of summer — digestion, assimilation, and nutrition being 
 rendered imperfect, and secretion and excretion defective ; that effete 
 products have thus accumulated in the blood ; that vitality has been 
 lowered, so that the system is less able to resist the attacks of bacilli. 
 The increased susceptibility incident to adult age, may be accounted for 
 by the active exertion, consequent on tlie daily duties of life, occasioning 
 more tear and wear of the system, and thus increasing the effete products 
 in the blood. 
 
 Again, it may be assumed that there is present in the system some 
 suitable jiabulum that affoi'ds support to bacilli, or ministers to their 
 germination, growth, and multii)lication, the presence of this pabulum 
 constituting the determining, or immediately predisposing, cause of the 
 disease. On this supposition, the mildness or severity of a case of fever 
 might be accounted for hy the amount of pabulum present in the blood ; 
 should the amount be small, it would speedily become exhausted by 
 bacilli, which would then perish, and become eliminated from the body. 
 
 How do bacilli gain access to the body 1 Are they inhaled ; or are 
 they swallowed with food and drink ? It is believed that they are 
 generally conveyed through the medium of food and drink ; that they 
 are taken into the stomach, and pass into the small intestine, where 
 they are supposed to meet with conditions favourable for their growth. 
 They are said to penetrate Peyer's glands, the mucous follicles, and 
 lymphatics, and thus gain access to the blood, where, it is presumed, 
 they grow and multiply. Their ])resence in the blood is, however, not 
 well assured ; and in that respect, the bacilli of typhoid conform to the 
 behaviour of the bacilli of tuberculosis, whicli are not, as a rule, observed 
 in the blood, but are found in different tissues and organs of the body.
 
 THE ETIOLOGY OF TYPHOID. 155 
 
 THE ETIOLOGY OF TYPHOID 
 By J. G. Carstairs, M.D. 
 
 Not so many years ago, it appeared as if the genu theory of typhoid, 
 evolved by the genius of Budd, would shortly become the universally 
 accepted belief of the profession. From some cause or another, the 
 progress of that theory received a check; and now, up to the year that 
 has just closed, with one exception, all recent English writers on fevers 
 regard typhoid through pythogenic media. 
 
 However, as they have abandoned the doctrine of the generation of 
 the poison de nooo, and acce])ted the belief that the contagium is truly 
 specific, and always derived from previous cases of the disease, the point 
 at issue is virtually settled in favour of the germ theory, and Budd's 
 views are vindicated. This forms my starting point. 
 
 By common consent, typhoid is admitted to be the result of the 
 entrance into the body of a specific living contagium, always derived 
 directly or indirectly from previous cases, which multiplies in the body, 
 flows in the blood, permeates all the tissues, and is thrown oft' from the 
 body to propagate itself afre.sh in suitable soil. The striking analogy 
 to plant life in the multiplication of the contagium is universally 
 recognised ; and as the processes set uj) by it in the living body are 
 always true to type, the conditions of its existence, growth, and other 
 characteristics must be subject to fixed law. That the contagium lives 
 indefinitely outside the body is indisputable ; that, like other seeds, it 
 lies dormant for a time, requires no proof ; that, like them, it grows and 
 multiplies, in obedience to natural law, is shown, on a large scale, by the 
 periodic annual i-eturn of typhoid; and, on a smaller scale, by the 
 cultivation expeinments of the bacteriologist. But as this last point is 
 an undetermined question with the pythogenic school, and virtually 
 commands the position, let me illustrate it. 
 
 Germination of the contagium outside of the body. 
 
 Parenthetically let it be noted, that the average annual mortality for 
 this colony from typhoid is 430, and that of Melbourne 212, or about 
 one-half. From monthly statistics of the mortality in Melbourne, 
 extending over twenty -four years, we learn that the average monthly 
 mortality is at a minimum in November ; thence it increases more or 
 less rapidly, attaining its maximum from March to May. In June 
 there is a sudden fall in the death-rate, which decreases monthly till the 
 minimum is again reached. Now, the mortality in one month must 
 arise largely from those wlio contracted the disease in the previous 
 month, and as the rise in the mortality (consequent on the prevalence of 
 typhoid) commences in December, most of the cases received their 
 contagion in November. 
 
 The seeds of the contagium, which have lain dormant in the soil and 
 elsewliere during the cold weather, have then begun to germinate in 
 November, and multiply; and the increase of the mortality, amounting 
 to 120 per cent, in December, is at once the result and the proof of 
 their growth and multiplication. 
 
 When you see a ci^op of thistles growing, you know that the seeds 
 from a i)arent thistle, which have lain dormant in the soil, have 
 germinated ; and when you see a crop of typhoid growing, you know 
 that its seeds have germinated. You did not see the seeds of the
 
 156 INTERCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 thistle any more tlian those of the typhoid, but you know the crop 
 would not have appeared if the seeds had not been in the soil, and 
 germinated. 
 
 The period of the germination of the contagium, therefore, commences 
 in November, and is coincident with a mean tenipei-ature of the air of 
 60"2°, and of the surface soil of 69"5^. That this is no mere coincidence, 
 is shown by the regularity of the yearly recurrence of typhoid, and 
 further, by the fact that when the temperature in November is above 
 the average, so is the prevalence and mortality in December ; and when 
 the former is below the average, so also is the latter. In other words, 
 the season for typhoid is earlier or later. But the increased mortality 
 in December is only the first fruit of the lethal crop. With the increasing 
 temperature, the rate of multiplication of the germs of contagium 
 increases, and as a consequence, the death-rate, till the maximum is 
 reached in March to May ; after that, the temperature having fallen 
 l)elow that of November, the germination in the open air is arrested. 
 Hence, in June there is a sudden fall in the rate of the mortality, and 
 as in December the rise was shown to be the result and proof of the 
 multiplication of the germs, so in June is the fall the result and proof 
 of its arrest. The specific living contagium of typhoid, therefore, 
 germinates and grows outside the body, in the soil, or where it finds 
 itself; and the condition of its growth and increase is a high temperature, 
 such as we have here from November to April. 
 
 Gati'ky, in his admirable treatise on "The Etiology of Typhoid," 
 recognising the importance of ascertaining the temperature at which 
 the bacillus of typhoid formed spoi'es, that is, multiplied, made it the 
 subject of careful experiment. The result I give in his own words, 
 only substituting the degrees Fahrenheit for the centigrade scale he 
 uses. He says : — 
 
 " The temperature most suitable for spore-formation seems to be 
 from 86° to 104°. At 77° it occurs somewhat latei", but still indubitably. 
 The lowest limit seems to be 68°; at least, at this temperature, after 
 eight days' growth, I have only observed a very few, and only moderately 
 developed, spores in the bacilli. After two more days, the process was 
 not much further advanced." 
 
 Further, Gaft'ky never found the bacilli " become causes of putrefaction, 
 although sown in substances very liable to piitrefy." A certain range 
 of temperature was the sole condition for the sporing of the bacilli ; and 
 so, in the case of the germs, the spores, lying about this city, obedient to the 
 law of their life they germinate, owing neither their evolution, nor their 
 ]J0wer of multiplication, to decomposition going on in organic filth, but 
 to heat alone. And what happens here, will happen all the world over. 
 
 But here it may be asked, What of those cases of typhoid occurring 
 from June to November "J If germination of the contagium is arrested, 
 why is the disease not arrested also 1 The reply is easy. The disease 
 is largely arrested, as shown by the mortality, and though the germs 
 cannot multiply at the outside temperature, yet they are there, and 
 living ; and as in the summer they find their way into the human body, 
 so they can in winter, and once there, they find the condition and 
 temperature most suitable for their growth. 
 
 Tills leads to the question of the entrance of the conta(/iiivi into the body. 
 Most recent authorities hold that the contagium finds its way into the
 
 TIIK KTIOLOGY OF TYPHOID. 157 
 
 living body almost exclusively by the alimentary canal, in water, food 
 milk, ikc. That it enters by the air-passages is admitted as a probability 
 only — a statement of ojunion that recjuires overliauliiig, like many 
 others regarding typhoid. 
 
 That any article of food or drink containing the tyi)hoid germs does — 
 nay, mnst—oi necessity produce the disease, goes without saying. That 
 widesj)read and limited outbreaks have been traced to contaminated 
 water-supply, is undeniable. But that the annual autumnal prevalence 
 of typhoid, here or anywhere, is due to a regularly automatic pollution 
 of food oi- drink, is neither consistent with observation nor common 
 sense. Therefore, as by far the greater num\)er of cases of typhoid 
 happen during this regularly recurring ])eriod, their contagium does not 
 enter the body by the alimentary canal, and must, therefore, do so by 
 the air-passages. So far, then, from this being a probability only, it is 
 a moral certainty. 
 
 A word about milk epidemics. I do not mean tlie spurious hypo- 
 thetical, which require such an amount of ingenious reasoning to give 
 them an appearance, and only an ajjpearance, of truth ; but the true 
 milk epidemics, which iiossess one constant characteristic feature, viz., 
 the presence at the farm or dairy of one or several cases of typhoid, the 
 patients being nursed by those who milk the cows and attend to the 
 supply. It is positively painful to read in the accounts of these out- 
 breaks the minuteness of the details about middens, drains, leakv 
 cesspools, and polluted wells, which are presumed to form the chain of 
 connection between the patients and the contaminated milk. It is 
 astonishing to see this roundabout wa}' absorbing all tlie attention of 
 the narrators, while the plain, the direct way, is staring them in the 
 face. Daily, and for weeks together, does the nurse leave the bedside 
 of the fever j)atient to milk the cows ; her clothes and hands are 
 saturated with the poison ; the milk-pail is steadied between the knees, 
 and the fingers are frequently dij^ped into the milk in order to lubricate 
 the teats. Could the milk escape being contaminated ? Long before 
 the drainage from midden or cesspool could percolate to the well, the 
 milk was infected by the hands, and the pail by the clothing of the 
 milkmaid. Says Lawson Tait, " We now know that the raid against 
 lying-in hospitals was a mistake. Destroy the germs on the hands of 
 those who attend parturient women, and the women are safe." Destroy, 
 then, the germs on the hands and clothing of the milkmaid, and the 
 milk is safe. 
 
 Exit of the contagium from the body. All agree that the contagium 
 leaves the body in the dejections; few admit of its elimination in the 
 breath, or persjnration. The jiythogenic school maintains that the fresh 
 f.eces are innocuous, and devoid of the power of contagion, but that after 
 decomposition, they certainly contain the typhoid poison. 
 
 In a former portion of this paper, it was shown that the multiplication 
 of the germs outside the body was due to heat alone. The question is 
 not one of acquired virulence, but of inherent life. If the specific contagion, 
 on leaving the body, has lost the power of contagion — that is, of 
 Tnidtiphjing, it is dead ; aiid decomposition, instead of infusing life, will 
 only disintegrate it. xVgain, if decomposed typhoid stools "certainly 
 contain the poison," then of necessity it existed in tiie recent stools, for 
 there is no spontaneous generation. No, the specific cause that has
 
 158 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 wrought such havoc in the human body leaves it a livirKj self -projnt gating 
 thing. 
 
 But further, a contagium vivum that circulates in the blood, finds 
 itself in the capillaries of the skin, and of all the organs of the body ; 
 and though we admit that its chief outlet is by the bowel, yet we cannot 
 deny its elimination by all the emunctories. I need not remind you 
 that, although the invariable anatomical lesion is situated in the ileum, 
 yet the whole intestinal tract, from pharynx to colon, may be, and often 
 is, the seat of inflammation and ulceration. To refer to the throat 
 affection only, at times so severe as to have been mistaken for 
 diphtheria, and which, if looked for, I fancy would be found more 
 frequent than is generally believed, how will, how can the poison be 
 eliminated but in the breath and sputum 1 and the same may be said of 
 the ulceration of the larynx, the bronchitis, pneumonia and gastritis so 
 often present. And what of the skin, with its extensive drainage surface, 
 does it remain idle in presence of the common enemy? Throwing off, 
 as it does, 80 per cent, of the body heat, and as the smell from its 
 surface indicates the disintegrated products of tissue change, why not 
 the contagium also 1 When the skin acts well in typhoid, the patient 
 does well. It may be said, sweating reduces the temperature. True, 
 but is it not by removing the fuel, the cause of the increased body heat ? 
 This brings me to the question of contagio7i. Not the conimunicability 
 indirect, which is generally admitted, but the direct, from person to 
 person, which most deny. Dr. Collie, of Homerton, is the only recent 
 English writer on fevers who contends, and rightly contends, for direct 
 contagion. If it is admitted that the views above stated are correct, 
 viz., that the poison is eliminated by the lungs and skin, then the 
 acceptance of the belief of direct contagion through their emanations 
 cannot be withheld. 
 
 The limited time at my disposal forbids the giving the histories of 
 cases in point to support the position — let me but indicate their meaning. 
 A patient is brought from a distance to a locality where there is no 
 fever ; a relative sits by the bedside for a few hours once only ; or 
 another sleeps one night with the patient before the nature of the 
 disease is known ; both fall ill within a fortnight. Now had it been 
 measles or scarlet fever, there would be no hesitation in saying they 
 caught the disease directly from the patient. And when you see typhoid 
 behaving in the same manner, arguing from the general to the particular, 
 you say the same thing has happened — direct contagion. Again, when 
 you find that a child of less susceptible age, who has been in this close 
 contact, takes the disease, while several other members Of the family of 
 a more susceptible age, but who have not been in such close contact, 
 csoapc — taking the positive fact that the less susceptible was attacked, 
 and the negative fact that the more susceptible escaped, and that the 
 only difference in their circumstances was that the one was in close 
 contact, and the otliers not — what is the legitimate inference 1 Is it 
 not, that the contagion distance is short 1 You admit this of typhus, 
 why deny it of typhoid, with whicli it was so long confounded ? The 
 contagion is not of a volatile, diffusive natiire ; it clings to the body and 
 clothing of the patient, it clings to its surroundings, it clings to limited 
 areas of towns. It may be in a drain or dung heap, yet show no sign 
 till the one is stirred up, or the other turned over.
 
 159 * INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 General Sketch of Locality. 
 
 FITZROY 
 
 COLLINGWOOD 
 
 MlLBOURNt 
 
 Scale, about ^ Inc1}e§ to iffe Tiple
 
 TYPHOID FEVKR CON'XECTED ^VITII MIMv SUPPLY. 159 
 
 In complete harmony witli this view is the spread of typhoid in rural 
 or thinly-poinilated districts from person to person, and f;imily to faniily 
 — first, to the members of the household to which a fever patient was 
 brought ; then, to the neighbours and friends who Yisit the house, and 
 assist in nursing the ])atients. You have seen this scores of times. 
 The journals here, and in the old country, abound with narratives of 
 such outbreaks. There can be little doubt of direct contagion from all 
 the emanations of the body. 
 
 To sum up, the contar/iian of ti/phoid grows outside the body, and 
 the condition is a temperature from 70° to 104°. It enters the body 
 largely through the air-])assages. It leaves the body in all the emana- 
 tions, though chiefly in the dejections. It is directly contagious, the 
 contagion distance being short. Though necessarily present in filth, it 
 owes nothing to that, save as ii vehicle. Prevention — destroy the germs 
 outside by improved sanitation. Let not another germ from typhoid 
 patient live. Isolate the patient ; burn the excreta ; disinfect bed and 
 body clothing, by exposure to a steam heat of at least 230" ; disinfect 
 the house. 
 
 TYPHOID PEVER CONNECTED WITH MILK-SUPPLY\ 
 By H. B. AllExV, M.D. 
 
 Professor of Anatomy and Pathology in the University of Melbourne. 
 
 On or about the 16th of March, 1879, the son of a milkman, named 
 M., residing near the west end of Jolimont Place, fell ill ; in a few 
 days, distinct symptoms of typhoid fever presented themselves, and the 
 disease ended fatally on the 2nd of April. Of ninety-three households 
 in ^Melbourne and its suburbs supplied by the milkman in question, 
 twenty -three were visited by the fever ; forty-three individuals were 
 attacked, of whom three died. 
 
 From this short summary, I may proceed to discuss— («) the sanitary 
 condition of Jolimont ; (b) the history of the illness of young M. ; (c) the 
 milk-supply ; (</) the outbreak of fever in Jolimont ; (e) fever among 
 M.'s customers in Collingwood, Fitzroy, East Melboiirne, and Melbourne. 
 
 Jolimont is a small suburb situated on a gentle slope, between the 
 Fitzroy Gardens on the north, and tlie low-lying paddocks by the Y'arra 
 on the south ; east and west, it is bounded by the Richmond Park and 
 the East Melbourne Cricket Ground respectively. It is thus compara- 
 tively isolated from the rest of Melbourne. The suburban railway line 
 separates it from the flat grounds by the river, which are used as 
 {lasturage for cows. A short distance to the south-west, on the bank of 
 the Y^arra, was the old Cor[)oration tip ; and between Jolimont and the 
 Fitzroy Gardens is a strip of open ground, which was used as a tip 
 during 1878-9. These I'ubbisli depositoi'ies were both extremely 
 offensive during the latter part of 1878, and the early months of 1879. 
 The new tip, though the smallei*, was especially obnoxious, on account 
 of its nearness to the houses. Decaying animal and vegetable matters 
 were freely deposited there ; the ground and the houses adjacent 
 swarmed with flies ; while the stench arising in the summer weather 
 (when the temperature of the surface soil was exceptionally high) was 
 almost unbearable.
 
 160 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Braina(je. — The highest ground in Joliaiont is at the north-east corner, 
 while the opposite corner is low-lying, witli a very slight full towards 
 the river. All the drainage of the suburb gathers into Jolimont Road, 
 wliich also receives the water f I'om the gnlly or open drain running through 
 the Fitzroy Gardens. Many complaints have from time to time been 
 published in the daily papers, concerning the offensive state of this gully. 
 
 Seivage. — So far as I am aware, there was not a single cesspool in 
 Jolimont ; the dry-pan system was universal. 
 
 Typhoid in Jolimont Prior to the Milk Outbreak. 
 In the fever season of 1878-9, the first case of typlioid in Jolimont 
 occurred in Noveuiber 1878, in a house in Jolimont Place, west of 
 Agnes-street, and immediately opposite the new tip. In December, two 
 cases occurred in a house about the centre of Jolimont Terrace. Of 
 these one died ; two fresh cases developed in the same house in the 
 January following, and the family shortly after removed to .Brighton. 
 There is a history of fever in the house adjacent to this in previous 
 years, but I have been unaljle to obtain any ])articulars. 
 
 Typhoid in the Milkman's Family. 
 
 There was then an interval until the middle of March, when a new 
 case occurred in Jolimont Place, in the house (marked M. in the street 
 plan of Jolimont) occupied by a milkman named M., and situated three 
 doors west of that in which the disease first ajjpeared, in the previous 
 November. I was informed, by a resident in Jolimont, that the very 
 worst rubbish was deposited on the tip just opposite these houses. 
 
 M.'s elder son, a schoolmaster, returned home from New Zealand early 
 in January 1879. He took no part in the dairy business. On the 16th 
 of IMarch, he fell sick, the jn-ominent symptoms at the outset being 
 rheumatoid pains in the trunk and limbs. But the disease rapidly 
 developed, and on the 21st, was diagnosed beyond a doubt to be .severe 
 typhoid fever. During this jjeriod of Jive dags, no disinfectants ivhatever 
 were emploged. Subsequently there was diarrhoea from time to tiuie, and 
 disinfectant.s were freely used in the bed-pan, and with the excreta after 
 removal. On the pathway of the lane, behind the house, a barrow was 
 kept, containing stable manure and earth. Into this the bed-pan was 
 emptied directly after use, the dejecta being covered with earth. Finally, 
 the barrow was wheeled away, and its contents buried in the tip. The 
 disease ended fatally on the 2nd of April. The father always took a 
 large share in the nursing. 
 
 The liou.se itself stands on an allotment 90 feet deep, with a frontage 
 of 20 feet to Jolimont Place. In front is a strip of garden 5 feet deep ; 
 then the main buildings 33 feet deep, and occupying the whole width of 
 the allotment. Behind them, on one side is the kitchen and a bedroom, 
 together 26 feet deep by 10 feet wide, succeeded by a shed for fodder, 
 &c., cattle stalls and stables, reaching to the boundary fence at the rear. 
 On the other side, behind the house, was a bathroom, 10 feet by 4 feet, 
 followed by an open dairy shed of about the same size, in which stood a 
 20-gallon boiler. The yard was thus about 32 feet by 9 feet, with a 
 narrow ])assage about 20 feet by 5 feet, extending up to the house 
 between tJie outbuildings ; it was paved throughout with square stone 
 pitchers ; in the corner was a diy pan closet.
 
 typhoid fever coxxkcted with milk supply. 
 Plan of ^F.'s Premises. 
 
 161 
 
 
 
 
 
 
 '^^^^ 
 
 
 » 
 
 dVt) 
 
 
 
 CI. 
 
 
 < 
 
 
 
 H 
 
 
 
 10 
 
 
 
 lift. 
 
 
 D9 
 
 
 
 
 
 
 |J] 
 
 
 
 <j 
 
 
 
 Eh 
 
 
 
 m 
 
 4fl. 
 
 SHED 
 
 
 % 
 
 
 o 
 o 
 
 
 OR 
 
 
 A 
 
 
 w 
 
 
 fi 
 
 
 s W 
 
 
 H 
 
 
 S ^2 
 
 
 w 
 
 
 ^2 fe 
 P5 
 
 
 
 
 
 
 i-i 
 
 
 
 
 <J 
 
 
 !z; 
 
 
 P 
 
 
 » 
 
 
 § 
 
 
 M 
 
 
 o 
 
 
 o 
 
 
 o 
 
 
 M 
 
 
 W 
 
 Eh 
 
 
 M 
 
 
 <! 
 pq 
 
 
 10 ft. 
 
 5 ft. 
 
 4 ft. 
 
 H 
 
 
 C5 
 
 
 <J 
 
 
 
 m 
 
 
 < 
 
 
 ^ 
 
 
 GARDEN 
 
 20 ft
 
 162 INTEKCOLONIAL MEDICAL CONfiRKSS OF AUSTRALASIA. 
 
 Concerning the cleanliness of tlie yard, the evidence is conflicting. 
 M. said it was washed out daily, except on Sundays ; but several 
 residents in Jolimont informed me that they were forced to discontinue 
 taking milk from M., on account of the filthiness of the yard, and of 
 the lane behind it. 
 
 The son, affected with typhoid, lay at flrst in a back room next to 
 the bath ; Ijut when the nature of the disease became manifest, he was 
 moved into the large front room, and the door and windows were ke})t 
 freely open. The stench from the ti[) was then " a perfect nuisance," 
 and the sickroom swarmed with flies, which Avere killed and removed 
 " almost by bucketfuls." 
 
 The INIiLK Supply. 
 
 ]M. had two carts used in the distribution of milk ; one stood eveiy 
 night in the yard ready for the early n orning start, the other was kept 
 in the lane behind, against the stable wall. He always attended himself 
 to the cleansing of the cans, and there was a general testimony from the 
 customers that the milk kept extremely well. Every night the cans 
 were scoured with a brush, and a scalding solution of soda, which was 
 allowed to remain some time in the vessels. They were then washed 
 with hot water, and dried with a cloth wrung out of the boiling water. 
 The only water used was Yan Yean, which was heated in the boiler 
 that stood in the dairy-shed. The cloths and brushes used to clean the 
 cans were kept on a bench in the dairy-shed. Titus, all the cans were 
 snhjected to the same treatment, being manipulated hy a person ivho was 
 taking a large share in nursing a patient safe)-ing from typhoid, fever. 
 Thus cleansed, the cans were left during the night, either in the cart 
 within the yard, or in the shed beside the boiler. 
 
 The customers in Jolimont were sup)plied with milk obtained from 
 cows kept at Jolimont. All other customers, with one or two exceptions, 
 received milk from a dairy at Croxton Park. Thus, the business was 
 twofold ; Mrs. M. taking charge of the Jolimont trade, Mr. M. of the 
 Melbourne and East Melbourne rounds. But, as above stated, all the 
 cans were treated alike hy M. himself. 
 
 The Jolimont Milk Supply and Fever connected with it. 
 
 At the time of the outbreak of fever, M. kept six cows at Jolimont, 
 which were not, however, in full milking. They depastured in a 
 paddock across the railway, adjacent to the large Corporation tip ; here 
 there was then no proper drinking trough, and the cattle used to drink the 
 impure water lying in hollows in the paddock and in the drains. There 
 is also evidence that at night these cows were accustomed to roam over 
 the new ti[), and rummage among the garbage there deposited. During 
 the day they came to the yard of M.'s house, and were there milked at 
 once, the milk being immediately sent to the customers in Ave and seven- 
 quart serving cans. This milk, according to IM.'s statement, was never 
 taken within the house. No settled round was pursued in its distribution
 
 TYPHOID FEVKIJ CONNECTED WITH MILK SUPPLY. 
 
 163 
 
 — different persons carried it on different days, sometimes M.'s dau'iliter, 
 or the wife, or one of the servants. There was never any sur[)lus. 
 
 Mrs. M. supplied thirty-one (31) families in Jolimont ; of these eleven 
 (11) were visited by typhoid fever between the 23rd March (one week 
 after the commencement of the case in her own house) and the 5th of 
 May. In these eleven households, twenty individuals were seized upon 
 by the disease, and three died. In a twelfth family, during the same 
 [)eriod, two cases of " febricula " occurred, of about a week's duration. 
 Durimj this ]>eriod, the fever did not attack a single individual in Jolimont 
 who did not drink the miUc in >/uestion. One family as a rule obtained 
 milk from another source, l)ut took milk from Mrs. IM. once, about 
 March 21, when young M.'s illness was declaring itself The servant 
 drank half a cupful of this milk ; a week later she was laid up with 
 typhoid fever. 
 
 Street Plan of Jolimont. 
 
 RICHMOND ROAD 
 
 N 
 
 N EW TI P 
 
 <^ 
 
 JOLIMONT PLACE «<<• 
 
 M 
 
 s-v 
 
 JOLIMONT STREET 
 
 1 
 
 
 2 w 
 
 
 R 
 
 
 S 
 
 
 W 
 
 
 o 
 
 
 
 
 Hd 
 
 
 
 H 
 
 
 m 
 
 
 m 
 
 
 W 
 
 
 iz; 
 
 
 C5 
 
 
 < 
 
 
 
 
 If we compare the different streets in Jolimont with one anothei-, 
 very striking peculiarities present themselves in the prevalence of 
 
 M 2
 
 164 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 typhoid among the customers of Mrs. M., as is shown by the following 
 table : — 
 
 Statistics of Households and Individuals Supplied with 
 M.'s Milk. 
 
 STREET. 
 
 Aspect of 
 Jolimont. 
 
 NUMBER SUPPLIED. 
 
 NUMBER VISITKD BY 
 TVPHOID FEVER. 
 
 
 Households. 
 
 Individuals. Households. 
 
 Individuals. 
 
 Jolimont Place 
 Jolimont Terrace . . 
 Jolimont Square 
 Agnes Street 
 Jolimont Eoad 
 Jolimont Street 
 
 North . . 
 East 
 
 North . . 
 Centre . . 
 West 
 South . . 
 
 5 
 6 
 3 
 
 9(6) 
 
 5 
 
 3 
 
 26 i 2 
 33 2 (a) 
 32 2 
 
 44 (b) 1 5 (h) 
 30 i 
 14 1 
 
 2 
 
 5 
 
 9(6) 
 
 
 
 
 
 Total 
 
 .. 
 
 31 
 
 179 11 ! 20 
 
 (a) One of these two houses, in which four cases occuiTed, is at the corner of Jolimont Terrace and 
 
 Jolimont Place. 
 
 (6) This includes the family in which M.'s milk was taken only once, a week before the servant 
 
 showed signs of typhoid fever. 
 
 Thus it is seen, that the high and comparatively well-drained parts of 
 Jolimont were visited by the disease, while the two low-lying streets on 
 the south and west, which receive the drainage from the higher ground, 
 escaped entirely. It is difficult, to explain this immunity; in only 
 one house in these two streets was M.'s milk scalded, and there 
 only on very hot days. But it may be remarked that these two streets 
 are farthest from the new tip, which seems to have been the great 
 sanitary blot of the district. 
 
 Thus ten cases occurred in Jolimont Place and Square, and the 
 adjoining corner of the Terrace, which all abut directly on the new tip. 
 Of the remaining ten, nine were in Agnes Street, which is more or less 
 built in on both sides, comparatively shut in, and which leads southward 
 from the centre of the tip. The other case was a weakly lad in Jolimont 
 Terrace, who drank a pint of the raw milk daily. 
 
 The next point to consider in the development of this outbreak is, the 
 number of cases of fever that occurred weekly in Jolimont, after young 
 M. fell ill on March 16. Disinfectants were tirst ordered to be used on 
 the 21 St. 
 
 Weekly Number of Cases of Typhoid in Jolimont, after 
 March 16, 1879. 
 
 From 
 
 March Hi to 
 
 March 23. 
 
 From 
 Marcli 23 to 
 Jlarch 30. 
 
 Prom 
 
 March 30 to 
 
 Aprrl 6. 
 
 From 
 April 6 to 
 April 13. 
 
 From 
 April 13 to 
 April 20. 
 
 From 
 April 20 to 
 April 27. 
 
 From 
 April 27 
 to May 4. 
 
 From 
 Mav 4 to 
 May 11. 
 
 — 
 
 4 
 
 7 
 
 5(a) 
 
 3 
 
 — 
 
 — 
 
 1(&) 
 
 (a) And two cases of febricula. 
 
 (6) This occurred on May 5, in a house adjoining another iu which an earlier case commenceil on 
 April 7. , 
 
 More than seventeen persons, who had been drinking this milk, 
 scattered during the time of the outbreak — some to England, some to 

 
 165 * INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Map of East Melbourne. 
 
 CO 
 
 o 
 
 Swampy 
 
 1 
 
 iSn 
 
 qipps f 
 
 
 
 — V 1 
 
 " 
 
 
 ^'"v. 
 
 " 
 
 
 
 
 <? 
 
 © 
 
 Sr 
 
 GEORGE 
 T — I ; 
 
 WELLINGTON 
 
 PARADE 
 
 NEW TIP 
 
 JOUMONT 
 
 NEW GROUND 
 
 RICHMOND PARK 
 
 Note. — Every mark | indicates a house supplied with M/s milk. A circle Q 
 indicates a house supplied by M., in which typhoid occurred. A square □ 
 indicates a house, not supplied by M., in which typhoid occurred. The number 
 of dots in the circle or square indicates the number of cases.
 
 TYPHOID FEVER CONNECTED ^VITII MILK SUPPLY. 165 
 
 different ])laces through the Colony. Five of the latter had typhoid 
 fever wliile away ; but I could not learn that any of the five couununi- 
 cated the disease to others. 
 
 Typhoid Fevek amoxg persons, outside Jolimont, supplied with 
 
 M.'s Milk. 
 
 The milk supj'lied by M. to persons living outside Joliinont was 
 obtained from a dairy in Croxton Park ; the dairy establishment itself 
 seemed to be well conducted ; the grazing paddocks around it adjoined 
 a slaughter-house in the park ; the drainage from the slaughter-house 
 ran, at least partly, into one of these paddocks. On an average, M. 
 took about 150 quarts of milk daily from this dairy. He left Jolimont 
 early every morning, in the cart which had been standing all night in the 
 yard, and took with him the cans which had been cleansed the evening 
 before, and which were kept during the night either in the scalding-shed 
 next the boiler, or in the cart, ready for the morning journey. After 
 obtaining his supply of milk, M. returned through Northcote and 
 Collingwood, to the corner of Gore and Gertrude streets, Fitzroy, where 
 he met his other cart, which stood during the night in the lane behind 
 his house at Jolimont, and which was driven by his second son, or by a 
 serving lad. One or two cans of milk wex'e then transferred to this 
 cart, which supplied the customers in East Melbourne and a few in 
 Cambridge Street (Collingwood), and the adjacent parts. M. himself 
 drove on through the Eastern Hill into Melbourne. If the Croxton 
 Park milk ran short, he bought more fi'om shops or from otlier dairy- 
 men, but ne\'er obtained any from Jolimont ; usually, however, he had 
 a slight surplus. 
 
 In Collingwood, Fitzroy, and the Eastern Hill, 13 households, com- 
 prising 96 individuals, were supplied by one or other of these carts ; 
 and all these families, ivhich ivere the first to receive the milk, escaped with 
 impunity. These 13 houses were not in the vicinity of any large 
 collections of decomposing organic matter, though the drainage around 
 them in some instances was imperfect. 
 
 Typhoid in East Melbourne. 
 
 In East ^Melbourne, 26 families, including 18-4 individuals, drank of 
 this milk. Among these, 13 persons in 7 families sickened with typhoid 
 fever. I heard also of a " suspicious attack " in another case. 
 
 If East IMelbourne be divided by a diagonal line running from the 
 north-west to the south-east corner, the gi-eat majority of M.'s customers 
 resided in the south-west division — that next to Jolimont. Almost all 
 the cases of fever were in houses close to the diagonal line where the 
 land is sloping downwards to the low level. The families living in the 
 highest part of East Melbourne escaped, with one exception. I made 
 many enquiries concerning the existence of typhoid fever among families 
 in East Melbourne who obtained milk from other sources, but discovered 
 only five cases in four households, supplied by as many different milkmen. 
 
 M.'s Melbourne Supply. 
 
 Between Spring and Swanston Streets, on the east and west, and 
 Bourke and Flinders Street, on the north and south, 31. supplied
 
 166 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 13 households, numbering 123 individuals; of these, 10 persons in .5 
 households sickened with typhoid fever. Eight of the 10 cases occurred 
 in Collins Street East, and 2 in Bourke Street. 
 
 But on the other hand, west of Swanston Street, 10 liouseholds, 
 inchiding 73 individuals, received similar milk during the same round, 
 and yet escaped with complete impunity. In this same district, M.'s 
 milk was also used in the ojjen luncheon and dining rooms attached to 
 two hotels, at which I was informed by the proprietors that about 120 
 persons partook of unscalded milk in some form or other daily, though 
 of course in very small quantity ; no cases of fever were known to have 
 occurred. 
 
 General Statistics. 
 
 Gathering together the facts recorded concerning the prevalence of 
 typhoid fever among M.'s customers in all these districts, Ave obtain the 
 following results : — 
 
 Statistics of Fever among all M.'s Customers. 
 
 
 Number 
 
 Supplied 
 
 Number Affected 
 
 Pf.rcextage 
 Affected. 
 
 
 House- 
 holds. 
 
 Indi- 
 viduals. 
 
 House- 
 holds. 
 
 Indi- 
 viduals. 
 
 House- 
 holds. 
 
 Indi- 
 viduals. 
 
 Collingwood, Fitzroy, &c. 
 East Melbourne . . 
 Melbourne, East of Swanston St. 
 Melbourne, West of Swanston St. 
 
 13 
 26 
 13 
 
 10 
 
 96 
 184 
 123 
 
 73 
 
 
 7 
 5 
 
 
 
 13 
 10 
 
 
 
 nil. 
 26-9 
 38-46 
 
 nil. 
 
 nil. 
 7-06 
 8-13 
 nil. 
 
 Total outside Jolimont . . 
 
 62 
 
 476 
 
 12 
 
 23 
 
 19-35 
 
 4-83 
 
 Jolimont, except J. Road & St. . . 
 Jolimont Eoad & Street 
 
 23 
 
 8 
 
 135 
 
 44 
 
 11 
 
 
 20 
 
 
 47-8 
 nil. 
 
 14-81 
 nil. 
 
 Total in Jolimont . . 
 
 31 
 
 179 
 
 11 
 
 20 
 
 35-48 
 
 11-17 
 
 Grand Total 
 
 93 
 
 655 
 
 23 
 
 43 
 
 24-73 
 
 6-56 
 
 Weekli/ jVumbers of Cases of Typhoid among JI.'s Customers. 
 
 
 From 
 Mar. 16 
 
 to 
 Mar. 23 
 
 From 
 Mar. 23 
 
 to 
 Mar. 30 
 
 From 1 From 
 Mar. 30 April 6 
 
 to to 
 April 6 lApril 13 
 
 From 
 April 13 
 
 to 
 April 20 
 
 From i From 
 April 20;April 27 
 
 to ' to 
 April 27 May 4 
 
 From From 
 May 4 May 11 
 
 to to 
 May 11 May 18 
 
 Jolimont 
 
 Melbourne 
 
 East Melbourne.. 
 
 
 
 
 
 4 
 1 
 1 
 
 7 
 3 
 2 
 
 5 {a) 
 
 2 
 
 4 
 
 3 
 
 1 
 6 
 
 10 
 
 i 
 2 (6), 
 
 
 1 (c) 
 1 (d) 
 ; 
 
 Total 
 
 
 
 6 
 
 12 
 
 11 
 
 2 
 
 2 
 
 (re) And two cases of febricula. 
 
 (b) Tiiree cases of typlioid commenced tliis week iu Collins Street East, in a family nut supplied 
 with M.'s milk. 
 
 (c) Beginning? in Jfay 5 in a house adjoining one in wliicli an earlier case commence I on April 7. 
 ((Z) Beginning on May 10 in a house iu wliicli there had been two previous cases. 
 
 It will be remembered that young M.'s illness was first noticed on 
 March 16, and that he died on April 2.
 
 typhoid fkver connected with milk supply. 1g7 
 
 Climatological Conditions. 
 Tlie most iiotcaLle fact in tlie climatic coiKlitions of Melbourno, during 
 the early months of 1879, was the high temperature of the surface soil, 
 us shown in the following table compiled from the recoi'ds of the 
 Melbourne Observatory : — 
 
 Mean Temperature of iSurface Soil. 
 January — 81 "8°, or 4-1° above average for January 
 February — 79-0^ or 3-8' ,, ,, „ Fel)ruary 
 
 March — 72-9% or 2-7" ,, „ „ March 
 
 April — 63-9°, or 2-5° „ „ „ April 
 
 May — 51 "6^ or 2-0° below ,, ,, May 
 Rain fell on six days in INIarch, ten in April, and fifteen in ^lay, the 
 falls for these months being respectively 0'43, 1-49, and 2-21 inches. 
 The temperatures registered in the shade during these months were : — 
 March — mean 63*2°, maximum 90-2" 
 April — ., o9-9" „ 88-0° 
 
 May — „ 51-4' „ 68-6^ 
 
 The main questions involved in the enquiry into this outbreak of 
 typhoid fever may now be considered seriatim : — 
 
 (1) Was contaminated milJc the cause of the outbreak ] The answer to 
 this must be an unquestionable atKrmative ; cases of fever occurred in 
 23 out of 93 families supplied with this milk ; the disease api>eared 
 suddenly among the customers a week after the primary case commenced 
 its course in the house of the milkman M. The outbreak ((uickly 
 reached its greatest degree of prevalence, and as quickly subsided. 
 
 (2) Wliat was the nature, and v:hat the method of this contamination / 
 Two explanations were offered ; one, that the milk was poisoned through 
 the cows drinking foul water, and feeding on the decaying A-egetable 
 rubbish found in the tip. Two objections to this arise at once : — firstly, 
 cows belonging to other dairymen depastured in the same paddocks, and 
 drank similar water, while the milk yielded by them did not induce 
 fever; and secondly, the milk obtained by M. from Croxton Park 
 induced fevei', just as did Jolimont milk, though not in so large a 
 })roportion of the individuals supplied. 
 
 The milk being thus derived from two distinct sources, and yet carry- 
 ing the same virus with it, whencesoever it was obtained, we are driven 
 for an explanation to the milkman himself and his cans. As before 
 remarked, " all the cans were subjected to the same treatment, being 
 manipulated Ijy a i)erson who was taking a large share in nursing a 
 patient suffering from typhoid fever." These cans stood all night 
 within ten to fifteen yards of a barrow containing a mixture of earth, 
 stable manure, and typhoid stools, to which was added from time to 
 time (so I was told) some disinfectant solution ; similar solution was 
 used also in the bed pan itself, but none of these precautionary measures 
 were adopted during the first five or six days of the patient's illness. 
 
 It is noteworthy that, while the fever ])oison was being distributed, 
 the milk that conveyed it kept sweet for days. The cleansing of cans 
 with soda, hot water, itc, may prevent milk from swiftly turning som-, 
 but will not destroy the typhoid virus ; nay more, this virus may 
 possibly be introduced into the cans in the very operation of cleansing, 
 scrubbing, and wiping them.
 
 1G8 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 As far as I could judge, it mattered little who served tlie milk to the 
 customers, or what had been the closeness of his or her connection witli 
 the sick room. But the evidence in this respect is very incomplete. 
 
 The condition of M.'s house and yard is the subject of many conflict- 
 ing statements ; probably care in many things was accompanied at times 
 1)y neglect of others. Thus, though M. could assure me that the cans 
 which he used never entered the house, yet he was unable to speak with 
 certainty about the cans and milk used in the Jolimont supply. He was 
 aware that in some instances his orders, " never to supply cold milk to 
 anyone," had been disregarded. 
 
 The Jolimont customers, in fact, ran many risks peculiar to them- 
 selves ; the cans used in supplying them were more constantly near, 
 perhaps in, the house ; the cows were frequently milked by persons 
 engaged in nursing a typhoid fever patient ; the distrilnition of the milk 
 Avas less methodical, and altogether the work was done in a slipshod way. 
 
 (3) Was the milk thus contaminated aJAe to p>^'oduce typhoid fever in 
 those inlio dranh it, in the absence of certain other conditions ; if not, tvhat 
 were these conditions ? The limitation of the outbreak among M.'s 
 customei's to certain definite districts shows clearly that the first part 
 of this question must be answered in the negative. The same milk being 
 supplied in the same daily rounds, ty})hoid fever prevrdled extensively 
 iu some quarters, and was entirely absent in others. No individual or 
 family ])redisposition can explain this away. Defects of drainage or of 
 ventilation in single houses will not touch the point at issue ; it is idle 
 to suppose that there were grave sanitary defects in all the houses of 
 M.'s customers into which typhoid entered, in East Melbourne and in the 
 eastern half of Melbourne proper, while all the fever-free houses in 
 West Melbourne, Fitzroy, Collingwood, kc, were in such matters with- 
 out reproach. No, we must look for conditions affecting districts, and 
 not merely single dwellinr/s. The problem presented is one of the 
 utmost difficulty, yd the facts seem to show that, apart from some 
 localising conditions, the poisoned milk would not, unless in exceptional 
 cases, piroduce an outln-eak of fever ; and even when these conditions 
 were present, personal and family peculiarities, age, drainage and 
 ventilation of special houses, &c., would be most important factors. 
 
 I can only guess the nature of the localising conditions. Nearness to 
 offensive tips for rubbish api^eared to be the most potent factor in 
 Jolimont. In East Melbourne, proximity to low-lying, badly drained 
 ground seemed the chief condition common to almost all the houses in- 
 vaded. Of the different incidence of the fever in the eastern and 
 western halves of Melbourne city, I can offer no explanation. In regard 
 to the milk obtained from Croxton Park, it is extremely strange that the 
 families fii'st sujjplied in Clifton Hill and Collingwood should go free, 
 that the families next visited in East Melboui'ue and the eastern half of 
 Melbourne should suffer in so many instances, and that the customers 
 in the western part of Melbourne should enjoy immunity. 1 do not feel 
 justified in taking up your time with vague speculations, but simply 
 place the facts before you, hoping that, in any future outbreaks, in- 
 vestigators will not be content when they have convicted milk of being 
 the carrier of contagium, but will closely study the conditions which 
 govern the prevalence of the fever among the families and individuals 
 supi)lied with the contaminated milk.
 
 TYPHOID FEVKR — HISTORY OF AX EPIDEMIC. 169 
 
 TYPHOID FEVER— HISTORY OF AN EPIDEMIC. 
 By A. V. Henderson, M.B. et Ch.B. 
 
 An epidemic of typhoid occurred in the year 1887 in the township of 
 Lilydale, a township composed in the greater part of hills and dales, but 
 which, in one particular ])art, rather thickly studded with houses, is a 
 large flat, undrained, and in a generally insanitary condition. Through 
 the township runs an ever flowing creek, which contained a clear and 
 wholesome sup[>ly of pure drinking water up to the time of its becoming 
 tainted. 
 
 This district had been free from ei)idemics of this fever, although 
 isolated cases had occurred. It was from the investigation of the 
 sporadic cases that I gleaned, to my mind, the most valuable information. 
 
 The following are the condensed facts of the outbreak. 
 
 In January of the year 1887, there was what would be considered a 
 drought in this district, which as a rule is well supplied with rain water, 
 in the winter months there being rather too much rainfall. At this 
 time the domestic supply had run very short, being in most cases 
 sujiplied from underground brick tanks. The water in these tanks 
 had become very low. and in many cases they contained only a foot or 
 two of stagnant water. The drains, which are of tlie primitive type, were 
 full of decaying and decomposing matter. In fact, the residents had 
 everything ])repared to welcome a visit from such a disease as typhoid. 
 I speak principally of those who resided on the tlat, undrained part before 
 mentioned. 
 
 It was when this state of affairs existed that a groom, named D., 
 came to Lilydale to recruit, as he had not been feeling well for some 
 days. He stayed at a grocer's sho)) and boarding-house kept by a man 
 named P.; not getting any better from the change, he came to consult 
 me, when, after seeing him two or three times, I pronounced him to be 
 suffering from typhoid fever, and ordered his removal to the hosjiital in 
 jNIelbourne, where he Avas treated for enteric fever. His wife had come 
 up in the meantime to nurse him, and began to show premonitory 
 .symptoms ; as soon as she consulted me, I advised her removal. She 
 went to the hospital also. 
 
 Closely following on the departure of these two cases, the wife of the 
 storekeeper took ill, but did not send for me until some time after she 
 had felt ill, and had served groceries in the shop. All precautions 
 possible had been taken to kee[) down contagion, but the harm seemed 
 to have been done. One of the children (belonging to the boarding- 
 house keeper) then contracted the fever, and in quick succession arose 
 other cases in this house and outside. 
 
 The next door neighbours — who lived right upon the creek — were 
 the subsequent victims. Their child, who had been accustomed to play 
 with the boarding-house keeper's children, being affected first ; this 
 being the probable source of contagion between these two families. 
 
 It was from this house ujjon the creek that a great deal of the 
 subsequent mischief arose. I found out, when called into this house, 
 that it was the custom of the occui)ants to throw most of their refuse 
 into the creek, and as the bedroom doors aljutted on to its banks, most 
 of the excreta would find its way into the water. It was some time after
 
 170 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 this cliild had been ill that I was called in, so that the mischief had 
 been done. 
 
 All along the same side of the street as the store arose a number of 
 cases, almost every house holding a victim. As the creek water was 
 now affected, and as numbers of the peojole had been to the creek for a 
 supply, how far these subsequent cases were due to neighbourly 
 intercourse, or to the creek water, it would be hard to say. All along 
 the banks of the creek below stream (not above it) the residents 
 contracted the fever, and all of these drank from its waters. The 
 navvies working on the new line of railway from Lilydale to Healesville, 
 whose tents were pitched on its banks, also suffered severely. 
 
 In a different situation to all these cases in the township, and where 
 the creek water was not used, I was surjirised to find typhoid had begun 
 with another series of cases, but soon learnt that they arose from a case 
 which had left the house on the creek. A mother, Mrs. W., a widow, 
 had taken her little girl away from here, on learning that typhoid fever 
 was in the house, and had taken her to this part of the township, but 
 too late, as she soon showed symptoms, and was treated by the mother 
 for some time, until fever symjitoms set in, which prompted her to apply 
 to me. 
 
 The next door neighbour who used to run in, and help to nurse the 
 little girl, not knowing what the disease was, and what precaution to 
 take, as can readily be understood, contracted the fever, and from them 
 again their relatives and friends. Thus the disease took full possession 
 of the townshi}), whose general system of drainage and sanitary condition 
 favoured its spread. And so the succession of cases all originated from 
 the one imported case, the virus acting quickly in constitutions rendered 
 liable to its action by the predisposing causes then existing. 
 
 This epidemic shows how a ruiming creek can be contaminated by the 
 excreta from a typhoid patient, and carry the germs far and wide to 
 numbers of unsuspecting people. Many more than the number which 
 came under my })ersonal care must have suffered from drinking its 
 water, and gone away to their homes, or to the hospital. 
 
 Thus, if a running creek, in a country district, can be polluted to such 
 an extent by one case, how much more easily can a reservoir be con- 
 taminated, and how many more lives can this reservoir then endanger. 
 With what extreme care then should the domestic supply of a large 
 community be guarded, or what dire results may follow. The illustra- 
 tions I have just given point to the moral, and the same would a])ply 
 to sanitary conditions. For suppose a dwelling-house to be situated 
 near a reservoir, at a higher level than its banks, and suppose an 
 unsuspected case of typhoid came to this dwelling, what is to prevent 
 the contamination of that reservoir? Hence the injudiciousness of having 
 near any domestic water supply, dwellings of any kind. 
 
 Now, as to sporadic or isolated cases of typhoid fever. I had collected 
 and investigated a great many cases, out of which I preserved a few 
 typical ones. I mention here only three or four cases. From these, I 
 have been led to this belief : " That in most sporadic or isolated cases, 
 the original cause of the fever lies in the virus generated in stagnant 
 decomjiosing water." The first case is this : — 
 
 A young man, about 23 years of age, named H., who resided about 
 seven miles away from Lilydale, and whom I visited professionally, was
 
 TVPIIOID FEYRR — HISTORY OF AN EPIDEMIC. 171 
 
 sutfeiing from a tyiiical case of typlioitl fever. On making the usual 
 inquiries anil investigations, I found the house situated on vising ground 
 in a jiretty locality, the drainage was very good, jirivy clean, and all 
 sanitary conditions of the best. The young man was building a house at 
 the time he fell ill, intending to get married and live in it with his wife 
 as soon as finished. He Avorked by himself, had not been awa}^ from 
 home for .six weeks, had had all his goods in from a place called Wandin 
 for some time previous to this ; and his mother, whom he lived with, had 
 not been away from home, neither had they seen anyone. On asking 
 questions about the water used for domestic purposes, 1 found they had 
 run out, and were getting their sujjply from a tank close by, which was 
 not used, and which was very low as to the depth of water it contained. 
 
 On examining this fluid, I found it was dirty, had a nasty decompos- 
 ing smell, and was full of aniinalcula^. The patient said he often felt 
 sick for some time after drinking it, but he was obliged to use it, as it 
 was hot weather, and he being busy had no time to go farther for 
 better. 
 
 In this case I could find no other cause, after fully investigating all 
 conditions, and therefore came to the conclusion that this case of typhoid 
 originated from the stagnant degenerated water which the patient had 
 indulged in. And given one case, where is the contagion to stop in 
 such a communicable disease, providing the surrounding circumstances 
 are favourable 1 In this case, everything was isolated. It was a country 
 farm residence, with no houses near, lieing built upon a farm of a con- 
 siderable number of acres. 
 
 In the other case, a young man, named J., aged 19, who lived about 
 9 miles from Lilydale (in the country), came in to consult nie, and 
 having ascertained clearly that his sickness was typhoid, I recommended 
 his removal to the hospital, where he was treated for such. I made 
 all inquiries, and found that he had not been to Lilydale, and that 
 when he left home it was to go in the opposite direction ; and as that 
 had been only once for a considerable time, he could vouch for the fact 
 that he had not met anyone, except to exchange a passing salutation. 
 The water this patient drank was in a somewhat similar condition to the 
 previous case, and the other sanitary conditions were very good. I 
 could come to no other conclusion than that which I arrived at in the 
 first case cited. 
 
 The next cases occurred in a family living 12 miles away from Lily- 
 dale. All enquiries led to the same results. Three of the family 
 contracted typhoid. They had not left their homes for some weeks 
 previously, and everything pointed to the domestic water as the primary 
 cause. 
 
 In the year 1885 a young fellow, W. B., aged 21, working at 
 Mitchell's lime kiln, took ill at his home and sent for me ; he developed 
 a typical case of typhoid. The house he was living in with his mother, 
 father, and brother, was fairly well drained. The water used for 
 domestic purposes seemed good, and as he had not mixed in any way 
 with people from Melbourne, or had been there on a visit, I could not 
 account for his contracting the fever, until I learnt he remead)ered that 
 some days previously, having felt thirsty after working hard on a hot 
 day, he had taken a drink from a stagnant pool of water in one of the 
 paddocks, which he pas.sed through on his way home.
 
 172 INTERCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 I saw this case early, and kept him well isolated, and used all pre- 
 cautions with the excreta, in which I was helped by his parents. His 
 brother, who was in the same house and used to nurse him, took the 
 fevei', and was sent to the hospital, but these were the only two cases 
 which occurred that year in Lilydale. 
 
 I took all possible care in collecting information and investigating 
 these cases, in all of which I was forced to come to the same conclusion. 
 
 What the constitution of the germ or poison is, I do not pretend to 
 state, but only that in the stagnation and decomposition of water a virus 
 is generated, which is capable of causing typhoid fever in the human 
 system. 
 
 It is noticeable that most cases arise after a drought, and the greater 
 the duration of that, the greater the number of sporadic cases. 
 
 Dr. Murchison held the opinion that typhoid fever was the result of 
 putrefaction, having called it pythogenetic, or fever born of putrescence. 
 If he would consider water in a state of stagnation, and consequent 
 decomposition, as putrescent, then the result of my investigations would 
 corresjiond with his. 
 
 It was for these reasons that in my re"[)ort to the Central Board of 
 Health I recommended the boiling and filtration of water, heat being 
 the best destroyer of the virus. 
 
 These precautions I had practised in Lilydale (by the residents), the 
 year following the epidemic, and I found that though a good number 
 of cases arose, not one occurred in which these precautions had been 
 taken with the water supply, and in those cases which arose, there was 
 total neglect of such ; in fact, disregard towax'ds the domestic su])ply of 
 water in country places is great, and it is not uncommon to find that 
 underground tanks have not been cleaned out for years. 
 
 In country districts investigations are more easily carried out, and 
 sporadic cases are far apart, giving greater facilities to glean informa- 
 tion, and all the attendant difficulties which arise in thickly populated 
 towns are lessened. 
 
 A NOTE ON THE INCUBATION PERIOD OF ENTERIC 
 
 EEVER. 
 
 By Jos. C. Verco, M.D. Lond. 
 
 Joint Lecturer ou Medicine at the University of Adelaide. Hon. Physician at the 
 Adelaide Hospital, &c. 
 
 The patient, a young man, was first seen by me in private practice 
 at his home on May 1st, 1888. He had come from Broken Hill, 
 N.S.W., the same day, where he had been ailing for about a week. He 
 was feverish. On May 4th he developed typhoid roseola, had an 
 unusually abundant eruption of spots in a few days, and passed without 
 unfavouraljle symptoms through a typical attack of enteric fever. 
 
 On the morning of May 17, one of the servant girls, who had been 
 complaining of headache and general malaise for a day or two, was seen. 
 Her temperature was normal, but she was sent to bed. At night, the 
 thermometer registered 100*4°, the next morning 101', in the evening 
 
 I
 
 NOTES ON TYPHOID FEVER. 173 
 
 101°, the following morning 100'4°, and in the afternoon above 102°. 
 On the 19th, she was sent to the Adelaide Hospital, where she developed 
 undoubted ty])hoid, with abundant spots, and with a continued fever, 
 lasting until June 7th, the first occasion on which the night temperature 
 was normal. 
 
 On May 21st, I saw the other servant girl, and learned that she began 
 to have headache on the 18th of May, followed by stiffness of the neck. 
 She was feverish, and was sent to the Adelaide Hospital on May 22nd, 
 where slie had an attack of enteric, the pyrexia disappearing at night 
 for the tirst time on June loth. 
 
 There had been no case of typhoid in this house since Dec. 1886, 
 sixteen months before. At that time, one of tlie sons came down from 
 Teetulpa Goldfields, where he had contracted the fever. Within three 
 weeks of the arrival of the patient from Broken Hill, both the servants 
 were aftc'cted. There can be very little doubt, therefore, that they con- 
 ti'acted the complaint from the recent arrival, and not from any germs 
 derived from the more remote case. 
 
 The usual precautions were taken, in reference to disinfection with 
 carbolic acid of all clothing and evacuations, but it appears that while 
 the nurses were at their breakfast, the serving girls relieved them at the 
 bedside, and watched the patient, and one of them had washed the 
 patient's linen after soaking in carbolic acid solution. But however 
 contracted, it certainly was communicated ; and so its contagious nature 
 is established, contraiy to the opinion of some. 
 
 The period of its incubation is, to some extent, fixed for us. Within 
 fifteen days from the entry of the patient into the house, the first girl 
 began to grow ill, and within seventeen days the second one. If, there- 
 fore, infection took place on the first day of his arrival, the incubation 
 period woiild only be a fortnight or sixteen days. It coitid not possibly 
 have been longer in these two cases. And inasmuch as it is not probable 
 they were infected quite so soon as the first day, the incubation period 
 for both of them was most likely under tiuo weeks. 
 
 NOTES ON TYPHOID FEVER. 
 
 By J. W. Springthorpe, M.A., M.D. Melb., M.R.C.P., Lond. 
 
 Physician to the Melbourne Hospital, Lecturer to the University of Melbourne ou 
 Therapeutics, Dietetics, and Hygiene. 
 
 The following is the statistical account of the cases of typhoid fever 
 under my care in the hospital during the past season ; — 
 
 No. of Cases. 
 
 Males. 1 Females. 1 Ages. Duration of Fever. Relapses. 
 
 Deaths. 
 
 Between 10 & 20-24 ) 
 84 62 22 „ 20 & 30-53 1 Average 26 clays 
 1 ., 80 & 40-7 ) 
 
 11 
 
 13 
 
 48 of the cases were admitted in January, February, and ]March, and 18 
 within the next three months. In 27 cases, constipation was marked ;
 
 174 IXTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 in 37, diavrlicea was severe ; in 16, the temperature rose above 105° 
 1 had four rehipses ; spots were found in about half the cases ; in 10, 
 haemorrhage occurred ; 6 had pneumonic attacks ; in 3, there was 
 peri-typhlitis ; in 3, thrombosis of the left leg ; in 6, perforation ; in 4, 
 pregnancy, the 2 in the early months aborting ; in 1, there was left 
 hemiplegia ; in 1, parotiditis ; and in 1, multiple pulmonary haemorrhage. 
 One had had a previous attack. The causes of death were — perforation 
 in 6, luemorrhage and exhaustion in 2, pulmonary complication in 3, 
 hyper-pyrexia and cardiac failure, each 1. Four cases were moribund on 
 admission. There is nothing new to add regarding treatment, except 
 that antipyrin, in single doses of 15 grains, was found very useful when 
 the temperature remained high after cold sponging and ordinary 
 diajihoretics, and that nepenthe (m. xv.) taken at night saved several lives, 
 when there was delirium and diarrhoea, the sncc. eucalypt. rostr. 3j being 
 a useful addition. 
 
 Regarding the incubation period. On several occasions, a crop of fresh 
 cases was noted in from two to three weeks after a rainfall. 
 
 As to diagnosis. — Difficulties were found in cases of tuberculosis, 
 tubercular meningitis, gastro-enteritis, and the gastro-intestinal form of 
 influenza. Cases of the three first were differentiated upon well 
 recognised general grounds. No doubt many cases are called typhoid, 
 esj^ecially amongst children, which are better classed under gastro- 
 enteritis. 
 
 An investigation into the influenza ejndemic has led me to the con- 
 clusion that there is a form of continued fever existent amongst us, 
 influenzal in origin, yet simulating typhoid fever in many particulars. 
 I have seen some dozen cases in which typhoid fever was so simulated, 
 and some three in which an exact diagnosis is open to dispute. At pi-esent 
 cases are coming into the hospital of an anomalous character, they are 
 iiot the ordinary typhoid ; my cases of such I can class as gastro- 
 intestinal forms of influenza. Some cases may be explained as true 
 typhoid supervening after an influenzal attack. Some have developed 
 an influenza sore throat after the typhoid has begun, but the majoiity 
 are quite distinct. The points in the differential diagnosis are as follows : — 
 In the influenzal class the incubation period is found to be short, the 
 onset sudden, the patient generally hepatic. There has been influenza 
 in the same house ; there is a history of an influenza attack in the 
 patient, and examination of the throat will show the naso-pharyngeal 
 catarrh, the sticky adherent mucus, the rounded hillocks, or the ulcers 
 or sloughs characteristic of the disease. There is pyrexia, like that of 
 typhoid in height and continuance, but generally coming down within 
 ten days. Profuse sweating from the outset, and marked prostration 
 are seldom if ever absent. Instead of the suffused heavy face, the 
 apathy, the delirium, the dry brown tongue, we have face and expression 
 natural, intellect unimpaired, tongue coated, and no epistaxis. There 
 are no spots or tympanitis. Constipation is present at first, possibly 
 with local pains, in some cases suggesting sub-acute rheumatism ; and 
 when diarrha'a occurs, the stools are those of milk diet, not " pea soup," 
 the light colour alternating with darker, the watery character being at 
 times rei)laced by the natural consistence. Some cases continue in- 
 definitely a puzzle to their attendants, and end in sloughing of the 
 mucous coat of portion of the alimentary canal, with or without the
 
 VARIATIOXS IN THE PATHOLOGICAL PROCESS 1\ TVPIIOII) FEVER. 175 
 
 supoi-vention of pulmonary oi- intestinal tuljeicular miscliief. In the 
 mikler cases, however, the after history is further evidence of their non- 
 typhoid character. The jiatient can he got up and placed on ordinary 
 diet at a time when the attemjit would have almost inevitably produced 
 a relapse in an ordinary typhoid case. Finally, cases of this sort were 
 noticed and satisfactorily accounted for at a time when the onus of proof 
 was, not to prove the case non-typhoid in character, but the reverse. 
 During December, however, many fresh cases have arisen, wlierein the 
 onus has been to prove them non-typhoid ; and by applying the 
 differential diagnosis already arrived at, a separation of cases has been 
 possible, and one wliich, in my judgment, is based upon a real ditference 
 in etiology and pathology. The nature of the lesion, and its viodus 
 openoidi in typhoid fever, are known to all ; the lesion and substratum 
 of intluenza are discussed in another jiaper. 
 
 XOTES ON VARIATIONS IN THE PATHOLOGICAL 
 PROCESS IN TYPHOID FEVER. 
 
 By H. B. Allex, M.D. 
 
 Professor of Auatomy and Pathology in the University of Melbourne. 
 
 The incubation of typhoid fever is sometimes accompanied by intense 
 depression, the pulse being abnormally slow and very compressible. 
 This depression may pass off, to some extent, with the development of 
 the fever, but it sometimes persists, and must largely govern the 
 treatment. Even when strongly marked, it is not necessarily followed 
 by a severe attack. 
 
 The usual insidious commencement of typhoid is sometimes replaced 
 by a sudden onset, with vomiting and purging, and other symptoms of 
 gastro-intestinal irritation, so that the case may resemble one of irritant 
 poisoning. The precise cause of these phenomena is not, so far as I am 
 aware, clearly ascertained. 
 
 In some cases, the fever runs a short typical course. Probably the 
 swollen follicles of the agminated glands slough separately, the patches 
 ac(juiring a finely-pitted appeai'ance (^plaqties a surface reticulee), and 
 rapidly healing. In other cases, after death, patches are found in all 
 stages, some ulcers being thoroughly cleaned, with bases formed by the 
 circular muscular fibres ; others, higher up the bowel, being coated 
 with sloughs in jn-ocess of separation ; while others are still swollen and 
 purple. These are not cases of relapse, properly so-called, but of 
 successive poisoning of separate patches. They are found in most 
 patients who die after prolonged fever. I believe that a dose of calomel, 
 given during the first week, before the sloughs are fully formed, does 
 much to prevent this successive invasion of patches. 
 
 In the pathological theatre, the varying extent of ulceration is very 
 striking. There may be but a single ulcer ; yet this may be deep, may 
 be accompanied with liigli fever, and may finally undergo perforation. 
 On the other hand, the agminated glands may be very generally
 
 176 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 affected ; and when a large surface is thus implicated, although the 
 patches are simply tumid and angry red, the shock to the system may, 
 in some degree, resemble that of an extensive burn. The solitary glands 
 are sometimes little affected when Peyer's patches are deeply ulcerated. 
 
 The intensity of the intestinal lesion is even more variable. In fatal 
 cases, there may be nothing more than intumescence and pitting of a 
 number of patches. But, at the other extreme, there may be rapid and 
 great swelling of the solitary and agminated glands, followed by deep 
 .sloughing. The inflammatory accumulation of cells iii the lymphoid 
 tissues may not be limited to the follicles, but may be general through- 
 out the mucous membrane of the affected area. Such general tumefaction 
 is, I believe, an occurrence of very grave import. When the intestinal 
 lesions develope in this rapid intense fashion, the mesenteric glands also 
 become so choked by aggregation of leucocytes, that caseous infarction 
 may ensue. This acute infarction differs gi eatly from the slower, more 
 bloodless caseation seen in tubercular processes. In other rarer cases, 
 the mesenteric glands undergo suppuration or sloughing. 
 
 The perforations which occur in the agminated glands are of two 
 kinds — fii'stly, there is the pin-hole ])erforation, a minute rounded 
 aperture at the bottom of a shelving ulcer ; and secondly, larger, more 
 irregular perforations following sloughing of the floor of the ulcers. The 
 pin-hole perforation results from the depth of the original sloughing ; 
 it seldom occurs in more than one patch. The large perforations are 
 not due to the separation of the primary sloughs, and to molecular 
 changes consequent thereupon, but to later processes of secondary 
 sloughing, probably induced by the ingestion of biscuits, apples, or other 
 improper articles of diet. The pin-hole perforation, therefore, forms 
 much more slowly ; it is not preceded by marked symptoms of iriitation ; 
 the intestinal contents cannot esca])e so freely into the peritoneal cavity, 
 and what little does escape is sometimes encapsuled by inflammatory 
 adhesions. Perforation due to secondary sloughing is not infrequently 
 multiple. These points have a bearing on the possibility of surgical 
 interference. 
 
 The degree, in which the large intestine is implicated, varies greatly. 
 In some cases, the large bowel escapes altogether ; in others, the lesions 
 are confined to the caicum ; in others, they extend throughout part or 
 all of the colon, even into the rectum. In certain cases, I have found 
 death caused by hremorrhage from ulcers in the ciecum or colon. The 
 vermiform appendix is often affected, as might be expected, seeing that 
 its inner surface is lined throughout with lymphoid follicles ; the lesions 
 are usually limited to swelling and pitting, but I have known perforation 
 to occur. 
 
 Clinically, relapses vary greatly ; sometimes there is a re-accession of 
 fever for a few days, with evening exacerbations ; sometimes a complete, 
 though short, re])etition of the attack. Between these extremes, various 
 intermediate forms occur. So also, pathologically, in relapses which prove 
 fatal, the morbid apjoeai-ances display great diversity. In many cases, 
 the ulcers in Peyer's patches, near the ileo-ctecal valve, will be found in 
 various stages of cicatrisation, with pigmentary deposit in the edges, 
 while patches further removed will be intumescent, or finely pitted, or 
 sloughing. Sometimes patches will be found, only part of which 
 suffered in the first attack, the resulting ulcer being clean based, with
 
 VARIATIONS IN THE PATHOLOGICAL PKOCESS IN TYPHOID FEVER. 177 
 
 shelving,' edges, and having ])erliiips transgressed the lateral limits of the 
 agniinated gland ; while in the relai)se, the remainder of the gland suffers, 
 being found swollen, with the slough still adherent. 8uch cases offer 
 the most striking illustrations of the well-known fact, that the lymphoid 
 follicles, in different parts of the small intestine, suffer very unequally. 
 Sometimes the large intestine escapes in the first attack, hut in the 
 relapse, when the ileum is jierhaps little affected, the whole length of 
 the colon is studded with tumid or sloughing solitary glands. It is well 
 known that typical relapses seldom prove fatal. The fatal relapses, to 
 which I have referred, were mostly cases of re-accession of the disease 
 during the healing of the ulcers of the fii-st attack. Not seldom, the 
 history of the first attack was very obscure. A phenomenon, which has 
 not excited much attention, is late sloughing, occurring long after all 
 ordinary sloughs have separated, and at a time perhaps when the ulcers 
 are in varied stages of cicatrisation. These late sloughs may be far 
 removed fiom the original ulcers. Thus I have seen large patches of 
 sloughing, affecting all the coats of the jejunum, within a few inches of 
 the duodenum ; 1 have seen sloughs in the splenic and in the sigmoid 
 flexures of the colon. Some of these ajtpear to be neurasthenic ; others 
 commence in ha^morrhagic erosion. I incline, therefoi'e, to connect 
 some of these late sloughs in point of causation with other still later 
 ])henomena, which may occur during imperfect convalescence, such as 
 necrosis of ribs, progressive dilatation of the heart, &c. These occasional 
 evils, which snatch patients away when the grave dangers appear past, 
 serve as a warning, that typhoid patients need watchful care for a con- 
 siderable time after apparent complete recovery. When neurasthenia 
 persists, the patient should be watched closely, for extensive lesions may 
 develop very insidiously. 
 
 IlajmorrhagH from the intestine, daring typhoid fever, mav be due to 
 oozing from distended capillaries over a considerable surface, or to 
 oozing from the angry edges and bases of ulcers, or to the opening of a 
 considerable A'essel by sloughing. In some cases there is a distinct 
 tendency to haemorrhage, evidenced not only by copious early epistaxis, 
 but by jjulmonai-y congestions, running on into hsemorrhage. In some 
 such cases, intestinal hsemorrhage is followed by distinct improvement. 
 The haemorrhages resulting from high vascular tension must be 
 distinguished from those due to depraved condition of blood, as in 
 ])urpura. 
 
 Tubercular infection of typhoid ulcers has not received much notice ; 
 yet in certain years I have found several cases. Mistakes in diagnosis 
 of such lesions can easily be made. Typhoid iilcers are frequently, in 
 cases which have lasted five or six weeks, wider transversely than 
 longitudinally; but this does not imply tubercular infection. Minute 
 patches and tags of fibrin may be found on the serous surface, opi)osite 
 deep idcers, and may be mistaken for tubercles. Acute caseation of 
 mesenteric glands in the early stage of fever should be distinguished 
 from tubercular changes. Well-marked secondary local tuberculosis 
 usually occurs late in the course of the fever. Many ulcers will present 
 the characters typical of typhoid ; but some, near the valve, will have 
 somewhat thickened bases, and in the sub-peritoneal tissue opposite 
 there will be distinct grey grains, and perhaps lines of similar grains 
 running to the mesentei-ic edge. The nearest mesenteric glands may 
 
 N
 
 178 INTERCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 present patches of caseation, and, at the edges of the cheesy areas, 
 tubercles may be indistinctly visible. But, much more rarely, distinct 
 tubercles will be seen on the peritoneal surface, opposite ulcers from 
 which thick sloughs are only commencing to separate. I have never 
 seen any generalisation of such tuberculosis in the peritoneum. In 
 some cases of secondary tubei-cular infection during typhoid, I have 
 found old encapsuled cheesy matter elsewhere in the body ; but in other 
 cases, no traces of old tubercular processes were ]iresent, and the patients 
 had been pi-eviously robust. Doubtless, the bacilli of tubercle are widely 
 disseminated in the atmosphere. We must frequently inhale and 
 swallow them. The issue depends largely on the presence or absence of 
 a prepared culture bed. 
 
 I am of opinion, rightly or wrongly, that too much has been made of 
 typhoid fever as inducing subsequent phthisis. I fancy that in many 
 cases in which phthisis has been said to follow typhoid, the mischief has 
 been purely tubercular from the outset. Cases of pulmonary tuber- 
 culosis, which begin acutely, not infrequently mimic typhoid. The 
 occurrence of sweats, without corres|)onding fall of temperature, is 
 sometimes a notable diagnostic symptom. But the appearance of the 
 patient ma}' be sufficiently characteristic. 
 
 Endocarditis is a possible complication of tyjthoid, which may easily 
 be overlooked, with evil results to the patient. Cardiac thrombosis now 
 and then occurs, with embolism in the spleen or elsewhere. Thrombosis 
 of the iliac veins, wuth phlegmasia, is more frequent. I may pass by 
 the familiar pneumonia, and barely mention the occasional occurrence 
 of pyaemia, tetanus, tfec. 
 
 No matter how severe the head symptoms attending typhoid may be, 
 even though wild delirium occur, instead of low muttering, meningitis is 
 not found. It is an extremely rare complication of typhoid fever. 
 Yet, in certain seasons, head symptoms have been so ]>rominent, that 
 jihysicians have called the disease " nervous fever," as distinguished 
 from typhoid. 
 
 I have often thought that man}^ cases of typhoid are complicated witli 
 septicasmic ])oisoning, by absorption of soluble poisonous substances 
 from the foul contents of the intestine. Still more is it borne in u]ion 
 me, that a degree of urajmia is often present ; there is rapid destruction 
 of muscular tissue, while the kidneys are more or less unfitted to 
 discharge their full functions, by reason of the febrile state. This may 
 explain why so many strong muscular subjects die; while slighter, more 
 delicate, patients recover. 
 
 It is with some hesitation that I have ])laced these scattered notes 
 before you. There is little that is new in them, as may be seen by 
 comparing them with the masterly descriptions given by the late Hilton 
 Fagge in his " Principles and Practice of Medicine." But I have not 
 mentioned, even incidentally, a variety or a complication of the morbid 
 process which I have not seen, and this must be my excuse for occupying 
 your attention.
 
 THE COLD BATH TREATMENT OF TYPHOID FEVER. 179 
 
 THE COLD BATH TREATMENT OF TYPHOID FEVER. 
 By F. E. Hare, M.B. 
 
 Ecsident Medical Officer, Brisbane Hosjjital. 
 
 Although the treatment of tyjihoid by cold bathing has been fre- 
 quently and powerfully advocated on the Continent, it does not seem 
 to have gained many supporters in England or the colonies. The reason 
 for this is not far to seek. The bath has been regarded as a heroic 
 remedy, justifiable only in desperate cases; whereas the very essence of 
 the treatment lies in the fact that it is above all a prophylactic against 
 the effects of continued pyrexia, and not a curative proceeding in the 
 ordinary sense of the term. Regarded from this standpoint, it may be 
 said to be absolutely free from risk of any kind. 
 
 Holding such views, I began the treatment at the Bvisl>ane Hospital. 
 Through the indulgence of the visiting staff, to whose kindness I am 
 much indebted, I was enabled to put every patient, who was admitted 
 on or after a certain date, upon a systematic course of cold bathing, very 
 similar to that recommended by Brand. 
 
 I will first briefly describe the treatment in a case of ordinary severity. 
 Should the patient not have reached the eighth day of fever, the 
 bowels are freely moved by castor oil, or some other unirritating purga- 
 tive. He is then put upon the ordinary diet of beef tea and milk, 
 administered in regular quantities at regular intervals, with an unlimited 
 sujjply of iced water to drink. 
 
 Brand's rule is observed in bathing, i.e., the temperature is taken in 
 the rectum every three hours, day and night, and whenever it reaches 
 102"2° F., a bath of about the temperature of 70° F. is given. The first 
 does not exceed ten minutes in duration for an adult. The temperature 
 is not taken while the patient is in the bath, but half-an-hour after its 
 termination, and always in the rectum. The fall should be to 101°, or 
 lower. Should this not be approximately attained, the next bath two 
 and half hours later is prolonged by about five minutes, and so on. 
 It is rarely necessary to continue the immersion for more than half-an- 
 hour. If this be insuflBcient, the tem])erature of the bath water is 
 lowered to G5°, or even 60° F. In most instances, the temperature only 
 just reaches its former level by the time the next bath is due, but in a 
 few, it rises with great ra])idity, attaining its maximum in an hour and 
 a half, or sooner. Here the frequency of the baths is increased, so that 
 as many as twelve in the twenty-four hours may be given. Stimulants 
 if required are given before the bath, and nourishment half an hour 
 after its termination, when the fail of temperature is being noted. The 
 interval is wholly devoted to sleep. 
 
 In ordinary imcomplicated cases, this treatment is carried out strictly 
 from the day of admission, until such time as the temperature ceases to 
 rise to 102 "2° F. The approach of convalescence is seen in the gradually 
 diminishing number of baths, so that usually for seme days before they 
 cease, one in the afternoon or evening is all that has been required. 
 
 Nervous dread of the bath is the most common difficulty met with. 
 Generally, this ceases after a few immersions, but sometimes it persists, 
 or even increases. Such cases are always benefited by a stimulant, just 
 
 N 2
 
 180 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 before the bath ; but the addition to this of a small quantity of morphia 
 is almost invariably successful. I have seen a patient who had a horror 
 of the bath thoroughly enjoy it after an eighth of a grain of morphia. 
 Cases marked by persistent high temperature early in the attack, 
 before signs of failure have appeared, rarely show any nervousness about 
 bathing, a most fortunate fact, for such cases are precisely those who 
 derive most benefit from it. The only absolute contra-indications are 
 jDerforation, haemorrhage, and advanced cardiac debility. The two 
 former, of course, require perfect rest ; the latter precludes anything in 
 the nature of shock. 
 
 Although the temperature is taken as the best indication for regulating 
 the number and duration of the baths, yet almost all the other symptoms 
 are as favourably modified. 
 
 Circulatory System. 
 
 Coincident with the fall of temperature, the pulse iliminishes in 
 frequency, often by twenty or more beats a minute, and at the same 
 time it becomes smaller, hai'der and more sustained, indicating a general 
 I'ise in blood pressure. Sometimes, indeed, this vaso-constriction is 
 excessive — the pnlse, though reduced in frequency, becoming thready, 
 the face and extremities blue. These symptoms need cause no alarm. 
 They are, if anything, of favoui'able import, and can alwaj's be relieved 
 by small doses of alcohol, which here is probably effective in virtue of 
 its action as a vaso-dilator. 
 
 In most cases of any duration, a certain amount of cardiac debility 
 gradually appears, as shown by the increasing frequency of the pulse in 
 proportion to the temperature. In those, however, that have been sys- 
 tematically bathed from an early date, it is unusual for this symptom to 
 I'each any degree of severity. But occasionally, in spite of the ti'eatment, 
 it continues to increase, and it then becomes no easy matter to 
 discriminate at what point the benefits of the bath are more than 
 balanced by its danger. In cases of doubt, the following plan is often 
 of great advantage : — A single dose of from 30 to 40 grs. of quinine is 
 given about ten p.m. This will usually cause a fall of temperature, 
 lasting from twelve to thirty-six hours, during which time of course the 
 patient will have a complete rest from the baths. Its effect on the 
 pulse is to reduce its rate, and increase its force. 
 
 That this tonic or stimulant action on the circulation is to a great 
 extent independent of its action as an antipyretic, is usually very 
 evident. For, in a few cases, although the drug fails to reduce the 
 temperature appreciably, the pulse is almost invariably slowed and 
 strengthened ; and in the majority, where the pulse and temperature 
 fall together, the former continues slower long after the latter has risen 
 to its former height. 
 
 Other antijiyretic drugs, such as antipyrin, antifebrin, the salicylates, 
 &c., have not, according to my experience, this power of increasing the 
 force of the circulation, but have seemed to act unfavourably in the 
 opposite direction. The rapidity of their action (which is no gain where 
 the bath system is used), is quite counterbalanced by the evanescence of 
 their effects. 
 
 I should Jicre say that, except in the cases already mentioned, the 
 condition of the circulation, as evidenced by the heart sounds, and more
 
 THE COLD BATH TKEATMEXT OP TYPHOID FEVER. 181 
 
 especially by the frequency of the pulse, is regarded as the only 
 indication for stimulants. Murchison's rule is for the most part 
 adhered to, although the limit of twelve ozs. of brandy per diem — 
 beyond which he considered it useless to go — is frequently much 
 exceeded in l):i(l cases. 
 
 Respiratory System. 
 
 Bathing modifies the respiratory act in a similar way to the pulse, 
 but to a less extent. When the short, catchy breathing, due to the 
 shock of immersion, has passed off, the respirations become slower and 
 deepQr. If bronchial catarrh is present, cough is invariable, and 
 sometimes violent. This is most beneficial ; and in consequence, it is 
 found that soon after the couniiencement of the treatment, the patient 
 coughs only during the bath, although [)reviously he may have been 
 troubled with constant and ineffectual efforts to clear the bronchial tubes. 
 The i)eriodic clearing of the air {)as.sages prevents plugging and 
 collapse, and the consequent gradual development of broncho-pneumonia. 
 No fact is more firmly established about this treatment, than its power 
 to prevent this complication. 
 
 Whether it is advisable to continue cold bathing when ])neumonia is 
 actually present, will depend altogether upon the condition of the 
 circulation. In my experience, more or less cardiac feebleness almost 
 always co-exists, and this I believe to be the best guide, without taking 
 into considei'ation the condition of the lungs. Rarely a pneumonia, 
 usually lobar in form, complicates, or even masks, the beginning of 
 typhoid. It may then be unattended by any degree of cardiac debility, 
 and is decidedly benefited by the bath treatment. On the other hand, 
 the usual form of pneumonia, which appears in the later stages 
 of the disease, is lobular or hypostatic. Ic is then probably 
 one of the immediate results of failing circulation, and when it occurs 
 in cases that have been bathed, should in my opinion be accepted as 
 an indication that the treatment has failed, at any rate, in its i)rimary 
 object, viz., that of preventing cardiac debility. If under these 
 circumstances baths are still considered advisable, they should be tepid 
 or graduated, so as avoid all shock. 
 
 Nervous System. 
 
 Nervous symi)toms are probably more favourably influenced than any 
 others. Delirium and stupor frequently disappear in the first bath, 
 almost always after the first few days' treatment. Headache is always 
 relieved, but returns with the rise of temperature. Sometimes the 
 immediate result of the bath is to increase the pain, but this can always 
 be avoided, by sponging the head with ice cold water before the rest of 
 the body is immersed. 
 
 Insomnia is almost unknown. Most patients require to be waked for 
 their baths, and I would here say that, although such frequent dis- 
 turbance may seem cruel, the aggregate of sleep that such patients obtain 
 is far greater than in those treated in the ordinary way. The density of 
 the sleeji, if I may use the expression, is greatest shortly after the bath, 
 and gradually decreases as the temperature rises.
 
 182 ixtekcolonial medical congress of australasia. 
 
 Alimentary Canal. 
 
 Symptoms having reference to the alimentary canal are all more or 
 less modified; sordes rarely appears. Tlie dry brown tongue, when it is 
 seen at all, becomes moist after each bath ; thirst is consequently 
 lessened and appetite improved, and herein lies the great advantage of 
 always giving food at this time. So great is the influence of the bath 
 in this direction, that one may often see a dry Ijrown tongue put in its 
 first appearance during early convalescence, when, from the falling 
 temperature, it has become unnecessary to continue the treatment. 
 Although it may not be permissible to judge of the condition of the 
 gastric mucous membrane by that of the tongue, yet it is certain that 
 digestion in the stomach is much improved. Vomiting is rare, and the 
 appeai-ance of undigested milk in the stools quite exceptional. 
 
 Diarrhoea, if it exists on admission, often appears at first sight to be 
 increased. The application of cold to the abdomen causes contraction of 
 the muscular fibres of the intestine, so that for some time a patient may 
 have an evacuation after each bath. This, however, soon ceases. It 
 has been said that external cold, by contracting the cutaneous vessels, 
 must cause an increased congestion of internal organs, and among them 
 of the mucous coat of the intestines. This has Ijeen disproved by actual 
 experiment, but were it not so, the fact remains that the constant 
 application of cold to the abdomen, preferably in the form of ice bags, 
 has a marked influence in restraining diarrhoea, and presumably therefore, 
 in diminishing the congestion on which it depends. 
 
 The constrictive action of cold on the intestinal muscle is most useful 
 in lessening meteorism. As the flatus is mostly contained in the large 
 intestine, the efiect is usually immediate, the patient passing large 
 quantities of wind during or immediately after each bath. Ice bags 
 applied to the abdomen in the interim keep up a tonic contraction of the 
 gut, and serve to prevent the reaccumulation of the gas. Haemorrhage, 
 as before mentioned, precludes bathing. Ice bags should be applied 
 locally, and are in fact in general use. Whether this accident has been 
 rendered more or less frequent by the cold bath system, has been much 
 debated. My own figures tend to the conclusion that it is absolutely 
 uninfluenced either way. 
 
 The same i-emarks apply to ])erforation, which, as the mortality 
 statistics show, carries off almost exactly the same number of patients 
 whatever treatment be adopted. There is, however, an interesting fact 
 in connection with the diagnosis of perforation which is worthy of note, 
 as it bears additional evidence to the rarity of brain symptoms. Since 
 the introduction of systematic bathing, there has been no instance where 
 it has not been possible to tell almost the exact moment when this 
 accident occurred. This is in striking contrast to what was observed 
 previously. Low forms of delirium and stupor were common, and it 
 was not rare to find perforative peritonitis post-mortem, Avhich had been 
 unsus])ected during life. 
 
 Urinary System. 
 The effect of bathing on the urinary secretion, is greatly to increase 
 its quantity and to lower its specific gravity. The total amount of urea 
 passed is said to be reduced, and this is attributed to diminished febrile 
 consumption of the tissues.
 
 THE COLD BATH TREATMENT OF TYPHOID FEVEH. 183 
 
 Upon this point, liowever, I have no data of my own, and the state- 
 ments of other observers are conflicting. Recently, indeed, ex]ieriments 
 have been cited, which tend to show tliat the excretion of urea is 
 increased by cold bathing ; and Dr. Macalister suggests that this is not 
 due to increased production, but rather to more perfect elimination. 
 
 If albumen be present in small quantities, as often happens in severe 
 cases, in connection with a .scanty secretion of high coloured urine, a 
 day or two of the treatment is usually sufficient to cause its disappear- 
 ance. The action of the bath, in causing prof use diuresis, contrasts ^"ery 
 favourably with that of the antipyretic drugs, none of which increase 
 the secretion of the urine. Some, indeed, notably anti})yrin, have been 
 shown to actually diminish it. My own experience is, that they all act 
 as powerful diaphoretics, and herein lies one of the great advantages 
 of the bath ; for, as has been duly remarked, the sweat glands, as organs 
 of <'limination, cannot be compared to the kidneys. 
 
 Such, then, is a brief account of the manner in which the cold bath 
 treatment modifies the principal symptoms of fever. It is no exaggera- 
 tion to say, that typhoid so treated is in its main clinical features a 
 ditl'erent disease, and as such merits a separate description. Instead of 
 the long catalogue of complications, with pneumonia at their head, that 
 wei-e liable to arise in any case of severity, it can be truly said that, 
 given a case admitted fairly early in the disease, one has little to fear, 
 except the occurrence of one of the accidents — haemorrhage or perfora- 
 tion. 
 
 Before estimating the mortality, some explanation is required. 
 
 During the year 1886, the bath was used in only one or two cases. 
 The treatment was mainly ex]iectant, but cold sponging, the cold wet 
 .sheet, and quinine in antipyretic doses, were frequently employed, 
 together with alcohol, according to the usual indications. In 
 1887, every case that was admitted on and after January 1st, Avas 
 systematically bathed; unless, of course, this was contra-indicated. Owing, 
 however, to the fact that there was then only one bath, and the wards 
 were quite full, the bathing, though regular, was infrequent. Many 
 patients who would later on have had six or eight baths a day, had then 
 only three or four. It was not until July that arrangements were suffi- 
 ciently advanced to allow of Brand's rule being strictly adhered to. 
 
 I propose, however, to compare the mortality of 1886 with that of the 
 following eighteen months, ending June 30th, 1888, the latter being 
 the whole j^eriod during which the bath has been in systematic use. 
 In doing this, I have made an endeavour to eliminate one common 
 source of fallacy in fever statistics. I allude to the variable number 
 of cases of febricula included. No two men are agreed as to 
 where to draw the line between this afTection and ty])hoid. I have 
 accordingly adopted an arbitrary rule, and classed as febricula all cases 
 of continued fever that convalesced before the tenth day. 78 such cases, 
 or 14| per cent, of the whole, are excluded from the first period ; and 73, or 
 15 per cent, of the whole, from the second ^Nlost of these were, in my 
 opinion, typhoid, and many were bathed. The\' all, of course, recovered. 
 
 In the first ])eriod then, there were 464 cases, with 68 deaths — a 
 mortality of 14-6 })er cent. 
 
 In the second, 415 cases, with 41 deaths — a mortality of 9-8 per cent. 
 So that during the time that the bath was in use, the mortality fell
 
 184 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 nearly 5 per cent. If, however, we take the twelve months, from July 1st 
 1887, to June 30th, 1888, during which Brand's treatment was rigidly 
 enforced, we find better results. Of 243 cases, 20 died-^— a mortality of 
 8 '2 per cent. This shows a reduction of mortality, as compared with 
 1886, of 6-4 i^er cent. 
 
 These figures appear to me sufficiently favourable, but to give them 
 their full weight, the following considerations must be borne in mind : — 
 (1) That a very large proportion of the cases were immigrants just 
 arrived in the colony, and unacclimatised. Tliis is admittedly an 
 unfavourable element in the prognosis. (2) That the Brisbane Hospital 
 is the only one for a large and scattei'ed district ; that the cases there- 
 fore are not selected, except in so far that the worst generally find their 
 way in. (3) While an unusually large proportion of febriculte (15 jter 
 cent.) are excluded, that on the other hand, every death from typhoid, which 
 occurred in the hospital during the time, is included, though many were 
 moribund on admission, and others succumbed from causes only indirectly 
 due to the disease. 
 
 Thus of the 41 deaths during the bath period, five died in less than 
 48 hours from admission; and six, who came in later in the disease than 
 the fourth week, were in such an advanced state of prostration, that cold 
 bathing was considered inadmissible ; whilst, among the exceptional 
 causesof death were — hyemorrhage from abortion; hyper-pyrexia following 
 an ineffectual attempt to pass a catheter on a case of tight stricture 
 during early convalescence ; old fatty heart ; and acute cystitis during 
 convalescence — one case of each. I do not think these results can be 
 explained on the hypothesis, that the type of the disease was milder. 
 
 The average duration of cases that recovered was almost identical in 
 both periods, viz., 23'1 days in the first, 23-2 in the second, and nearly 
 the same proportion of febriculte were excluded upon each, i-ather more 
 in fact from the second. Moreover, a strong argument in favour of the 
 identity of the type of the disease in the two periods, is found on 
 analysing the modes of death. 
 
 Of the 14-6 mortality in 1886, 5*2 per cent, of all the cases died from 
 hoemorrhage or perforation. During the bathing period, of the 9-8 per 
 cent, mortality, perforation and haemorrhage accounted for 5-5. It is 
 evident, therefore, that the accidents due to the intestinal ulceration 
 were absolutely unaffected, and that the whole saving was in the 
 diminished number of deaths due to febrile causes. Exactly the same 
 conclusions were arrived at by Drs. Cayley and Coupland, at the 
 Middlesex Hospital. These observers contrasted the results obtained, 
 during the period from 1872-78 inclusive, with those of the 
 following five yeai-s, during which the antipyretic treatment was 
 practised. By comparing the total number of cases under treatment, 
 they found that the rate per cent, of deaths from hajmorrhage and 
 perforation was almost exactly the same in the two series, showing that 
 there was a diminution of the other causes, but no inci'ease of these 
 complications. 
 
 Again, since of these two accidents, perforation claims many more 
 victims than haemorrhage, and as it is an established fact, that the former 
 is far more common in men than women, we should expect to find the 
 female mortality more favourably affected than the male — and this has 
 been the case to a marked degree. In the fii'st period, the male mortality
 
 ox -n'PlIOID FEVER AXD ITS TREATMEXT. 185 
 
 was 12-G per cent, the feinalo lS-9. In the second, the male 12-2, the 
 female O"!. On analysing the causes of death, this result is found to be 
 entirely due to the coin])arative immunity of women from perforation. 
 I should here say that in the 109 fatal cases, the immediate cause of 
 death was verified by post-mortem examination in all but live. 
 
 I have hitherto avoided discussing the rationale of the bath treatment. 
 Its original introduction into Germany was the practical outcome of the 
 theory, that the temperature was the immediate cause of most of the 
 symptoms and complications of the disease. Of late years, the truth of 
 this has been much questioned, and yet those who are foremost in 
 attacking the doctrine, admit that cold baths deserve the first place 
 among the thei-apeutics of fevei'. Quite recently Dr. Macalister, in his 
 Ci'oonian Lectures on Anti})yi-etics, recalls the theory of Murchison, 
 that most of the phenomena of the typhoid state are urtenuc in origin, 
 and suggests that the benefit of the cold bath is due to its powerful 
 diuretic action, causing free elimination of accumulated waste nitrogenous 
 products. The beneficial action of cold bathing can be undei'stood on this 
 hypothesis, as well as on the other, and it is jjrobable there is much 
 truth in both. But neither are sufficient. Delirium and stupor 
 occasionally clear up too rapidly to be accounted for, either by reduction 
 of tempei-ature, or improvement in the composition of the blood, so that 
 it is evident that any theory, to be complete, must include a more direct 
 action on the central nervous system. All these, however, are questions 
 for ]iathologists to decide. Fortunately, the success of the treatment is 
 not dependent on their correct solution, but rests at the present day 
 upon a vast accumulation of clinical facts. 
 
 In conclusion, I must allude to a recent valuable monogra})h on the 
 subject, by MM. Tripier and Bonveret, of Lyons, which all who are 
 interested in this method of treatment should read. In this work, the 
 whole question is treated with such minute attention to clinical detail, 
 that I regret it did not fall into my hands until the latter part of 1887, 
 when the system was fairly well established. Otherwise, much needless 
 trouble and anxiety on my part might have been avoided. 
 
 XOTES ON TYPHOID AND ITS TREATMENT. 
 
 By F. H. BoNXEFix, L.R.C.P., Stockton, Newcastle, N.8.W. 
 
 In tlie present state of medical science, we must confess that know- 
 ledge about the etiology and treatment of typhoid fever is still very 
 imperfect. For whilst some hold that typhoid fever (or better, enteric 
 fever) is a specific disease, produced by a bacillus or its spores, and that 
 the disease cannot arise de novo ; others assert that, though the disease 
 is due to micro-organisms, yet it can arise de novi by the transformation 
 of ordinary bacilli into a virulent variety. There is still another sect 
 who hold that enteric fever may, undoul)tedly, arise from deconq)Osing 
 animal matter, placed under certain conditions of heat and moisture. 
 All the above theories tend to .show that the subject is far from l)eing 
 settled, and therefoi'e, anyone holding views on the subject, not incon- 
 sistent with reason, and arrived at by scientific deductions, may claim
 
 186 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 also to have a hearing. AV^hatever may be the cause of typhoid, all 
 agree on the pathological lesions, which are characteristic. In all cases 
 the small intestine is affected, but more specially the glandular structures 
 known as Peyer's patches, and the solitary glands. In them, we may 
 find .simple inflammation, or proceeding one step further, necrosis of the 
 tissues and iilceration. The real use of Peyer's patches and solitary 
 glands has not yet been cleai'ly defined, and when this is perfectly 
 demonstrated, I am certain that a very great step will have been made 
 towards the knowledge of the disease. 
 
 I will now briefly state my views, ho])ing that by inducing criticism, 
 more thought and discussion may be excited on a subject of vital 
 importance in these colonies. I have always thought that enteric fever 
 was symptomatic, and not idiopathic. A good many of the fevers, which 
 were formerly classed under the heading of idiopathic fevers, have, in 
 the light of more recent knowledge, been proved to be pyrexiie, caused 
 by acute inflammation in some part of the organism. Why, therefore, 
 should we not consider enteric fever as a pyrexia, caused by in- 
 flammation of certain specified structures of the body, to wit, Peyer's 
 patches and the solitary glands. It is certain to be objected, that the 
 height of tlie pyrexia has been proved not to depend absolutely on the 
 amount of the lesions observed. But it may very well be in direct 
 proportion to the absorption of inflammatory or septic products ; and 
 knowing that the implicated structures are in direct communication 
 with large lymph spaces, is there any wonder that absorption is simply 
 regulated by the blocking oi- patency of such spaces 1 
 
 The rise and fall of temperature is ver}' often typical, and we may 
 understand why it is more so in this than in other fevers, if we bear in 
 mind that absorption is generally more active when the circulation 
 is more rapid, and this is more the case with lymphoid structures and 
 lymphatics generally, than with any other tissue or organs in the body. 
 The morning temperature of enteric is generally lower, because the 
 circulation at night is slower, and therefore the absorption of inflamma- 
 tory or septic products is less. In that way, the tem})erature gradually 
 falls during the night, and again rises during the day. It is generally 
 considered as a bad sign, when the morning temperature is not lower 
 than it was the previous evening ; this shows, either the patient has 
 been sleepless, or has had very troubled sleep, and so, the absor})tion 
 going on uniformly, the intensity of the malady is increased. 
 
 It is on the foregoing assum])tions that I have based my treatment of 
 enteric. What I wanted to use was some medicinal agent, which could 
 at the same time slacken the circulation, cause elimination of efl'ete and 
 noxious substances, disinfect the contents of the bowels, promote the 
 healing of ulcers, or check inflammation, without causing distressing 
 symptoms, as very often is the case with quinine and salicylic acid. I 
 need not give in detail my difi"erent trials in this direction, but will simply 
 state that, since the second part of 1887, I have used the following ; — I 
 give a mixture of naphthalin and antifebrin (gr. vi.-viii. of each), three 
 or four times a day, according to the urgency of symptoms. Should 
 there be consti[)ation, I get the bowels moved at least once a day by 
 means of a simple enema, or one containing a little starch, soap, or 
 castor oil. I draw special attention to this measure, for I have found 
 naphthalin of little use xuiless the bowels are moved, so as to allow of
 
 ON TYPHOID FEVER AND ITS TREATMENT. 187 
 
 the local eftect of the drug. Intense diarrhoea also must be checked, as 
 it does not allow the naphthalin to act beneficially. I ordei' such diet 
 as will not produce much faecal matter, or form any solid or irritating 
 material ; so I prefer a mixture of milk and barley water, in equal 
 projiortions, or some chicken or veal broth. Sometimes concentrated 
 beef tea is too irritating. 
 
 The average duration of cases has been under fourteen days, and this 
 year it has come down to twelve days. 
 
 I hope that this treatment may be given a trial, for the results in my 
 hands have been very good. Since I have adopted it, I have lost only 
 one case, and this under the following circumstances : — 
 
 Mrs. R., aged about 30, just returned from England, began to show 
 signs of enteric fever the day after landing. Saw her two days after, 
 when she had a temperature of 104", bad headache, and all the other 
 signs of enteric fever. I was using then the antipyrin-naphthalin 
 treatment, instead of antifebrin-naphthalin. In eight days the patient said 
 she felt entirely well, and the temperature remained normal for twenty- 
 four hours. I asked her to be careful, notwithstanding, and go on with the 
 milk and barley water diet, and remain in bed. I had scarcely left her 
 place before she partook of a heavy meal, composed of roast mutton, 
 boiled potatoes, cabbage, and beer. Half an hour later, she was taken 
 with intense vomiting and griping pains. The temperature the next 
 day, when I saw her, had run up to 104"8\ By energetic measures, and 
 same treatment as before, I succeeded in getting her right again about 
 six days after. I told her that she must be more careful this time, but it 
 was all to no purpose, as she left her house this same afternoon for a walk 
 by the seaside, and was found there and brought home in a very weak 
 state. She died two days after, all my efforts this time being 
 unavailing. 
 
 I should have stated that, before employing the naphthalin-antifebrin 
 treatment, I had recourse to antipyrin and naphthalin for nearly a year, 
 but that I adopted antifebrin as being safer, and causing greater elimina- 
 tion of effete products, whilst at the same time I found that its 
 antipyretic effects lasted longer. 
 
 The naphthalin and antifebrin are ground into an impalpable 
 powder, and administered as such. 
 
 [Appended to Dr. Bonnefin's ])aper were notes of ten cases, illustrating 
 the course and termination under the treatment recommended.]
 
 188 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 DISCUSSION ON TYPHOID. 
 
 The Chairman, when calling on Members to take part in the discussion, 
 said that, on account of the time which had been given to the reading 
 of papers, it would be necessary to confine remarks made to points 
 connected with the etiology of typhoid. 
 
 Dr. Whittell said : — It has been my duty during tlie last five and a 
 half years, in connection with the Central Board of Health of South 
 Australia, to pay particular attention to the etiology of typhoid fever — 
 to the origin of cases in South Australia, to their mode of progression, 
 and to the best means by which we were able to put a stop to the pro- 
 gress of different outbreaks that have occurred during that ))eriod. 
 From my ex])erience, and from my experiments in bacteriology, I have 
 arrived at pretty much the same conclusions as were arrived at hj Dr. 
 Carstairs, in the paper which he has read to us. 1 believe that typhoid 
 fever is due to a bacillus of a specific character, always the same 
 bacillus, and that that bacillus proi)agates itself partly in the bodies 
 of the persons affected, and jiartly in the various materials with which it 
 may be brought into contact, after it has passed through the body in the 
 evacuations. It is very important that we should have a fixed notion 
 about this bacillus and it habits, and the means by which it is propa- 
 gated. Proljably, we shall have to take many yeai'S in the study of the 
 bacillus, before we shall know all about the etiology of typhoid fever ; 
 but thus far, all pathologists have arrived I think at the conclusion, that 
 the bacillus passes in the dejecta of the patients, and that it may be carried 
 away in various modes. It may propagate itself in those waste matters 
 which are too frequently allowed to surround houses ; may be carried 
 into our water at long distances from where it was originally deposited; 
 may contaminate our milk supplies, owing to the negligence of milk 
 sellers, and the want of laws to regulate them and their dairies ; and, I 
 believe, too, although it would be disputed by a good many people, that 
 it may be disseminated through the air. I will just mention some three 
 or four outbreaks, in vi^hich I have been personally interested, during 
 the time I have occupied the position in connection with the Board of 
 Health in South Austi-alia. During that time, I have had personally to 
 investigate two cases, where undoubtedly the outbreak of the disease 
 amongst the people was due to milk. In one case, after a good deal 
 of troublesome inquiry, in which we were resisted by the dairyman 
 in all directions, and told there was no disease in the man's house, 
 although we had traced, as we believed, several cases of tyj)hoid fever to 
 the milk he had supplied, we succeeded in finding that there had been a 
 case of typhoid fever in the house, and that when the medical officer 
 went down to inquire into the history of the case, the patient, wjio was 
 then convalescent, had been hidden away from the sight of the medical 
 practitioner — ])ositively hidden amongst the milk cans in the dairy 
 behind. I had a good deal of difficulty with that dairyman, he 
 defied me, he said he would not stop the sale of milk, or sell the cows, 
 or do anything he had not already done. However by a threat, that if 
 another case of ty[)hoid fever should occur in connection with any of his 
 customers, I should certainly call on the Coroner to hold an investigation, 
 
 i
 
 DISCUSSION ON TYPHOID. 189 
 
 I succeeded in inducing him to remove the cows, and ])lace them under 
 the care of persons who had not been in contact with this typhoid fever 
 patient, and by that means we succeeded in arresting that epidemic. I 
 had another simihir case, where, after investigation, we found a boy who 
 had l)een undoubtedly affected by fever, and had been nursed by his 
 mother and friends, who had had the handling of the milk cans, and of 
 the various dairy utensils. These cases illustrated well enough to me, 
 and to any one acquainted with their history, how typhoid may be con- 
 veyed through milk, to ])ersons living in houses where everything that 
 is desirable, so far as regards sanitary arrangements, is to be found. 
 Now with regard to water ; we know that French practitioners of late 
 days have nearly all come to the conclusion, that typhoid is ])ropagated 
 chiefly by water. In Melbourne, where there is a water supply like the 
 Yan Yean, which I am told by competent authorities is pretty fair, though 
 it has a few faults that must be corrected, but which on the whole is of a 
 very fair, good, and wholesome quality ; or in a place like Adelaide, which 
 also has a very good water supj)ly, it is difficult to understand how the 
 water can be a source of tyjihoid fever. S{)eaking as to our own towns 
 in South Austi'alia, and I think I may say the same of Melbourne and 
 its suburbs, I do not believe that the water su])ply has anything to do 
 with the typhoid cases. Still, we know that water will become con- 
 taminated, and may be a source of conveyance of the typhoid microbe. 
 I have seen cases where that undoubtedly has been the case, and one of 
 these was just outside Adelaide, where, owing to the wells supplying the 
 household water being near the cesspools, there was an undoubted con- 
 tamination, detectibie by smell, caused by the passage of faecal matter 
 from those cesspools into the wells. 
 
 Dr. Jamieson said that it might be interesting, so far as Melbourne is 
 specially concerned, that he should say a few words about what he had 
 seen and known, and try to sum up some facts as to the spread of the 
 disease in the city, and the causes of that spread. Before going further, 
 he would like to draw attention to a chart, which illustrated in a graphic 
 way the prevalence of typhoid in Melbourne and suburbs, during a 
 period of 23 years, from 1866 to 1888. The ])articular point to be noted 
 is, that at periods recurring with great regularity, at intervals of four 
 years, the mortality from typhoid attains a maximum, and then subsides. 
 The curves were based, not of course on the absolute number of cases, 
 which would be fallacious in a rapidly growing town, but on the pro- 
 portion per hundred thousand of the inhabitants. Tliis fact should be 
 kept in view, in reference to all questions of causation, which would 
 have to be tested to some extent by the comparative prevalence of 
 disease. As to the probable causes of the spread of the disease in Mel- 
 bourne, of course it is clear, as everyone knows, that in a large city there 
 must be always special difficulties in inquiring into the occurrence of 
 cases, how they come about, and why they spread. About the special 
 causes that are always adduced, he might refer first to the water supply. 
 In regard to that point, already mentioned by Dr. Whittell, he could 
 not believe that the contamination of the Yan Yean water su])ply has 
 any appreciable effect in spreading typhoid in this city. Even if 
 there is a possibility of an occasional contamination of that water, the 
 possible sources of contamination are so small and scattered, that such 
 eontamination could be only a comparatively rare event. It seemed
 
 190 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 inconceivable that contamination of that water sup]jly, which is dis- 
 tributed all over the town, if it were an important cause, would allow of 
 the disease beginning, with some severity, in November, and increasing 
 in January, February, March, April, and May, year after year. If the 
 contamination of the water supi)ly had much to do with it, the out- 
 breaks ought to be in great epidemics, and then stop ; but year after 
 year it goes on in the same way. The next question is as to milk, how 
 far that may be supposed to have much to do with the spread of disease 
 in tliis town. He did not question at all the probability that milk does 
 get contaminated, and is distributed in Melbourne, and causes typhoid ; 
 he did not question the validity of the argument that Professor Allen 
 adduced. He was acquainted with the Jolimont outbreak referred to, 
 and was prepared to believe that milk was the cause of the spread of 
 typhoid at the time, but the same argument must be applied to milk as 
 to water. It was not easy to see why milk should go on year after year 
 causing this regular rise and decline of typhoid. As to specific ex- 
 perience, he could say that during the years 1887-8, he had occasion to 
 inquire officially, as health officer, into this milk question in relation to 
 typhoid. And though he had started witli the expectation of finding a 
 connection, he had not been able to put his finger on one single instance, 
 in which he was satisfied that milk had been the cause of the spread of 
 the disease. Then, what are the causes? There remains the di-ainage ; 
 there remains nightsoil disposal, especially. It could not be questioned 
 at all, that Melbourne is an excessively badly drained cit}'. The most 
 recent visitor must have seen the foul water trickling slowly along, never 
 reaching its destination, unless that destination is to sink below the 
 surface. In the course of enquiries, he had made this distinct observa- 
 tion repeatedly, that where serious outbreaks of typhoid occurred, 
 it could almost regularly be shown that it was usually in a crowded or 
 badly drained locality. Not long ago, Dr. Simpson, the Health Officer of 
 Calcutta, was here, and having made the remark, " I have seen the good 
 streets of Melbourne, the fair side of Melboiirne, can you show me the 
 other side?" He (Dr. Jamieson) took him to places where cases 
 of typhoid occurred, which he attributed to soakage of foul water round 
 the houses. After visiting a number of these localities, Dr. Simpson was 
 satisfied that the cause of the outbreak was to be found in the fact, that 
 the water had been soaking down to these houses on the low level ; that 
 they got it, and with it the typhoid. Of coui'se, we must admit that the 
 mere soakage of foul water will not do it, that goes on all over the 
 world ; but if you get that, and a sj^ecific infecting material, you are 
 bound to get typhoid largely. He would like to narrate a curious 
 instance that came under his notice within a few days before, illustrat- 
 ing the influence of a bad arrangement for the disposal of nightsoil, and 
 with it, the neglect of precautions. The medical man attending a patient 
 reported that there was a case of tyjihoid in a certain house. There 
 were two children ill in the house at that time, but there had been a 
 ])revious case six weeks before. On visiting tlie house, he learned that 
 tlicrc had been expended, one tin of carbolic powder and one little bottle of 
 Condy's fluid, which had been spread about the house in saucers. That 
 several cases should occur in such a house was to be expected. But the 
 matter did not end there. The closet belonging to this house, in which 
 those three cases had occurred, had been pushed away, naturally enough,
 
 DISCUSSION 0\ TYPHOID. 191 
 
 from the people's own lionse, and made to abut on the fence of another 
 Iiouse, so that tlie back wall of the closet actually formed part of the 
 fence. There was no communication between the houses, which faced 
 to diderent streets. About the same time that the two cases occurred in 
 the first house, two children in the other house got the disease, and both 
 died. There was no absolute proof that these fatal cases were caused by 
 the emanations from that closet, but it looked like a deliberately 
 arranged experiment to prove that nightsoil, not properly dealt with, 
 will cause the spread of typhoid. Those were the two points lie wished 
 specially to bring out. 
 
 Dr. Leger Ei!S0X said that, having come recently from Auckland, 
 where there was a great deal of typhoid, he was deeply interested in the 
 discussion. The question had been raised, whether typhoid can arise 
 de novo. He had seen cases in the bush, where there had been no 
 ty])hoid ; no history of any within the memory of Maori or white man 
 — cases where one, two, or three children had been affected from a 
 distinct source of causation — merely some putrid animal matter lying 
 about where the children played. He had also seen typhoid occur on 
 board' ship, when three months out at sea. Where was the previous 
 source of causation there ■? He made inquiries, and came to the 
 conclusion that it came from neglected bilge water, no cases liavin^ 
 occurred in the ship before. In towns, there was often a mistake in 
 getting an artificial water supply, without a single thought given 
 as to the disposal of sewage, though they should go together. He had 
 remarked that in Melbourne there was a system of earth closets where 
 no earth was used, and that is an important point in the causation of 
 typhoid. Even in Fiji they are more advanced in sanitation than we 
 are. There they have a man inspecting the closets, and if the earth is 
 not used, a heavy fine is inflicted. That was a suggestion for adoption 
 in Melbourne. 
 
 Dr. IviRTiKAR (of Bombay) said that it would be of some interest to 
 the members of this Congress to know what was thought of typhoid 
 fever in India. The late sanitary commis.sioner of Bombay (Dr. 
 Hewlett), said that the natives of India are born in filth, brought up in 
 filth, and die in filth ! Of course there will be very few who wnll accept 
 this wholesale condemnation of India, but there is a good deal of truth 
 in it. There is a good deal of filth around us ; a good deal of cholera 
 around us; a good deal of malaria around us. There are all sorts of 
 malarial fever — intermittent, quotidian, quartan, tertian, and a very 
 terrible form of remittent fever. Well now, this remittent fever, to a 
 certain extent, corresponds with the typhoid fever of Europe and of this 
 country, but the true typhoid fever is said to be almost absent. It is 
 found to prevail among European troops alone, and among Europeans 
 arriving in India. It is scarcely seen amongst natives. The army 
 doctors of the British medical service all combine in thinking that the 
 members of the Indian medical service are not able to diagnose typhoid 
 fever among the natives, but we think we ought to know something 
 of the diseases prevalent among the natives of India, as we have the 
 whole field of medical practice in India to ourselves. The British army 
 doctors think we make a mistake in not diagnosing more cases of 
 typhoid in India ; but as a student of bacteriology — that large 
 department of science — I consider that, although we have remittent
 
 192 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 fever, Avith diarrhcea very often fatal, the absence of tyi)lioid is a very 
 signiiicant fact. Tliere is a something in typhoid that has a particular 
 cause — a special germ — which as yet has not been able to find a 
 congenial soil in India. Now, it is for me and others in India, who 
 work in the field of bacteriology, to find out hereafter, from what I 
 learn from you here, whether there are any special circumstances in 
 this colony causing typhoid, which are absent in India, and vice versd ; 
 and it will be an impoi'tant lesson for us to leai-n that mere filth cannot 
 cause typhoid. I am sure this consideration will afford an interesting 
 field for further investigation. But there is one point which I Avant to 
 bring before this Congress, with reference to the ])articular form of 
 remittent fever we have in Bombay. There is a kind of fever that 
 corresponds with typhoid fever, but there are certain points of 
 difference. We have the remittent fever, which lasts very often over 
 twenty-one days ; there is the remission, the morning remission, and 
 the evening rise, but it is not the remission of typhoid fever. There is 
 a kind of diarrhoea present sometimes, though very often it is absent. 
 Where the diarrhoea exists there are stools, very nearly allied to the 
 " pea-soupy " stools of true tyjihoid. We have occasionally haamoirhagic 
 patches under the skin, corresponding to those in real typhoid. We 
 have also, when vv^e come to study the ])athology of the intestinal tract, 
 the Pej'erian patches also affected, but not to the same extent. 
 Strangely enough, in this particular kind of fever, the secreting glands 
 of the wall of the intestinal tract are attacked, swollen and fringed. 
 The mesenteric glands not so largely and so early implicated as in 
 true typhoid. These pathological a|)pearances show some kind of 
 connection between the typhoid fever you find here, and the septic 
 Bombay fever I am describing, and a careless observer is liable to 
 mistake the post-mortem appearances of the one for the other. It will 
 afford an interesting field for research to pursue the pathology of this 
 Bombay fever. In 18S6, Dr. Vandyke Carter first directed our 
 attention to the Peyerian ulcer lesion found in the remittent fever of 
 Bombay, attended with diarrhoea and simulating typhoid. It will be 
 my pleasure, when I return to India, to send to the Medical Society 
 here, and to any other society in the colonies which the Secretary 
 informs me about, copies of the Transactions of the Bombay Medical 
 and Physical Societ)^ for your information — Transactions in which Dr. 
 Carter gives us his first instalment of researches on fever with Peyerinn 
 lesion — in order that you may be able to know that, although in India 
 we have no typhoid, we have this particular kind of i-emittent fever 
 which is the scourge of the Indian peasant, as also the Indian citizen. 
 It is a terrible disease, and its origin can be traced to sej)tic poisoning 
 from filth. The great danger from typhoid, as far as I know from 
 my books, and as far as I learnt as a student in England, is pneumonic 
 complications, and complications especially connected with the heart, as 
 Professor Allen has just told us; but in India, this remittent fever is 
 very often complicated with bi^ain symptoms, and we have what they 
 call " the brain fever." This form of fever in Bombay is particularly 
 dangerous in the earliest stages, the ninth day being the most dangei-ous. 
 We know that even in its early stages, typlioid is very dangerous. In 
 some cases, the person is actually bowled over long before the stage of 
 diarrhoea sets in, or petechiie appear. So far, the two fevers resemble 
 
 i
 
 DISCUSSION OX TYPHOID. 193 
 
 cacli other ; but on the otliei- huiid, in the Bombay remittent fever, we 
 have a special kind of pathological and final result, which is not quite 
 characteristic of typhoid. 
 
 Dr. Newmax said that it was important to note the variation of the 
 type of the disease in this country. It is altogether different in some 
 respects from typhoid fever in the old country. Very rarely we have 
 diarrhcea, but we have constipation ; and as to spots, we often do not see 
 a sign of them. About the variations of typhoid disease, we find in 
 some epidemics we get nothing but head symptoms, and in others 
 troubles connected with the bowels, though not necessarily diarrluea, 
 and even we get sometimes haemorrhage in the bowels, with the con- 
 stipation. I tliink there must be something different in the typhoid fever 
 in these colonies from that at home, or we would not have such remark- 
 able changes. . 
 
 Dr. Ellis (Sydney), said : — We have all been talking about germs, and 
 I do not know how many here have studied them scientifically. Tliere 
 seems to be an idea that if one germ gets in, it causes tyj)hoid fe\ er. The 
 great question is, the quantity of germs necessary to cause typhoid. Some 
 people have taken in a certain amount of germs, and not got it, and a 
 great deal dejjeuds on the dilution. Ordinary tilth, by standing, does 
 not cause it, or it would be mucli more common than it is. The question 
 is — How far does the filth hel]) the germination, so that they can come 
 together in large quantities, sufficient to attack the individual, and cause 
 typhoid fever ? and on this point I lay stress as to milk. I think if you 
 get contaminated milk, and let it stand for some time at a certain 
 temperature, you will very greatly increase the probability of giving 
 typhoid fever to those j)eoi)le who drink it. The ordinary process of 
 scalding it does not sterilize the spores ; you must steam it for ten or 
 twelve minutes, and less injury is done to the milk in that way than 
 any other. This especially a])plies to milk for children. As to the use 
 of filters, the ordinary filters are perfectly useless — the only one I know 
 of that is any use is Chamberlain's. I made some cultivation experi- 
 ments with those. I took some water from an ordinary tap in Sydney, 
 and found that it had 30 germs to the cubic centimetre. I took the 
 water from the Chamberlain filter, which had no germs, but I passed the 
 water through that, and then through my own filter, which I had been 
 using, and after that I found 300 germs to the cubic centimetre. Sup- 
 j>osing your filter got contaminated in this way, you simply have the 
 ground for growing the typhoid germs. I do not think it is conceivable, 
 to any person who has studied germs, that it is possible for the typhoid 
 germs to be developed out of any other germ ; but where the tjphoid 
 germ gets into ground that is jirepared for its propagation, it will 
 develop rapidly. There is another point. The ordinary idea as to 
 rendering the stools aseptic in the ordinary way, is by adding a small 
 amount of carbolic acid or corrosive sublimate. You may do a great 
 deal more harm than good. That is a very curious statement, but it is 
 true all the same. You will find generally — I do not know that it holds 
 exactly with tyjihoid — that the poisons and ptomaines generated with 
 the ordinary putrefaction, are very deadly to the ordinary fever germs ; 
 but the ptomaines are more easily prevented from growing than the fe\"er 
 germs, and if you put a small amount of antiseptic into the stools, you will 
 
 o
 
 194 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 prevent the ptomaines generating, whereas you give a splendid oppor- 
 tunity for the typhoid germs to develop, especially if a little later ou 
 the matter gets spread over the soil. 
 
 Dr. Bright (Hobart) said : — I think I can throw a little light on the 
 subject of typhoid. In regard to the paper read by Di-. Robertson, 1 
 wish to say I know a few facts that do not quite coincide with some of 
 the statements he made. He told us that typhoid is not conveyed 
 from the sick to the healthy. I am sorry to say I have had pretty 
 strong proof that it is. J have seen a good deal of typhoid fever the 
 last twenty-tive years; but within the last two years at Hobart, at the 
 hospital of which I am one of the staff', we have had 500 cases — 200 
 last summer, and 300 the year before. Fully a fourth of those cases 
 had to pass under my hands. Thex'e we found a large number of our 
 nurses were knocked up by nursing the sick ; and it goes to contiadict 
 another statement of Dr. Robertson's — that recent stools are not in- 
 fectious, but they must be first fermented. I think they are infectious 
 from the first, and I believe it was in that way the nurses in the 
 Hobart Hospital became knocked over with fever in the way they 
 were ; and when we found they were being made so ill, we began to 
 look carefully into it, and we found that from ihe number of cases 
 they had to look after, the practice of removing the bed-pans was 
 rather lax. The pans were not sufficiently disinfected, and not covered 
 over when they had to be carried a short distance from the wai'ds ; and 
 sometimes this was done at once, the same as an ordinary stool might 
 be. When we found this out, we insisted on disinfectants being used, 
 and had the pans covered, and after that the nurses ceased to be affected. 
 That goes to show that recent stools are infectious. Then Dr. Robertson 
 told us that one attack gives immunity from future attacks. I am 
 sorry to say I have had positive proof that that is not the case. I 
 attended a patient three or four years ago for a moderate attack of 
 typhoid ; there were spots and all the ordinary symptoms, and last year 
 I attended him for a more severe attack. As to the SjU'ead of typhoid, 
 the conviction has been forced upon me that hospital patients, after 
 they have left the hospital, and are supjiosed to be convalescent from 
 typhoid, are capable of spreading typhoid among the healthy. Numbers 
 of ])atients have left the hospital, after recovery from typhoid ; not in 
 one, two, or three, but in a good many instances, we have had cases 
 come back again from other members of the family a few weeks after 
 they have gone home, where there was no typhoid previously in their 
 houses. I have known typhoid patients, who have been asked to stay 
 in houses in the country to regain their strength, and typhoid has 
 broken out after they have gone there ; so I am fully convinced that 
 typlioid ))atients, for some weeks after their recovery, are rather 
 dangerous pei'sons to have about liouses, unless precautions are taken to 
 disinfect their stools, the same as when they are suffering from the fever. 
 In order to prevent the tyjihoid, the stools of convalescents should be 
 disinfected, for at least three weeks after they are supposed to be quite 
 well. 
 
 Professor Kernot, speaking by ])ermission, as a member of the 
 Central Board of Health, desired to raise the question of the best kind 
 of channels. Lai'ge towns might be ]iroperly sewered, but small towns 
 would have to dejjend on surface di'ainage.
 
 DISCUSSIOX ON TYPHOID. 195 
 
 The Chairman, in t-lossing tlie discussion, regi-etted tliat the time had 
 been so sliort tliat tlie gentlemen wlio si)oke did not speak as fully as 
 they might have wished, and that others had no o[)[)Oitiinity to speak at 
 all. We all agree, no matter how much we may disagree as to how 
 typhoid is jirodiiced (whether it can be produced <h' novo or not), that 
 filth is a very important factor in its production, and the question is, how 
 can we best get rid of all the causes which go to ])roduce or propagate 
 this disease ? As to the (juestion which Professor Kernot asked, the 
 best way to make surface channels, J may mention that in the city of 
 Brisbane, they are made with cement, the advantage being that the 
 channels are impervious to water, and are very easily cleaned, and they 
 appear to answer very well as surface channels, where they are needed 
 to convey sewage. But where at all j^racticable, I think it can be 
 ascertained that sewage on a separate system, by which the rainfall is 
 excluded, will be found the best and cheapest, and most easily managed. 
 On this question I read a ])aper before the Health Section, which, I 
 believe, will be i)ublished and made generally known. There is a dis- 
 cussion of the .system, which has been in operation in the United States 
 for the last ten years, and has answered admirably well. 
 
 The Chairman then stated that certain resolutions had been drafted 
 by way of ])ractical conclusions, and these would now be put before the 
 Congress. 
 
 Dr. Vkrco (Adelaide) said : — The following resolution has been given 
 me to move, which I can do with all confidence : — "That the members of 
 the Intercolonial Medical Congress regard it as ])roved, that typhoid fever 
 is a preventable disease, which owes its prevalence mainly to insanitary 
 conditions, and above all to contaminated water supply, defective drainage, 
 and improi)er disposal of nightsoil." It will be noticed that this is a 
 very practical sort of resolution , that it leaves out almost entirely all 
 theoretical considerations. It is not a question as to whether we have 
 to deal with a sini)»le organic poison in the shape of a ptomaine, or an 
 organism like the bacillus. Jt does not traverse the question as to the 
 exact amount of heat that may be required for the cultivation of these 
 germs, if gei'ms they be ; nor does it shut out the possibility of the 
 origination of the disease de novo ; nor does it involve the necessity of 
 the ))ythogenic origin of typhoid fever. We all allow it is a disease 
 that can be prevented, and that it is a disease which owes its prevalence, 
 apart from its specific origin, mainly to insanitary conditions. We all 
 allow it is very frequently brought about by contaminated water .sui)ply, 
 and proofs are given of its connection with defective drainage, and with 
 the improper disposal of nightsoil. 
 
 Dr. D. CoLQUHOUN (Dunedin) seconded the motion, saying : — I think 
 there can be no question that it is amply justified by our knowledge of 
 tyi)hoid fever. 
 
 The motion was carried unanimously. 
 
 Dr. Turner (Melbourne) moved the .second resolution : — " That while 
 there is reason to believe that the sources of the water-supply of Mel- 
 bourne are carefully guarded, it is certain that, as regards drainage and 
 nightsoil disjiosal, the arrangements are very unsatisfactory ; and to 
 these defects must be ascribed, in great measure, the excessive prevalence 
 of typhoid fever year after year." 
 
 o 2
 
 19G INTERCOLONIAL MEDICAL COXGHESS OF AUSTRALASIA. 
 
 Dr. J. Davies Thomas (Adelaide) seconded tlie resolution, saying : — 
 Our object, I am sure, is to strengthen the hands of the medical pro- 
 fession in Melbourne, in bringing about a very much needed reform. It 
 happens to me to have lived for some years in Adelaide. I have lived 
 there under circumstances when sanitation was completely neglected; and 
 now, when the sanitation is excellent, I can speak in the most decisive 
 terms about the enormous advantages that have arisen to Adelaide 
 from the introduction of a proper system of water-carriage of sewage, 
 and its distribution on the soil. To the best of my belief, there is no 
 serious drawback which can be urged against it. At the outset there 
 were some objections, because the ventilation of the sewers was not all 
 that could be desired, but that has all been remedied. I may say that 
 I have had an opportunity of visiting many cities in Europe, and T can 
 say, with all humility, that I know of no city the sanitation of which 
 is, to my mind, so nearly perfect, as that of Adelaide at present ; and 
 with the fi'eest acknowledgment of all I see to admire in this city, I am 
 simply shocked at the system for the disposal of nightsoil, and the 
 drainage that obtains here. 
 
 The motion was carried unanimously. 
 
 Mr, E. M. James (Melbourne) said : — Many of our visitors have noticed 
 very painfully the imperfect condition of our closet system. The pan 
 system must undoubtedly be condemned, and that in no measured terms. 
 On those very hot nights, when the temperature is high, we are obliged 
 to shut out even the cool southerly breeze, to keep out the odours which 
 I can certainly characterise in no other terms than as abominable stinks. 
 T think there can be no doubt about the propriety of this resolution, 
 which I now move — " That in the opinion of this Congress, it is the 
 imperative duty of the Government to take immediate steps for bringing 
 about an improvement in the sanitary condition of Melbourne, and 
 specifically for the construction of a proi)er system of underground drain- 
 age, which shall include the removal of nightsoil by water-carriage." 
 
 Dr. Bright (Hobart) said : — I second the resolution with very great 
 pleasure, and without any hesitation at all. I do so all the more readily, 
 because I am sorry to say that, within the last two years, I have seen 
 two or three cases of typhoid, which have been taken back to Tasmania 
 by young residents there, and visitors here for a short time, infection hav- 
 ing been caught from the closets at hotels and coffee palaces here. I can 
 bear out the statement, that the pan system is an abominable one. We 
 have had it only two years in Tasmania, and I believe we have to thank 
 that for an outbreak of tyjihoid fever the last two years, which has been 
 quite unprecedented. For 25 years before, we had not more than 50 or 
 60 cases per annum. Last summer it was 200, and the summer before 
 that .300, and that is since the pan system came into use; and I know of 
 one case, at least, where the cause was traceable to the patient only 
 getting one whiff, in passing one of those pans which contained these 
 abominable contents. 
 
 The motion was carried unanimously.
 
 SECTION OF SUEGEEY. 
 
 PRESIDENT'S ADDRESS 
 By Edward C. Stirling, M.A., M.D. Cantal)., F.R.C.S, Eng. 
 
 Surgeon to tlie Adelaide Hosi^ital ; 
 Lecturer on Physiology and on Clinical Surgery in the University of Adelaide. 
 
 Is SURGKRY A SCIENCE? 
 
 To have been appointed to the honourable position in which I find 
 myself to-day is a signal compliment to the youngest of the rising 
 medical schools of Australasia, which demands that my first expression 
 should be one of grateful and respectful thanks to those who have thought 
 fit to confer upon me an unmerited and wholly unexpected honour. 
 But any pride of place I may feel disposed to feel is tempered by the 
 knowledge that high office bears its inevitable train of duties and respon- 
 sibilities, which, in the present instance, may well excite a profound 
 distrust of my ability to discharge with credit the task that is laid upon 
 me. That I should presume to make the attempt is largely due to the 
 fact that, in addressing this distinguished assembly, I speak also to 
 those who can best appreciate the difficulties of such an office, and who, 
 therefore, in virtue of our genial brotherhood, will surely make the 
 most generous allowance for deficiencies which I fear must be inevitable. 
 
 (3n what subject, then, shall I, lacking the li^te experience of many of 
 those who honour me by their presence to-day, venture to address my 
 honoured colleagues ? Instruction is not in my power to ofier. New 
 truths are few and far between, and come not to ordinary mortals. 
 Retrospect, though a wholesome and salutary exercise, is a well-worn 
 way. The future, who shall foretell it 1 Nay, how even shall we read 
 aright the present ; offspring of the past and parent of the future, how 
 shall we discern the manner of its growth, and in the tendencies of 
 to-day, perchance, foresee the realisations of to-morrow 1 AVhat are the 
 signs of the times ; are they messages of a hopeful and unbroken pro- 
 gi-ess, or is there for us, too, a writing on the wall ? Are we surgeons 
 but expert craftsmen of a finer sort — mere artistic handiworkers in a 
 benevolent calling, or liave we borne our part in the amazing march of 
 science that has characterised our age 1 This may fitly bring me to my 
 theme, for I propose to seek an answer to the question — Is surgery an 
 art merely, or has the time yet come, or is it coming, when we may 
 speak of a science of surgeiy, and of the boundless hopes of progress in
 
 198 IXTKRCOLONIAL MEDICAL CON'GRESS OF AUSTRALASIA. 
 
 the future wbicli such a definition cannot fail to excite in our minds ? 
 An ambitious effort perhaps, yet one which shouhl be made, and surely 
 there can be no more fitting occasion to proffer such questions, and to 
 seek their answers, than in this assemblage of fellow workers and joint 
 seekers after truth. 
 
 I think no one will question tlie ]tro})riety of the term art as applied 
 to surgery, indeed the healing art is perhaps the best, as it was the 
 earliest designation of our calling. Its antiquity is })robably as great as 
 that of the human race itself, and it is easy to picture to ourselves how 
 the surgical craft had its earliest beginnings, among primeval men, in 
 crude attempts to alleviate the pain and inconvenience of those wounds 
 and fractures to which the predatory habits of our ancestors must have 
 given frequent rise. In short, the fii'st surgery was the rough and ready 
 practice of the battlefield. And thus, the art of surgery is probably one 
 of the oldest as well as the most cosmopolitan of all the arts, having, 
 like tlie art of agriculture, owed its rude beginnings to the pressing and 
 painful necessities of mankind ; and yet again, like agriculture, with 
 A\hich our own art has so many interesting analogies, having reached 
 even in very early times a high degree of wholly empirical success. 
 
 Truly the words of the Preacher, "There is no new thing under the 
 sun," come Tiome to us with unexpected force, when we have good reason 
 to believe that at the time our neolithic ancestors were chipping and 
 ])olishing their flint flakes and celts, building their lake-dwellings, and 
 laying the foundations of those arts of spinning, weaving, pottery- 
 niaking, agriculture, and raining — without which we can scarcely realise 
 what our lives would be — -they were also, with tlieir rude stone imple- 
 ments, sawing, scraping, or drilling live skulls, almost certainly for 
 depressed fracture, and probably also to set free the evil spirits they 
 held to be the cause of ei)ilepsy; thus laying the foundations of an art 
 of surgery, and even forestalling by some thousands of years its most 
 boasted and promising achievements of modern times. 
 
 Passing from these amazingly interesting indications of prehistoric 
 surgery to the period of history, if we look at the records of the practice 
 of our art from the time when they become intelligible to us, first as rare 
 and scattered episodes of })eace or war sung l)y the poet* or chronicled 
 by the historian, then as systematic treatises liy acknowledged teachers, 
 it is iuqiossible not to be struck with tlie appositeness of many of the 
 means employed in the treatment of surgical emergencies, the high degree 
 
 * Aincip enei I'cev eXKo<} 06^ efnreae TriKpov uiaioi 
 uijii fcVuf^M<T«9 tV up ijTriu (j:api.iUKa eictvi 
 TTc'iaae, t« 01 ttotc TTurpi 0/\« (Jypoi'Ltcv Trope ^i^eipici'. 
 
 Hum. II. iv., 217-219.
 
 presidext's adduess— section of surgery. 199 
 
 of onterpiisc sliowu in th<^ nncleitaking of some of tlie most serious 
 operations, and the remarkable ingenuity disitlayed in the invention and 
 construction of the necessary instruments and a])pliances so plainly the 
 prototypes of many of the best modern tools of our craft. 
 
 If already I should seem to stand forth as a mere laudator temporis 
 acti, it is because I think we are all of us sometimes not a little prone, 
 while boasting of the achievements of the present, to overlook the deep 
 debt of gratitude that modern surgeons owe to their great forefathers, 
 remote as well as near, and as a great English statesman has said, there 
 is^no greater folly upon earth than to undervalue the past. Indeed, 
 considered as an art, it is almost impossible to over-estimate the large- 
 ness of the debt that is due, and any self-complacency we may feel in 
 boasting of our modern progress, may well receive a wholesome check in 
 the contemplation of the accurate and successful work done by many of 
 the men of old time. But if we may .truly say, as I believe we may, 
 that s\n-gery does now enjoy a position and vitality which distinguish it 
 as something ditieiing in kind, as well as in degree, from the surgery of 
 past ages; if, in truth, we are .something more than glorified descendants 
 of our barber forefathers and stone-age ancestors, the reason is that 
 surgery is no longer merely an art. It is something more. It is, as we 
 hope and believe, a science. And while as an art, as I shall attempt to 
 show, our craft is within a measurable distance of finality ; as a science 
 it is only in a healthy and vigorous infancy, which otiers abundant hopes 
 for a splendid maturity. 
 
 At first purely empirical in its methods, the healing art came at 
 length to be dominated by theories of pathology. Wind, bile, phlegm 
 and humours of \ arious sorts pervaded the system, and were the causes 
 of all bodily ailments ; the treatment was a direct attack to effect their 
 exj)ulsion and translation as material entities, and, as we know, the 
 mind has scarcely yet shaken itself free from the strong hold taken 
 upon it by the humoral pathologies, nay, do we not find even in 
 ourselves survivals of our old beliefs in theories of metastasis, and in 
 the potent and etfi.cacious drawing and driving powers of issues, plasters, 
 blisters, and such like medicaments. Perhaps we are inclined to laugh 
 at theories such as these, but we should remember that erroneous and 
 often ludicrous as were these practices, they were at least genuine 
 intellectual groping.-^, representing the first crude attempts to pass from 
 isolated and emjiirical facts to general truths. It was the dark hour 
 Vjefore the dawn, and for our craft at least, marked the beginning of a 
 distinction which, in other arts, had long since been recognised by 
 Greek philosop>hers between a technique or art of which certain rules 
 were to V)e put in practice, and a science which, by a series of inductions 
 or deductions, enunciated certain propositions showing on what
 
 200 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 conditions the effect, which the art aims at producing, depends. 
 While as an art, surgery, as well as medicine, long remained a calling 
 apart -not always one of honour — as a science, its progress soon 
 "became inseparably connected with that of physiology or biology. 
 Hence, its scientific history is that of the biological sciences, and 
 surgery is scientific only as biology is scientific. 
 
 To an English physician, largely influenced no doubt by his Italian 
 teaching, we owe the discovery of that, which is alike the starting point 
 of scientific physiology and the central factor of practical surgery, viz., 
 the cii-culation of the blood ; but it is not a little remarkable, that that 
 great and potent factor in sui-gery, the ligature, dates from a period a 
 hundred years before Harvey's great discovery, a conspicuous example 
 of the potential value of an isolated and empirical fact. And, j'et again, 
 in the use of anaesthetics, we have another such example of how 
 prodigious and unexpected may be the influence exerted Ijy ])urely 
 accidental discoveries. Remove these two i)illars of our craft, the 
 ligature and the anaesthetic, and how much of the modern edifice of 
 surgery would crumble down. So, too, who would have anticipated, in 
 the early investigations and discoveries of Leeuwenhoek and Ehrenberg 
 into microscopic organisms, the seed of that rich harvest which is now 
 being reached in the application of theories of germs and of })utrefactiou 
 not only to surgery, but to medicine, sanitary science, the economics of 
 food and drink, and to many of our staple industries. Such illustrations 
 as these, which accentuate the influence of isolated facts upon the 
 progress of surgery, may seem to be contradictory to my general 
 contention for the greater importance of scientific theories, but it is not 
 really so. As an art, no doubt, surgery has been largely benefited by 
 empirical discovei-ies ; but qud science, isolated facts — and the above 
 are no exception to the rule — have no real and enduring value until 
 their relations are determined and brought under the scope of general 
 laws. Ambrose Pare, we have reason to believe, " attached a higher 
 value to the efficacy of a /rt?-;T///o of boiled pupi)y-dog and earth-worms 
 pickled in white wine as a cure for gunshot wounds — to learn the secret 
 of which we are told he ])aid two yeai's' court to a surgeon of Turin- — ■ 
 than he did to the ligature;" and until the fact of the ligature came to 
 be fitted in with the theory of the circulation, its use could only have 
 been a subordinate factor in the art of surgery, and of next to no 
 account in the science of disease. 
 
 Tiie anaesthetic projjerties of various drugs have been known as facts 
 from the time of the Egyptians, l)ut until it was perceived that in- 
 sensil)ility and the relief of pain might be made applicable to surgical 
 procedures, and become closely related to their results, these were 
 regarded as drugs more curious than useful ; and so also, the early in-
 
 PRESIDENTS ADDRESS — SECTION OF SUKOERY. 201 
 
 vestigations into niici'oscopic organisms were scarcely more than isolated 
 zoological facts, until their relationship to the ])rocesses of fermentation 
 anil i)utrefaction came to be perceived. 
 
 All this may be perfectly admissible, aud yet this very unexpected 
 outcome of isolated experiences should cause us both to have a profound 
 respect for the potentiality of new facts, as well as to manifest our 
 recognition of their possible value in the future, by faithfully recording 
 them, so that, by-and-bye, we may have them at hand to fit into the 
 theory which may hereafter be found to embody them. Then will they 
 become an integral part of the body corporate of science, with its infinite 
 powers of extension and adaptation to new facts and new conditions. It 
 is lamentable to think how great a loss science must have sustained in the 
 past, by reason of waste of opportunities of recording simple every-day facts. 
 
 AVe live now in an age of acute observation and systematic record, 
 which bears constant fruit in the bringing to light of vaiious symptoms 
 and diseases too numerous to mention, of which formerly we had no 
 knowledge ; but, except perhaps in the case of some which doubtless 
 are the evolved products of new and modern conditions, these must have 
 exi.sted for ages under our eyes. Some are so obvious and consjucuous 
 that they must have been noticed by men whose work testifies that they 
 were not lacking in acuteness and powers of observation ; but yet, from 
 the absence of any record in the past, we now labour under the dis- 
 advantage of having to approach them, fortified with the few facts of to- 
 day, instead of with tlie accumulated experience of years ; and we may 
 depend upon it that, even now, owing to a simple want of observation 
 and attention, and to an absence of a sufficiently systematic record of 
 passing signs, we avo daily committing the same sins of omission which 
 we lay at the door of our i)redecessors. 
 
 It is an easy thing glibly to admit the close connection of medical 
 with biological science, and the fact that year by year we lay increasing 
 insistance on the biological part of the medical curriculum, is evidence 
 that this connection is well recognised ; but it is not so easy to define 
 within the limits proper to this address, either the nature or extent of 
 the influence of biological theories upon that which is still so largely 
 and essentially a practical art. Such an attempt, however, I have 
 rashly undertaken to make. If we are to forecast the future, we must 
 realize the ])ast, and the appreciation of what science has ah-eady 
 done, and is now doing, for surgery is a necessary antecedent to the 
 understanding of what its future lines of progress will be. 
 
 As the most striking example of the profound influence exerted by 
 biological methods and reasoning on surgery with the hajipiest results, 
 the mind turns naturally to those brilliant chemico-biological conceptions 
 of the origin and causes of fermentation and putrefaction, that occupy so
 
 202 IXTERCOLOXIAL MEDICAL COXGRESS OF AUSTRALASIA. 
 
 much of our thoughts at the present time. There is a ])recisiou in their 
 methods and a brilliancy in their results that speak for themselves, and 
 constitute the best apology for the prominence which, with one accord, 
 we extend to them. If these stood alone, they would be a standing 
 monument to the labours of the biologist, and leave the surgeon for ever 
 in his debt, permeating as they do the whole range of that chief part of 
 the surgeon's work — wounds and their consequences, operations and their 
 i-esults ; nay more, profoundly influencing, and even revolutionizing, all 
 our past ideas of the aetiology of morbid processes. 
 
 The name of Lister is revei'ed wherever the civilized surgeon dwells ; 
 antiseptics and asepticism loom large in the foreground of the picture of 
 modern surgery ; and yet, while we welcome the benefits, we must admit 
 that, envelo]ied as it is in clouds of uncertainty and even misconception, 
 the theory is far removed from finality. Hitherto, attention has been 
 chiefly devoted to the magnification of the role of aerial germs, and the 
 Listerian method has been chiefly devoted to their exclusion or destruc- 
 tion. A prodigious ingenuity in the multiplication of germicides, and 
 an endless search after perfection in this direction, has probably tended 
 to divert attention from matters of more vital and deeper import ; and, 
 in fact, the experience of many surgeons has shown that successful 
 practice is possible without the exclusion of exti'insic germs. One dis- 
 tinguished member of our ])rofession has observed, or almost boasted, 
 and his practice is largely imitated, that he is in tlie habit of flushing the 
 abdomen after section " with water containing spores and germs of thirty 
 different kinds of beasts," and that his results are as good as those of the 
 strictest disciple of Lister. This is of course the language of hyperbole, 
 liut still it is abundantly clear, that aerial germs are not the be-all and 
 end-all of wound pathology. The role of the living tissues themselves is 
 the one great unknown quantity. Why is it that some wounds are 
 obnoxious to putrefactive changes, or to the aljsorption of harmful 
 products, while others are less so, or escajje unscathed in atmospheres 
 and fluids that literally reek and swarm with germs 1 What subtle 
 property of blood or tissues enables the fleld-mouse to resist the 
 septict^mia which is so fatal to the house-mouse, or the white-cocooned 
 silkworm the disease that devastates the yellow ; or what constitutional 
 peculiaricy shelters the Cochin-China fowl from chicken cholera, or the 
 Algerine sheej^ from anthrax 1 Why wei-e the black pigs mentioned by 
 Mr. Darwin unaffected by blood-root, which poisoned their white fellows, 
 or only the white pigs j)oisoned by buck-wheat 1 Or, even amongst the 
 race of man, what is the essence of these numerous racial peculiarities 
 which here confers immunity, and there a special predisposition to 
 certain diseases. All these and many other similar instances of 
 idiosyncrasies of race and colour in respect of drugs and of diseases have
 
 PRESIDENTS ADDRESS — SECTIOX OF SUKCiKKV. 203 
 
 l)ocn recently set fortli in an adniiraMe address by Dr. T. Clifford Alll)utt, 
 and it is impossible not to see in this new science of comparative 
 nosology, the beginnings of investigations wliicli are bound to lead us to 
 facts of the highest importance, both in the science and practice of our 
 calling. In short, what is the value of the mysterious and unknown 
 factor that has been termed "tissue resistance?" To say that this is a 
 cpu>stion which will be soon, if ever, accurately and fully answered, is to 
 admit tliat by somewhat of a by-path we shall reach that ultimate goal 
 of physiology — the realization of the essence of organic life, and he would 
 indeed be ])resumptuous who would assume that this knowledge is in 
 store for us. This is not the place to discuss such a question, but it is at 
 least stiimilating to the mind to be always keeping such a definite and 
 crucial issue before it, and whatever failure there may be, and perhaps 
 must ever be, to reach the comprehension of the great ultimate laws of 
 life, it must surely be that facts of the highest practical value will be 
 unearthed by him who will dig deejily into this scarcely opened mine of 
 ]>hysiological action. 
 
 In such a connection, I cannot refrain from calling your attention to 
 the very remarkable observations of Metschnikoff, which threw quite a 
 new light u}>on the whole question of the capacity of tissues to resist 
 the invasion and progress of morbid processes. Many of tiie results 
 obtained by this observer have been confirmed by that accom[>lished 
 observer, Mr. Sutton, who gives the following graphic account of events 
 as read by the light of their experiments : — 
 
 " The story of inflammation may be likened to a battle. The leucoctyes 
 aie the defending army, their roads and lines of communications, the 
 blood-vessels. Every composite organism maintains a certain propor- 
 tion of leucocytes, as representing its standing army. When the body is 
 invaded by bacilli, bacteria, micrococci, chemicol or other irritants, 
 information of the aggression is telegraplied by means of the vaso-motor 
 nerves, and leucocytes rush to the attack; reinforcements and recruits 
 arc (juickly formed to increase the standing army, sometimes twenty, 
 thirty, or forty times the normal standard. In the conflict, cells die and 
 often are eaten by their companions ; frequently the slaughter is so great 
 that the tissue becomes burdened by the dead bodies of the soldiers in 
 the form of pus, the activity of the cell being testified by the fact that 
 its protoplasm often contains bacilli, itc, in various stages of destruction. 
 These dead cells, like the corpses of soldiers who fall in battle, later 
 become hurtful to the organism which they in their lifetime were anxious 
 to protect from harm, for they are fei-tile sources of septicaemia and 
 I'ytemia — the pestilence and s^courge so much dreaded by operative 
 surgeons. The analogy may seem to many a little romantic, but it 
 apj)ears to me to be warranted by the facts."
 
 204 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 We further learn from the I'esearches of Metschnikoff, that when the 
 ■white corpuscles first come in contact with bacilli in a virulent form, 
 they are unable to touch them, but if they have been educated, so to 
 speak, by having first had presented to them the attenuated form, they 
 have afterwards no ditficulty in gra()pling with the more malignant. 
 If this be so, we get a long step nearer to a rational explanation 
 of the modus operandi of vaccination, and of protective inoculation 
 generally. 
 
 Nor can we shut our eyes to the importance of the recent researches 
 on those alkaloidal products of ])utrefaction, or of normal physiological 
 tissue activity, called by the somewhat barbarous name of ptomaines and 
 leucomaines, for the knowledge of which, and especially for the distinc- 
 tion between the two kinds, we are largely indebted to Gautier. 
 Intensely poisonous, continually being formed even in the healthy body, 
 demanding constant excretion, the body seems to exist in constant peril 
 from the foes of its own household, and it is possible that the retention 
 of these products may be found to account for many hitherto unexplained 
 phenomena. Already a fundamental distinction seems to have come out 
 between the hyperthermia which attends poisoning by the physiological 
 extractives and the hypothermia which is a feature of poisoning by the 
 putrefactive alkaloids. 
 
 The pole-star of the eftbrts both of the biologist and surgeon is, the 
 hope of a better understanding of the nature of these living actions ; 
 towards tJie much wished for goal we are travelling, the one along the 
 broad road of normal processes, the other along the more crooked jiath 
 of abnormality and disease. To the biologist belongs the credit of 
 having discerned that his road lay through the cellular theory; to the 
 surgeon a timely discrimination in having quickly |)erceived that the 
 track taken by his fellow-traveller — the biologist — was in the right 
 direction. Thus, the establishment of the cell theory was quickly 
 followed by a cellular pathology, and henceforth, the two paths slowly 
 converge, and if ever they meet and coalesce, it will be in the solution 
 of the ultimate jjroblems of organic life ; but it may also be that these 
 two paths represent the familiar mathematical concejition of two lines 
 which are continually nearing one another, but which, even if prolonged 
 to infinity, will never meet. 
 
 I think that we surgeons may often scarcely realise the important 
 bearing which this cellular theory and pathology bears to the science of 
 surgery, inasmuch as its establishment signalizes that holy alliance 
 between })hysiology and pathology, to whose fruitful union we owe the 
 all-important generalisation, that morbid pi-ocesses are but perturbations 
 of those of health ; and that to couii)rehend therefore the abnormal, we 
 must first understand the j;iormal, not forgetting that tlie converse may
 
 php:side\t'.s address — section' of suRfiEuv. 205 
 
 ])e true, in that the abnonnal may sonietiine.s shed an uuexjiccted light 
 upon the norniah 
 
 Wliat thoughtful and conscientious surgeon is there who is not deeply 
 sensible of the opjtrobrium which rests upon his calling, as well as of his 
 own impotence, for his incapacity to arrest the ravages of cancer, and of 
 those tumours we call malignant, in acknowledgment of their baneful 
 jirogrcss ; how ignoi'ant are we yet of their real origin ; how unable even 
 to state bald but incontestable facts as to their infectiousness or hereditary 
 descent. True it is, that neither any theories of cells or germs have yet 
 enabled us to answer these questions; nevertheless it is plain that, 
 whether we regard cancer as due to the vagaries of cell growth, or to the 
 running riot, so to sj)eak, of the activities of primordial pi'otoplasni, 
 independently of cell growth, or with whatever theory we approach the 
 ([uestion, it must bo to a better understanding of the normal processes of 
 living tissues that we must look for the explanation of this terrible 
 example of aberration from them. What boasted triumi)h of operative 
 surgery, indeed, could compare with such a knowledge of the caiises of 
 these activities as would enable us to forefend the direful consequences 
 of this, it is to be feared, increasing scourge of humanity ? 
 
 There are few questions of greater importance to the surgeon than 
 that of inflammation ; kept within bounds, his best and surest ally ; but, 
 running wild riot, his most dreaded enemy. Ignorant of its nature, 
 origin and causes, our treatment of it has hitherto l>een hardly better 
 than a rule of thumb ; and yet, nothing seems more clear tlian that the 
 whole process may be expressed in terms of perturbed nervous action, 
 and heightened tissue metabolism ; the conditions dete)-mining which it 
 is permissible to us to think might possibly be determined, averted, or 
 attacked with scientitic precision. Already, T think, we have made 
 some distinct advances in this direction, and I am confident that the 
 [)liysiological basis on which we are proceeding is at last sound and 
 rational. 
 
 It is, as we know, often unwise to prophesy, but such a concej)tion as 
 that just stated raises in the mind visions of what may be some 
 important lines of ad\ance for our calling. We surgeons are sometimes 
 in the habit of indulging in not a little self-glorification at what we 
 have done for the assistance of our medical brethren, by the importation 
 of surgical procedures into what, by an artificial distinction, have been 
 considered as medical diseases. Physicians will, I am sure, ungrudg- 
 ingly acknowledge the great assistance they have thus received ; but 
 there is a way in which medicine may reciprocate, and repay with 
 interest its debt to surgery. Its professors and practitioners may make 
 themselves responsilde for more rational and precise methods in pharma- 
 cology and therapeutics. For too long has the whole of our profession,
 
 206 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 physicians as well as surgeons, rested under the stigma of being mere 
 empirical administrators of drugs, or exponents of a haphazard poly- 
 pharmacy. There has been too much truth in the observation of that 
 scorner of physic, who compared nature and disease to two men fighting, 
 and the doctor to a blind man with a club, who strikes in, sometimes 
 hitting the disease, and sometimes hitting nature. But there are signs 
 of great improvement. Already in the case of curare, atropine, 
 muscarine, physostigmine, pilocarpine, strychnine, veratrine, cocaine, 
 and some other drugs, notably those termed antipyretics, we see the 
 dawn of better days for pharmacology and therapeutics. There is a 
 degree of precision in their application, and of accuracy iu the effects 
 produced, that augurs well ; and, in the case of some of these drugs, 
 there is an encouraging approach to knowledge of physiological action of 
 a precise kind that was undreamt of not long ago. As Professor Huxley 
 has stated the case, "there can surely be no ground for doubting that, 
 sooner or later, the pharmacologist will supply the physician with the 
 means of affecting in any desired sense, the functions of any physiological 
 element of the body. It will, in short, become possible to introduce 
 into the economy a molecular mechanism which, like a very cunningly- 
 contrived torpedo, shall find its way to some j/articular group of living 
 elements, and cause an exjjlosiou amongst them, leaving the rest 
 untouched " 
 
 There is yet another fertile but as yet almost untilled field of 
 research for the surgeon, as well as for the physician, which, if it is to 
 yield its harvest, must be dug with biological tools. What do we know 
 about tliat great factor in disease — hereditary influence, and its laws 1 
 Almost nothing ; and yet w^e cannot doubt that the laws of evolution, 
 of which heredity is so great a factor, are as ap[)licable to disease as to 
 health. That mysterious influence which stamps the offspring with 
 resemblance to its parent, cannot be sui)posed to be confined only to face 
 and form, or to mind and morals. It must extend to all organs alike. 
 If there is a family heirloom in faculty and feature, there will also be a 
 davmosa ha-reditas in liability to disease ; but saving that in a vague 
 and general way we recognise that there is some sort of liability exist- 
 ing for certain diseases, such as gout, phthisis, malignant tumours and 
 deformities, to be transmitted, we can make very feAv definite statements 
 concerning the extent of such liability, still less can we formulate any 
 quantitative laws which regulate their transmission. Although it is 
 scarcely likely that we shall understand the intricacies of jtathological 
 heredity until wo liave a better understanding of its normal or 
 physiological aspects, there is, notwithstanding, but little doubt that 
 bright and discriminating side-lights, revealing facts and clues of 
 high importance, may b(! thi-own u])on the whole general question of
 
 president's address— section of surcery. 207 
 
 descent by instances of the transmissiou of defonnities and disease, 
 just as in tliat very difficult and obscui-e suliject of nerve physiology, 
 the experimental method has received niuch elucidation from 
 pathological observations. Now, the whole (juestion of heredity, 
 with its inextricably interwoven factors of anatomical, physiological, 
 psychological, and pathological effects, is of such enormous import, 
 both to the human race in general, and to our own profession 
 in particular, as bearing on the transmission of actual disease, of 
 liability to sj)ecial disease, or whatever exjiression we may adopt to 
 describe something we do not very well understand, that it behoves 
 medical men, who alone as a class are in a position, and who, by their 
 education, are especially fitted for the task, to contribute and accumulate 
 facts which are calculated to throw light upon a subject of such impoi't- 
 ance. This is onl}' one of the many ways in which collective investigation 
 in Australia might be turned to the best account, and might supplement 
 similar labours elsewhere. 
 
 By methods, singularly ingenious and painstaking, Mr. Galton, whil(3 
 always begging for co-ojieration from the medical i)rofession, has set us 
 an exam{)le of how this kind of research may be successfully carried out 
 on statistical ])rinci^)les ; and 1 believe this Congress might, with the 
 greatest advantage, set on foot a scheme that would in the end result in 
 the accumulation of a vast amount of well observed and well recorded 
 facts, without which assuredly there will be no recognition of the general 
 laws of which we are in search. Not only are these cpiestions of 
 heredity of immediate importance to us as practitioners, but it is impos 
 sible to forget how great a factor it is in the great law of evolution, 
 })erpetuating and fixing, as it were, the variations of organic life ; and 
 assuredly the time may, and I think will, come when we shall have to 
 ask ourselves whether that mighty force is ever to drive us before it like 
 dead leaves, or whether rather, we have not the knowledge and the 
 ])Ower to direct and regulate its influence for the benefit of our race, 
 as we have already been at some pains to do for the beasts of our 
 fields. 
 
 To talk now of evolution under any aspect, would lead me far beyond 
 my mark, but there is no doubt that a wholly new and often unexpected 
 light is thrown upon many pathological produ.cts, such as tumours, 
 deformities, and abnonnalities, by reference to their mode of origin from 
 structures that are, so to speak, relics of inferior organisms or of early 
 conditions which, by their survival or re-appearance, stamp us indelibly 
 with the mark of our lowly origin. Labours, such as those of Sir James 
 Paget and Mr. Sutton, have made us fully alive to the alsundant harvest 
 of facts to be gathered from this wide and neglected field of comparative 
 pathology.
 
 208 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 I am well aware, Mr. President and Gentlemen, that the facts which 
 I have been permitted by your forbearance to relate, however interesting 
 and important they may be in themselves, do not, as thus crudely and 
 badly stated, constitute an answer to the inquiry which stands at the 
 head of this address. I have not been desirous of shirking that issue ; 
 but I felt that I should approach it better if the ground were cleared by 
 a sort of preliminary survey of some points which, I hope, ai'e not without 
 a distinct bearing upon the main question. And, being thus now in 
 some Avay fortified, I propose to attack that question to the best of my 
 ability. 
 
 It has been often said that there is no ideal science exce])t that which 
 is exact, or in other words, which can be submitted to the control of 
 number, weight, and measure, and the statement is })erha})S correct, but 
 it is not true that there is no science except that which is exact. If 
 this were so, the domain of science would be narrowed down to 
 mtithematics and portions of physics and chemistry ; nay more, we 
 should have to despair of bringing much knowledge, that we now rightly 
 count as scientific, within such a definition. For instance, with the 
 most sanguine expectations, it is to say the least of it doubtful whether 
 the primary and fundamental facts of biology, and of the numerous 
 branches of knowledge which proceed from that gi-eat parent trunk, can 
 ever be satisfactorily submitted to such tests. But short of this, we may 
 have science both in substance and in method. As in the case of INI. 
 Jourdain's prose, it sometimes comes as a sur})rise to people who have 
 looked upon scientific knowledge as diff'ering toto ccelo from the ordinary 
 knowledge of every-day life, to learn that there is no such difference, 
 and that such knowledge as they themselves ]>ossess, which is based 
 upon accurate observation and logical deduction, is truly and genuinely 
 scientific. Science, in fact, is not a mode of knowledge sui generis 
 and it employs no methods wliich are exclusively its own. Its difl'erence 
 from the ordinary knowledge of every-day life is one of degree only, in 
 respect of the greater extent and complexity of its range, and in the 
 exactitude of its methods and deductions. Just as in nature, niliil fit 
 per scdtum, there is no sudden transition from one kind of knowledge to 
 the other, bat the higher and more de\'eloped form has grown out of the 
 other by a gradual and rational process of evolution, which is ever con- 
 tinuing and ever widening in its range. Still, if it be permissible to 
 mark off roughly epochs in this gradual process, one may recognise three 
 sta"X's in the growth of a science. In th(> first place, there is the 
 collection of a numl)er of accurately observed, well attested and carefully 
 recoxxled facts, obtained by experiment or otherwise. Then comes the 
 tlie detection of tlu; genuine and constant element pervading the facts, in 
 other words, the determination of tlic^ law which covers and includes
 
 PKKSIDKXTS ADDHKSS — SECTION" OF SUllOKliV. 209 
 
 them. Lastly, there is the verifieiitiou of the la\v, by its ai^plicatiou to 
 new facts. To these three stages we may in the case of tlie iileally-exact 
 sciences add a fourth, that of <iu:uititative determination, or subjection of 
 the facts to tlie criterion of nunil)ers, weight, and measure. 
 
 With such a definition of tlie nature and aims of science, there can be 
 no hesitation in admitting the claims of both medicine and surgery 
 as deserving of the name ; and the degree to which it is deserved will 
 depend entirely upon the extent to which the specified conditions are 
 fulfilled. In the preceding remarks, the attempt has been made to draw 
 attention to some lines of promise, along which certain progress has 
 been made in the directions demanded by this scientific exigency, and 
 which offer good hopes for further advance. Tims, in the isolated 
 and often fragmentary details — which, for the most part, constitute the 
 sum of our knowledge — of extrinsic and intrinsic gei'ms ; of tlie history 
 and behaviour of cells and tissues generally ; of the possiljle influence of 
 autochthonous toxic products of tissue activity, or of the physiological 
 action of drugs ; of inflauiniation and of hereditary influence, we may 
 perceive many undoubted and substantial facts, and even scattered 
 portions of great biological laws which, if developed to their fullest 
 extent, should cover the whole knowable range of vital activities. Of 
 the existence of these laws we are dimly sensible, but we see them only 
 yjer speculum et in enir/niaie. 
 
 Of the terrible gaps in our knowledge even of elementals, of its 
 lamentable shortcomings, of its failure even to ap])roach completeness in 
 any one direction, no one can better admit than ourselves, who suffer 
 not only scorn and rejiroach from others, but also the severer sting of 
 our own conscious ignorance. Still, I think we may take heart of grace, 
 and look ho[)efully into the dim and misty future. All along the line 
 there has been great and manifest advance. Never was tliere a more 
 devoted and enthusiastic band of labourers in the field ; nevei-, liy 
 training and education, were these better fitted for the great work 
 before them ; never was that work more penetrated by the scientific 
 spirit of tlie age, of which the watchwoi'ds are — observation, experiment, 
 deduction, and verification. 
 
 It is with pardonable pride that one finds one's-self justified in turning 
 to the latest development of modern surgery, in illustration of this 
 growing tendency towards calculated accuracy and [irecision both in 
 method and I'esult, which are the qualities on which its scientific character 
 essentially depends. Everyone will anticipate me in referring to the recent 
 X'emarkable achievements in the sui'gery of the brain and spinal cord. 
 
 Based upon a large variety of facts, drawn partly from accurate 
 pathological observations, partly upon a series of oft-repeated experi- 
 ments of the biological laboratory, certain deductions are drawn 
 
 e 
 
 '■*«*
 
 210 INTEKCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 wliicli enable the surgeon to calculate, with a truly scientific precision, 
 the locality of certain lesions. The accuracy of liis anatomical 
 knowledge, which perhaps more nearly than any other of the Liological 
 sciences represents an approach to our ideal science, enables him to 
 define, with still greater accuracy, regions of the brain or cord which 
 correspond to the seat of the anticipated disorder. Whatever be the 
 real truth lying at the bottom of our theories of germs and putrefaction, 
 there is, at least, no doubt that, in the aggregate, the adoption of 
 modern methods have enabled these, amongst other dangerous regions 
 of the body, to be explored and attacked with a minimum of risk of the 
 ordinary surgical calamities, and the maximum of hopeful prospect of 
 recovery. 
 
 Here, indeed, is food for hope ; here is a bright exemplar of the 
 happy results accruing to the art of surgery by the adoption of the 
 methods of science ; and though the measure of success already achieved 
 in the directions indicated may be both absolutely and relatively small, 
 as compared with the life-saving work tliat has been done in other 
 regions which present less intrinsic difficulties, the character of the 
 results ol.)tained are of the highest importance, as indicating what can be 
 done and what must be the manner of our work. 
 
 If I have selected brain surgery as the latest and perhaps, as yet, the 
 best tribute to the beneficent influence of science, I must not be 
 thought unmindful of those other great l)enefactors of our profession 
 and of mankind, whose work has, in a like manner, been made what 
 it is by their overmastering sense of the importance of accuracy and 
 precision. The triumphs of abdominal surgery have been often sung, 
 and I can do no more now than offer, to those great masters of our 
 craft who, hapjjy in their generation, have lived to see their labours 
 crowned with success, the tribute of a renewed assurance from their 
 Australian disciples, that they will ever be remembered as the 
 acknowledged pioneers and leaders in the van of scientific surgery. 
 
 It might, perhaps, have been my duty, Mr. President and Gentlemen, 
 to make some excuse for the extreme biological bias of a surgical 
 address, did I not understand that it was not desired to make a difficult 
 position more difficult by restrictions as to subject matter. This being 
 so, I will make no apology if the exigencies of my thesis have caused 
 me to dwell almost exclusively upon those conceptions of all jiervading 
 law and order which, as I have endeavoured to show, have both 
 determined the present condition of surgery, and alone offer us almost 
 unlimited hopes for its future progress. It may be perhaps, that in 
 dwelling with insistence upon the l)iological aspects of surgerj% I risk 
 the charge of a theorizing transcendentalism, from some of my surgical 
 brethren who, not without reason, pride both themselves and their
 
 PRESIDKXTS ADDKESS — SECTION OF SUUCiERY. 211 
 
 calling on their eminently practical character. Tt is impossible, 
 however, not to contrast the ureat possibilities for the improvement of 
 surgery as a science, that would l)e suggested by a l)etter knowledge of 
 fundamental biological and ])athological laws, with the more circum- 
 scribed sphere of action oftennl by the expectation of increasing the ran^e 
 of our operations. The finality of surgical art was the main text of an 
 address by Mr. Erichsen not long ago, for which he was somewhat 
 severely taken to task by his critics ; but I cannot help sharing his opinion. 
 As Mr. Erichsen points out, there is no artery in the body on which it is 
 possible to jiut a ligature, which has not been tied with every sort of 
 material ; every limb has been amputated to its highest limits ; almost 
 every joint has been re-sected which it is })hysically possible to re-sect ; 
 no abdominal organ that has not been attacked with the knife, eithei- 
 for complete or partial removal, or at least for incision : bones are 
 re-sected, sutured, transplanted, and so are nerves ; larynx, thyroid and 
 lymphatic glands are freely removed. No longer are brain and spinal- 
 cord sacred from interference; indeed, here is perhaps our most 
 ])romising field for an extension of the range of surgery, as distinct from 
 its methods. In intra-thoracic surgery, too, surgical interference has 
 been jmshed, and with admitted advantage, almost to extreme limits. 
 
 Now, I am not saying that absolute tinality even in the scope of our 
 operations has actually been reached, but we cannot conceal from our- 
 selves that we are within a measurable distance of it. As far as 
 anatomical and physiological possibilities are concerned, we must have 
 nearly reached the limits of our art. New worlds there doubtless are to 
 conquer in tlie realms of surgery, but these can scarcely be found in the, 
 as yet, untouched portions of the human frame. 
 
 So, too, as to the manner of our opeiating. It can scarcely be 
 possible to make mucli imi)rovement upon the careful methods of precision 
 adopted by our greatest masters, and taught by them to every student 
 who is willing to learn. Every reasonable, nay almost every practical, 
 way has been suggested for reaching every vessel or organ which is to 
 be approached ; modification after modification of various o])erations has 
 been described with the most careful minuteness of detail, and with the 
 less satisfactory result of bui'dening our surgical nomenclature Avith a 
 host of bai'barous names that is positively bewildering. As a strikin" 
 example of this multiplicity of methods, I have the high authority of the 
 President of the Ophthalmological Section of this Congress for saying, that 
 there are at least forty ways of extracting a cataractous lens, that have 
 been described and claimed as new and distinct operations. A very 
 wealth of ingenuity has been expended in devising new instruments, 
 new splints, new germicides, new ligatures, and new dressings, without 
 number. All along the line, there has been no doubt great and manifest 
 
 p 2
 
 212 IXTERCOLOXIAL MEDICAL CONOR KSS OF AUSTRALASIA. 
 
 improvement in the technique of surgery, but there has been much also 
 that is simple change, begotten of the restless spirit of our age ; and we 
 should be careful to remember that change is not always progress, and 
 that in surgery, as well as in fashion and function, there is a tendency 
 to cyclic recuri-ence, of which it would be easy to mention other 
 examples besides that of the present remarkal)le and profitable revival of 
 supra-pubic cystotomy. 
 
 In speaking of a possible approach to linality in the range of surgery, 
 we are dealing with that which must necessarily be limited by the hard 
 and fast structural and functional facts of anatomy and physiology ; but, 
 it is more liiizardous to suggest similar finality in the technique, because 
 so many of the maniinilative details in the ])ractice of surgery aie in- 
 extricably associated and interwoven with its science. In our own 
 time, we have had many opportunities of seeing what fundamental 
 importance mere manipulative details may assume ; as, for instance, in 
 the case of brain-surgery, ovariotomy, extirpation of the uterus, spleen 
 and kidney, and in the operative treatment of hydatids, where all the 
 difference between frequent failure and brilliant success has been made 
 by alterations of simple technical procedures which, in fact, are but the 
 practical embodiment and application of biological truths that have been 
 consciously, if only partially, perceived, or it may be, have been uncon- 
 sciously anticipated. If indeed we exclude from the practice of surgery 
 all that has a direct reference to scientific principles, whether recognised 
 or not, we have left to us an art which differs only in degree from that 
 of our forefathers. 
 
 All this is merely sa3ang, in another way, that the real and great 
 development of surgery in the future depends upon the extent to which 
 the true relations of physiological and pathological facts can be 
 ascertained and made available ; but it is also implied that, if surgery is 
 to be placed on a sound footing, there must be a close connection 
 between the practical and scientific. If there is a danger for Australiaia 
 surgeons it is that, under the busy and active and often restless 
 circumstances of our lives, there is a strong temptation to neglect the 
 latter, a mistake which is fatal to improvement. We live, it must be 
 confessed, in a world in which pure science receives little in the way of 
 honour or emoluments, save that internal consciousness of well doing, 
 which is glibly I'opresented to be its own and sufficient reward ; and 
 under the chilly atmosphere of neglect and disregard, any sacred fire of 
 science with which our education may once have ins[)ired us, is apt to 
 smoulder and die out. Partly for this reason, but partly also because 
 the management of set details, and of the routine of our art, calls forth 
 so much less of our much prized energies than the hard bending of the 
 mind to laws and principles, there is a strong tendency for us to neglect
 
 i'in;sii)i;NTs addkks.s — section of .suiujeky. 213 
 
 the refining jxinoiples of scitjiice, without which surgery is so apt to 
 
 degenerate into quackery and lule of thumb. 
 
 Nor can we liohl oui- training in tlie past as wholly blameless, for wo 
 
 must be conscions how nnu-h gi-eater store we learned in our student 
 
 days to set upon tlie ihaumatnrgic proceedings of tlie operating theatre 
 
 than upon the less brilliant, only because less evident, work of the 
 
 laboratory and post-mortem room. Now, we know that the glory of the 
 
 most brilliant of operators pales before that of the man of science. And, 
 
 wliere we find eminence Ijoth in surgery and science combined in one and 
 
 the same individual, it is for the latter, rather than the former, that we 
 
 deem him great. No name stands higher in the annals of surgery than 
 
 that of Jolin Hunter, tlie freshness of whose imperishable fame age 
 
 cannot wither, 
 
 •• Nor custom stale liis infinite variety." 
 
 But when, on each occasion of the jiious tril)nte to his memory in that 
 S])len(lid institution which he founded, we survey his life and labours, 
 we realise more and more that if John Hunter, the surgeon, was great, 
 Jolni Huntei', the physiologist and man of science, was still greater. 
 
 If, indeed, there be in us a natural tendency to subordinate principles 
 to jiractice which, if not encouraged, was to say the least of it, not suffi- 
 ciently sternly repressed in our past traiuiiig, we should take warning, 
 and see that we do not perpetuate the evil in those whom we are 
 educating to follow us. Bearing this always in mind, we may look with 
 hopeful confidence to the effect of our medical schools, of which we may 
 be proud ; and in this connection, I cannot refrain from ofiering a tribute 
 of admiration to the success which has followed the zealous and energetic 
 efforts of our Victorian hosts, who, being first in the field, have been 
 closely follo\ved by our common friends in Sydney, and still more 
 )-ecently we, in Adelaide, have endeavoured to follow, not unworthily, in 
 their stei)S. vSo long as we adhere to the high standard, which I think 
 we have nil wisely adopted, we may hope not only that the true scientific 
 spirit will be inculcated and fostered, but also that, by serving as 
 rallying points for all that is best in our profession, our schools will 
 conduce to an active and healthful esprit dt corps, whose watchword is — 
 thorough. If there are .some, as there undoubtedly are, who only see 
 liopelessness in the chance of a successful medical career for a large pro- 
 portion of our alumni, to such critics I would answer — it may be that the 
 struEfgle for existence in our own jn-ofession is as severe as in others : all 
 cannot succeed in it, and many will be disappointed ; but there is this 
 immense countervailing advantage, namely, that no training can be sug- 
 gested which (itfers a better, or even so good, training of the mind — 
 such a technical education, in the best sense of the term, of eye, ear, hand 
 and muscles ; in short, such an all round equipment both of suggestive
 
 214: IXTEUCOLOyiAL MEDICAL COXfJRESS OF AUSTRALASIA. 
 
 and useful knowledge, and of the means and methods of acquiring more 
 of it than does the curriculum of our own profession. Surely, as a means 
 of education alone, a medical training is worth a great deal, not to speak 
 of the intrinsic value of the facts acquired, or of their usefulness and 
 adaptability in all climes and countries. 
 
 80, too, I might speak of the good influences in the same direction that 
 may be exei'cised by these Congresses, and by our local medical societies, in 
 co-ordinating and directing the eilbrts of individuals, and in collecting and 
 legistering the results of their scattered labours. And while we should 
 be undoubtedly im[)roving ourselves, we may also cherish the high hope 
 and laudable ambition, that our united efforts may contribute something, 
 be it ever so little, to the growing store of human knowledge, and to that 
 science of medicine and surgery which, owning no nationality, yet serves 
 all humanity in its endeavour to alleviate the ills to Avhicli it is the heir. 
 An ambitious effort perhaps in these days of progress, but neither pre- 
 sumptuous nor lioi)eless ; for, though we, in far Australia, labour under 
 the great and manifest disadvantages of being widely sepaiated from the 
 active centres of intellectual life of the older countries, and are deprived 
 of the magnetic personal influence of the master minds of the age, our 
 very isolation is not without certain advantages of its own. Tradition 
 and ancient usage bear not upon us with so heavy a hand. The perspec- 
 tive afforded by our distant point of view brings into prominence, in 
 sharp outline in the foreground, much of that which is best, and enables 
 us to discern and discard, perhaps quicker than some of those who are 
 nearer to their origin, doctiines and practices that are reaching their 
 vanishing point. Of practical enterprise, as becomes a young and 
 vigorous race, there is no lack. Save in brain surgery good work has 
 been done in almost every dej)artment, and here also a promising 
 beginning has been made. The facts recorded in Dr. Pinnock's paper in 
 the Transactions of the last Intercolonial Congress, on " Ovariotomy in 
 Australia," ai'e a substantial ])roof that the general avei-age of our surgical 
 work is, to say the least of it, respectable. As a })rofes.sion, we possess 
 the inheritance of a sturd}' independence, which let us take heed we do 
 not imperil by our invitations for Government patronage and protection. 
 We have the splendid opportunities afforded by tiie special circumstances 
 and conditions of our country, for the much-prized privilege of initiating 
 new work, as well as of throwing new light u[)on old questions. Do we 
 make the most of our opportunities? If we Jiave not hitherto done so, 
 these Congresses are an earnest that we have awakened to our duties and 
 responsibilities. Of the value of our work, it will be for others to judge. 
 
 But, Mr. President and Gentlemen, I must be mindful of the whole- 
 some, if unpalatable, advice given to us Australians by a distinguished 
 Englishman. That advice was, as we remember, " Don't blow," and I
 
 PRESIDENTS ADDRESS — SECTIOX OF SUr.fiERY. 215 
 
 feel it is just possible that, in thus dwelling upon our advantages, upon 
 our liopes and prospects, I might find them good enough and bright 
 enough to lead me into temptation. 
 
 It is not so pleasant, but it is a wholesome exercise, for members of a 
 profession Mhose conscious motive is, above all things, a sincere desire 
 that, in the march of progress, there should be no deterioi^ation of their 
 moral and scientific fibre, to ask themselves occasionally whether that 
 position of independence and isolation of Avhich I spoke just now, in 
 reference to its advantages, is not also at the same time fraught witli 
 attendant danger. It is impossible that, in the restless sea of progress, 
 there should not be rocks ahead for all who belong to the craft of 
 surgery ; but it is worth more than a passing thought to consider whether, 
 with so great a separation from the steadying example and intluence of the 
 great master-minds of our profession, and with so great a distance from 
 the head-centres of scientific thought, there is not for us here a special 
 danger, lest we fall into those mental and moral snares with which the 
 practice of our profession is everywhere beset. Lest, in fact, we mistake 
 enterprise for ])rogress; lest we be too little prone to correct that uncon- 
 scious mental bias which, with such cheerful o[)timism, leads us to con- 
 found recovery with cure ; leyt we do not sufficiently restrain that nimia 
 ((iligentia medicorum which, with fatal facility, glides into that which a 
 great surgeon, with warning voice, has termed a prurigo secandi, and 
 that again iilto a veritable /'wror excisorius ; lest, too, in seeking to build 
 up a school of Australian surgery, we do not ever keep before our eyes 
 those solid j)illars of our craft — accurate knowledge, infinite painstaking, 
 and sacred reverence for human life, that constitute the splendid 
 traditions and still guiding })rinciples of British surgery. 
 
 And now, ^Ir. President and Gentlemen, I fear that whatever 
 indulgent consideration you may have been disposed to extend to me 
 has been severely strained. I am consciou.s, deeply conscious, that in 
 the treatment of a difficult theme, I have fallen short, even of the 
 moderate degree of competence of which I had the temerity to believe 
 myself possessed, when asked to undertake this address; but I shall be 
 satisfied, if there should be considered aught of fitness in its unmistakable 
 exhortation, that we study the science of life and of disease while we 
 practice our art of healing. Here, and here alone, lies the promise of a 
 progress unbroken which is limited only by the bounds which are set to 
 the understanding. " The day is short and the work is great, the reward 
 also is great ; it is not incumbent upon tiiee to complete the work, but 
 thou must not tlierefore cease from it." Thus spake an ancient writer 
 of an ancient race, whose stern admonition towards a high ideal of 
 duty is yet tempered by a just appreciation of human power, and a 
 rea.sonable regard for human weakness.
 
 216 INTKKCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 S LAPAROTOMY, WITH REMARKS UPON SOME OF THE 
 INJURIES AND DLSEASES WHICH MAY RENDER 
 THE OPERATION NECESSARY. 
 
 By Sydney Jones, M.D. 
 
 When the Executive of this Congress did me the lionour to ask me 
 to read a ])aper iijjon some surgical subject of prime imjtortance and 
 wide interest, I acceded to their request witli much diffidence. When, 
 however, I called to mind the fact, that I had had the great advantage 
 of being an eye-witness and a close observer of the operation of 
 laparotomy, as performed in numerous cases, and under varied conditions, 
 by some of the great masters in this department of our art in Europe — 
 Knowsley Thornton, Lawson Tait, Granville Bantock, Meredith, Martin 
 of Berlin, Thiersch of Leipsic, and others not quite so distinguished, and 
 that I had myself had some exjierience in abdominal surgery — 
 remembering these things, I say, I thought it might not be altogether 
 unprofitable if I passed in review the o])eration itself, and then briefly 
 discussed some of the conditions which call for its performance. I 
 shall not attempt to describe in detail the various procedures of which 
 I shall make mention ; I shall dwell only upon those points which I 
 regard as of especial importance, or which have attracted my particular 
 attention. In this paper, therefore, I make no pretension of giving an 
 exhaustive account of all or any of the procedures involving a 
 laparotomy. My aim is to discuss some moot i)oints in the o])eration, 
 and thereby, to elicit the opinions and experience of others. I feel 
 assured that there are a great many valuable clinical facts bearing upon 
 this subject, as upon others, stored up in the minds of many of our 
 professional brethren, which have never been put ii])on ])uper, and 
 which I hope my feeble i-emarks may be instrumental in calling forth. 
 If I succeed in doing this, my pajjer will not have been written in 
 vain. It will, I think, be admitted by all, tliat my subject is second 
 in importance to none in the whole domain of surgery. It is certain 
 that the operation of laparotomy has saved more lives during the last 
 decade, than any other surgical procedure. More than this, the 
 sj)lendid successes which have been achieved have given impulse and 
 encouragement to surgeons to invade other regions of the body, 
 lieretofore held still more sacred from the surgeon's knife than the 
 peritoneal cavity itself. It cannot but be that— with the ])ossibilities of 
 more precise diagnosis which physiological research, more perfect 
 ])athological knowledge and closer clinical observation hold out to us, 
 aided by the imj)rovcd mechanical methods suggested by scientific and 
 inventive genius — the saving of life during the next decade will be mucli 
 greater than it has been in the past. Upon the same diagnostic 
 certainty, arrived at Ijy the same methods, will depend the possil)ility of 
 still furtiier extensions of the application of the operation of laparotomy. 
 I believe that in coming years the peritoneum will be more frecpiently 
 opened, with the view to the prevention of disease ; that lesions of the 
 hollow viscera will be more frequently treated surgically ; that aneurism 
 of the abdominal aorta and its branches will be exposed by abdominal 
 section, and treated like aneurisms of the limbs ; that displacements of the 
 
 I
 
 LAPAROTOMY. l' 1 7 
 
 litems will be remedied by direct manipulation of the organ througli an 
 abdominal incision, and that polypi and other diseases of its cavity will 
 be treated by direct incision of its wall, as has, indeed, been done 
 already in one ease by Martin, of Berlin ; and that the appendix 
 verniiformis, as proposed by F. Treves, will be removed for recurrent 
 typhlitic symptoms. xVll these will, without doubt, become ordinai-y 
 procedures. Jt niay, jicrhaps, not be unj)rotitable here, to sketch briefly 
 the rise and progress of the oi)eration of lajjarotomy. Such a sketch 
 will, at anyrate, serve to show how an operation, foreshadowed by the 
 most advanced minds, but condemned by the majority, has ultimately 
 become of universally acknowledged benefit. 
 
 The Operatiox. 
 Of the incision, it is scarcely necessary to say more than that the 
 median will be found the most generally useful in the great majority of 
 cases, and certainly should be selected in all cases where the exact 
 situation of the lesion cannot be ascertained. It is evident, however, 
 that in many ca.ses it will be best made laterally, and it niay need to be 
 vertical, or transvei'se, or oblique. That site which will enable the 
 surgeon most readily to reach the part to be operated upon should be 
 selected ; but, other things being equal, the median should be 
 preferred. The wound being less deep at the linea alba, there is greater 
 facility in manipulating the abdominal contents. In most cases also, I 
 think the incision at the middle line will not need to be so long as when 
 ])laced laterally. According to Ashhurst, muscular wounds in the 
 abdomen are likely to lead to hernia, and we should therefore ex])ect 
 that ventral hernia woidd be more likely to occur after an abdominal 
 section through muscle, than when made at the linea alba. My own 
 limited experience, however, tends to the opposite view, namely, that 
 hernia is more likely to occur after incision in the middle line. An 
 observation made by Dr. HagoiiTorn, in Centralblatt fiir Cldrurgie, No. 
 35, 1884, gives support to my view. He found in a case of ventral 
 liernia, after la])arotomy, in which the abdomen had been opened in the 
 middle line, but in which a cut had also been made in the rectus 
 muscle, that the cicatrix in the muscle was quite firm, and the linea alba 
 had yielded. No doubt this inconvenient sequela of the operation is, in 
 most cases, due to insufiicent care in taking up one by one all the layers 
 of the abdominal wall when introducing the stitches. It is generally 
 agreed, that the length of the primary incision should not be more than 
 two to two and a half inches. This affords sufficient room to insert two 
 fingers, and make such an examination of the parts within, as will 
 enable us to decide upon the nature of the lesion or disease, and the 
 best proceeding to be adopted. An incision of this length will be long 
 enough for the removal of man\' ovarian and all parovarian cysts. If 
 found nece.s.sary, it can of course be i-eadily prolonged, and it will be 
 better to do this than to bruise the edges of the parietal wound l>y 
 dragging, as I have sometimes .seen done, a semi-solid growth through 
 an aperture far too small to admit of its easy extraction. When the 
 parietal i)eritoneum is found to be adherent to the parts beneath, the 
 usual plan of prolonging the incision upwards, until a pai-t is reached 
 where no such adhesion exists, is the best. A long incision is 
 infinitely less disadvantageous than the dehiy and injury caused by
 
 '218 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 stripping tlie parietal peritoneiun from tlie abdominal wall, a mistake 
 ■which I have seen committed on more than one occasion, when the 
 above mentioned rule lias been neglected. 
 
 Absolute luemosfasis. — The importance of checking bleeding, during all 
 stages of the operation, cannot be too strongly urged upon the young 
 operator. The surgeon of large experience in abdominal operations may, 
 perhaps, afford to neglect absolute lu^emostasis until just before opening 
 the peritoneum, but the inexperienced one should never do so. The flow 
 of blood renders the different structures difficult of recognition, thereby 
 prolonging the operation, and adding to the risk. Especially is it im- 
 portant to stop all bleeding in the case of patients in whom the layers of 
 the abdominal wall are matted together, owing to a previous laparotomy, 
 and in whom, also, adhesion of the intestines to the parietal peritoneum 
 is likely to be found. It is exactly in this last condition that free 
 haemorrhage is met with. 1 am firmly convinced that the slipping of a 
 ligature has, in many cases, arisen from the imjjerfect manner in which 
 it has been tied by the slippery blood-stained hands of the operator. 
 Here, in passing, I should like to emphasise the value which I attach to 
 irrigation, which keeps the fingers of the operator clean, and washes 
 away all traces of blood. It is reasonable to suppose, that the saturation 
 of the ligature with blood increases the risk of septic infection. We all 
 regard it as of the highest importance to sponge or wash away all traces 
 of blood from the peritoneal cavity, and yet perhaps we are indifferent 
 to the retention of some of that fluid in the meshes of our ligature. 
 Inflltration with blood of the tissues of the abdominal wall, contiguous to 
 the line of incision, also increases the risk of septic infection, as well 
 as the formation of abscess in the parietes. To assist in ol)viating this 
 infiltration, and at the same time to prevent disturbance of the planes of 
 tissue and retraction of the cut edge of the ])eritoneum, it is, I think, a 
 good plan to pass a ligature through either side directly the peritoneum 
 is opened. These ligatures also enable the assistant to hold the edges of 
 the wound apart during the further progress of the operation. 
 
 Fiat sponr/es. — The peritoneal sac being opened, warm flat sponges 
 should be brought into as extensive use as possible. For isolating the part 
 to be operatetl u[)on; for protecting the bowels and other viscera from un- 
 necessary handling and exposure to the carbolic spray, if that be em- 
 ployed ; for sopping u[) blood and other fluids, and for shutting out the 
 large absorbing anil s:ensitive surface of the peritoneum, and thus 
 obviating the risk of carbolic acid poisoning and shock — for all these 
 pur[)oses, flat and warm sponges are most useful. I am confident, from 
 observation, that they are not made as much use of as they shoidd be. 
 By their use, also, is obviated that prolonged final sponging of the 
 peritoneal cavity which we sometimes witness. 
 
 Clamping hleedinr/ vessels and adhesiovs.— It is scarcely necessary to 
 urge the propriety of not waiting to tie vessels or adhesions, but to 
 clamp them until the operation is completed. Many vessels will then 
 be found not to requiie the ligature, the compression of the forceps 
 having been sufficient permanently to stop tlie bleeding. I make 
 mention of this practice, because of its bearing on the duration of the 
 oi)eration — an important element in the immediate mortality of many 
 ca.ses of lai)arotomy.
 
 LAPAHOTOMV. 219 
 
 W(ii<Ii/))f/ (int. — The removal of tlie tumour, or tlie repair of tlie injury 
 having heeu completed, the question arises, shall we wash out the 
 alxloniiual cavity ? Lmavsou Tait advises and emi)loys washing out as 
 jtreferahle to sponging, which he thinks involves the risk of rubbing oft' 
 the epithelium when the peritoneum is inflamed, and also increases the 
 risk of conveying septic matter into the body of the patient. If there 
 has been much escape of blood, of the contents of a tumour, of pus, of 
 fiDcal matter, or if the peritoneum has been fouled in any way, tliere 
 can be no question of its necessity. But in the absence of these 
 conditions, the opinions and practice of different operators vary. For 
 my own part, in perfectly simple cases, say of cystic ovarian disease, I 
 have avoided washing out as unnecessary and meddlesome, but when 
 extensive adhesions have been separated, or large raw surfaces opened 
 u{), as in the enucleation of tumours, or when there is troublesome 
 Itleeding from numerous oozing points, then I think it is imperative to 
 employ it. There can be no question, that washing out the peiitoneal 
 sac with a large quantity of hot water, at a temperature of about 105° 
 Fah., exercises a luemostatic influence, and it is believed also to be an 
 efficient agent in counteracting shock. I have thought that perhaps hot 
 weak saline solutions would have a still more powerfully restorative 
 effect, in the same way as saline intiavenous injections have been found 
 serviceable in collapse from loss of blood. 
 
 Artificial ascites. — This is perhaps the best jilace to discuss the 
 suggestion first made, I think, by Prof. Peter MuUer, of Berne, viz., 
 that of producing an artificial ascites after laparotomy, with a view to 
 prevent adhesion of coils of intestines to one another, to other viscera, 
 or to the parietal peritoneum. There is but little doubt, that the 
 adhesions just mentioned are the common cause of the tympanites and 
 vomiting, which so often occur after the ojieration, and it is ])ossible that 
 the sepaiwtiou of the coils, brought about by the fluid, in which they are 
 made to float, may Jielp to ])revent the formation of such adhesions. 
 The slow absorption of the fluid would also assist to counteract shock. 
 The suggestion is certainly worthy of consideration, but I am not aware 
 that it has been acted upon to any large extent. INIy friend. Dr. 
 Walter Brown, of Parramatta, so long ago as the 3'ear 1878, with the 
 same object in view, in three cases of ovariotomy, poured warm carbolic 
 oil, 1 to 40, into the abdominal cavity, and moved it about freely among 
 the intestines. He also filled the cavity with the same fluid, before 
 closing the abdominal wound. The drainage tube was not used; all 
 were successful. Mr. Knowsley Thornton has also, 1 believe, used 
 carljolic oil for the same purpose. The adoption of this plan will pro- 
 liably be limited to those cases in which adhesive peiitonitis has existed 
 before the operation, and the peritoneal covering of the intestines is 
 sticky. 
 
 Draiiiarje tube. — Before closing the abdomen, we have to decide 
 whether we shall, or shall not, use a drainage tube. In some cases the 
 necessity is obvious, as wjien the jieritoneum has l)een fouled, or when 
 broad adhesions have been separated, and oozing of blood continues from 
 numerous small |)oints, which cannot be secured. Tait says that the 
 tube is a most useful hsemostatic. In other instances, it is often difficult 
 to come to a decision. We have to gauge the absorbing power of the 
 peritoneum, which varies in deirree in different conditions, and in
 
 220 IXTKRCOLOXIAL MEDICAL COXfiRESS OF AUSTRALASIA. 
 
 patients of diflerent ages. Tn an aged patient, the powei* of absorption 
 is less than in a young one, other things being equaL The use of a tulte, 
 besides the x'isk of pressure on, and injury to, the viscera, adds to the 
 risk of septic infection, and weakens the abdominal wall at the point of 
 exit, and should be avoided when ])0ssible. 
 
 Sutures. — I do not think it matters much whether we use Chinese 
 silk, silkworm gut, or silver wire stitches to close the wound, provided 
 that we are careful to take up each layer of the parietal wall. The 
 thicker the cicatrix the better, as the less liability will there l)e to 
 subsequent ventral hernia. Silver wire stitches, with coil antl shot, 
 undoubtedly possess tjie advantage that the stitches can be readily 
 relaxed if the tension should become great. I saw Pi'of. Thiersch pass 
 wire button sutui'es quite two inches from the edge of the wound. 
 These when tightened up brought together broad surfaces of peritoneum, 
 and had the effect of projecting the line of incision above the level of 
 the surrounding skin. Such an adhesion of peritoneal surfaces would, I 
 imagine, be likely to give way as soon as the stitches were removed, and 
 would therefore offer no advantage, except in protecting tlie superficial 
 sutures from sti'ain. 
 
 Dressings. — Dry absorbent dressings are admitted by all, I think, to 
 be the best. In the after-treatment, the question of feeding by the mouth 
 will depend in some measure on the nature of the lesion for Avhich the 
 operation has been performed. In a case of bowel lesion, for instance, 
 110 prudent surgeon would allow his patient anything more than ice to 
 suck, or a few teaspoonfuls of water to drink for the Hrst forty-eight hours, 
 whereas in a simple case of ovariotomy, liquid nourishment may be tuken 
 at a much earlier ])eriod. Rectal feeding in all cases should be emjAoyed 
 for some days, and I must confess to a preference for jjeptonized home- 
 made enemata, to tlie more solid nutrient masses which pharmaceutical 
 ingenuity has given us. 
 
 Opium and Aperients. — Until within the last ten years, it was the 
 almost invariable practice to kee}> the i)atient for several days under the 
 influence of o[)ium. Lawson Tait in England, and Dr. T. M. Baldy in 
 America, have opposed this practice, and maintained the advantage of 
 administering saline aperients afcer the second or third day, unless the 
 bowels have been moved spontaneously. They regard this treatment as 
 specific against the tyni|)anites, vomiting, and jiain, which we so fre- 
 quently meet with a few days after laparotomy has been performed. 
 Tait says — "I always find tliat as soon as a motion has been passed, the 
 symptoms of distension, vomiting, elevated temperature, and quick 
 pulse rapidly disappear." Dr. Baldy .says — " Logically, salines are 
 infinitely better than opium. We are taught tliat opium puts the bowels 
 * in splints,' and in this manner keeps the peritoneal surfaces from 
 rubbing together and increasing the inflammation. But the bowels are 
 already in splints, as it were, and anyone trying to make them move will 
 be quickly convinced of this fact — therefore, for this purpose, opium is 
 superfluous. The drug i-elievcs the pain, it is true, but oftentimes it 
 does not even do this, except in enormous doses. Belief of jiain is 
 practically all that opium can do for good in peritonitis. It, however, 
 does a world of harm — it helps to keep the bowels in splints, and so 
 favours the forujation of those great masses of adherent intestines which 
 we And so often the cause of subse(]uent intestinal ob.struction; also the
 
 LAPAHOTOMV. 221 
 
 formation of numerous l)an(ls of organised lymph, wliicli as often brin<^ 
 a patient to one in after years. Still worse, it closes all tlie avenues of 
 escape for the poisonous products of intlannnation formed in that great 
 lymph sac, and in this manner, sup])lies material the best possible for 
 keeping up and spreading the intiamniation, much more surely than the 
 rulAiing together of the parietal and visceral peritoneum will. With 
 salines, on tlie contrary, the bowels are kept in active peristaltic motion, 
 and this very motion tends to prevent the formation of adhesions and 
 I'linds — they literally drain the peritoneal cavity of all products of 
 inflammation. This is not merely theoretical, but has been repeatedly 
 observed." Dr. Cxill Wylie advocates enemata for the relief of tym- 
 panites, vomiting, and pain ; and if these fail, a quick purgative. This 
 question of the administration of salines and ai)erients bears upon that 
 which I discussed a few minutes since, namely, the production of 
 artificial ascites. I opine, that the peiistaltic action of the bowels serves 
 the same purpose as the artificial dropsy- — jn'eventing adhesion — in the 
 one case by causing the intestines to alter continually their relative 
 positions; in the other, by keeping them asunder with a layer of fluid. 
 No doubt salines have also the effect of promoting absorption of fluid 
 from the peritoneal cavity, and of carrying off septic nnitters. In my 
 own practice, the custom has been to administer, per rectum, only a 
 moderate dose of opium immediately after the o})eration, to relieve pain 
 and shock, and to give no more unless the pain should become continuous 
 and severe, the bowels being relieved \\h\i enemata. 
 
 When to Operate. 
 
 In all injuries and diseases of the abdominal cavity where operation 
 is entertained, there are ahvays special circumstances which influence 
 our decision as to the [iroper time to operate ; but there are also some 
 general considerations common to all forms of disease and injury of that 
 region, wliich may now be mentioned. I may say, by way of ])reface, 
 that the introduction of the antiseptic method has modified, in a 
 remarkable degree, the views formerly held as to the best time to 
 oi)erate. And when I sjjcak of the antiseptic method, I mean every- 
 thing calculated to secui'e absolute cleanliness, and therefore, the 
 prevention of access of pathogenic germs into the wound, as well as 
 the employment of germicides. It was reasonable, that when the 
 ojieration of laparotomy involved great risk to life, that it should be 
 delayed as long as possible, and oidy performed as a last resort. When 
 that risk became greatly reduced, postponement to a late date in the 
 course of the disease was no longer propei-. I venture, however, to say 
 — though in saying it, I am awai'e that I shall run counter to current 
 opinion — that in the case of ovarian and other tumours, there is still 
 some advantage in waiting for a time until the peritoneum has become 
 accustomed to the i)resence of the growth. There is, I feel convinced, 
 some value in what may be called the " apprenticeship of suffering." 
 Previous suffering, pro\'ided it lias not been excessively severe or 
 prolonged, does, in my oi)inion, in some way prepare the nervous 
 system for a severe operation. In fat subjects, delay also is advantageous, 
 for the difficulty of the operation in them is increased by extreme 
 deposit of adipose tissue in the abdominal wall, and in the cavity of the
 
 '22'2 IXTERCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA, 
 
 belly. Ill them also, the risk of septic absorption is increased, owing to 
 the unavoidable disturbance of the fat cells, and the escape of free fat 
 into the abdominal cavity. In the following conditions, however, 
 laparotomy should be performed without delay : — 
 
 (1) In acute general peritonitis arising from injury, or in the course 
 of disease. 
 
 (2) In any case in which blood, pus, urine, or any foreign matter lias 
 escaped into the peritoneal cavity. 
 
 (3) Where urgent pressure-symptoms, especially those affecting the 
 lieai't, lungs, or kidneys, arise. 
 
 («) Dr. Bedford Fenwick has well pointed out, that the most 
 common cause of sudden death after laparotomy for ovarian, 
 renal, or cystic disease of the abdomen, is fatty degeneration 
 of the cardiac muscle, with thinning of the walls of the right 
 ventricle, and dilatation of its cavity— effects directly due to 
 the powerful upward pressure of the increasing cyst, ])ressing 
 upon the afferent and efferent vessels of the heart and u])on 
 the lungs ; interfering in the one case with its blood-supply, 
 and in the other, bringing about deficient oxygenation. 
 
 (b) Rapidly-developing bronchitic irritation, or dyspnoea, due to 
 
 pressure upon the lungs and pleura, or due to hydrothorax, 
 though the last named may, of course, be temporarily relieved 
 l)y paracentesis of the pleura. The grave bronchitic trouble, 
 with jn-ofuse purulent expectoration, which sometimes arises 
 from the ]>ressure of the rapidly-enlarging ovarian cyst, was 
 well illustrated in my first case of ovariotomy, performed 
 eighteen years ago. It was so severe, as to cause considera1)le 
 anxiety as to the condition of the lung substance, and as to the 
 ])ropriety of operating at all. Twenty-four hours after the 
 operation, the cough and expectoration had entirely dis- 
 appeared. 
 
 (c) Eapidly -increasing albuminuria, from pressure on the renal 
 
 vessels, is a manifestly urgent cause for immediate operation ; 
 as also is direct pressure on the ureters, producing symptoms 
 of suppression of urine. 
 
 (4) Where there is great and )-apidly-increasing emaciation. 
 
 (.5) Finally, where the patient is of advanced age, if operation is to 
 be done at all, it should be done without delay. Cardiac degeneration 
 is much more likely to ensue in a patient suffering from ovarian tumour 
 of large size when over forty years of age, than when younger. 
 
 The general contra-indications to laparotomy are those which pertain 
 to the performance of all major oj^erations, namely, extreme collapse 
 from injury, injuries to other parts which must necessarily prove fatal, 
 very advanced disease of the kidneys, heart, or lungs. 
 
 Pregnancy, although adding somewhat to the risks of laparotomy, is 
 by no means a contra-indication. Many ovarian tumours have been 
 removed during pregnancy, which has, nevertheless, gone on to full 
 term ; and I have myself seen the abdomen opened in a case of suspected 
 extra-uterine foetation, when the condition i)roved to be normal, and no 
 ill result followed. Hei'editary tendency to insanity should caiTy some 
 weight, as a conti'a-indication to ovariotomy, in a case where the
 
 LAPAROTOMY. 223 
 
 advantages and disadvantages of tlie operation are otherwise ))retty 
 equally balanced. Cases of madness following tlu; operation liave been 
 recorded by Barwell, Keith, Thornton, Bryant, Alban Doran, and 
 myself. It is trne that all recovered their sanity, thongh in some, as 
 in the case recorded by me, not for many months after the operation. 
 
 Laparotomy has been i)erformed for gastrotomy, gastrostomy, 
 pylorectomy, ruptured intestine, punctured and incised wounds of the 
 intestine, gnnsliot wounds of intestines, rupture of liver, rupture of 
 spleen, rupture of large blood-vessels, rupture of urinary or gall bladder, 
 rupture of uterus, ruptured tubal pregnancy, perforation from ty])hoid 
 ulcer, abscess, intussusception, acute intestinal obstruction, chronic 
 intestinal obstruction, tuberculous pei'itonitis, purulent peritonitis, 
 liydatids, hydro-, hfemo- and pyo-salpynx, Ciesarian section and Porro's 
 operation, removal of spleen, nephrotomy and nephrectomy, chole- 
 cystotomy, oophorectomy and removal of tlie appendages, hysterectomy, 
 enucleation of fibroids and cysts, ovarian and parovaidan cysts, cysts 
 arising from dilatation of a patent urachus, extra-peritoneal cysts of 
 unknown origin, cysts of the mesentery and omental cysts, lipoma of 
 omentum, aneurism of the abdominal aorta and its branches, and finally, 
 for exploratory purposes. 
 
 Gastrotomy. 
 
 Gastrotomy, for the I'emoval of foreign bodies from the stomach, 
 has now been performed several times with success — the incision 
 in the wall of the viscus being closed with Lembert's, or the continuous 
 suture. With far less success, as might be expected, but still with 
 some encoui'agement, it has been done with a view to dilatation of the 
 orifices in cases of cicatricial structure. Pi'ofessor Loreta, of Bologna, 
 originally proposed and ])erformed the operation with this object, and a 
 few others have followed his example. 
 
 Gastrostomy. 
 
 Gastrostomy has now been ])erformed in a large number of cases for 
 obstruction of the cardiac orifice of the stomach, or of the cesophagus 
 — malignant or cicatricial. The mortality in the malignant cases has 
 been high, but in the cicatricial as low- as 29 ])er cent. If done in the 
 early stages of obstruction, the mortality is much less than if deferred to 
 the later. A painful death by starvation, at any rate, is obviated. 
 The fatal issue in the malignant cases has been due to the spreadin<'- of 
 the disease which rendered the oj)eration necessary. 
 
 Several methods have been adopted of fixing the stomach in the 
 abdominal wound. Tliis may be done by double suturing, after Howse, 
 by hare-lip, or acu-pressure or safety pins, or by pressure forceps, the 
 blades of which are covered with indiarubber, and the handles stitched 
 to the abdominal vv'all. By the last mentioned method we avc^id 
 puncture of the walls of the stomach, but I think, from observation of 
 two cases in w])ich the forceps were used, that close contact of the 
 gastric and parietal peritoneum is not so perfectly secured as by sutures 
 or hare-lip jiins. 
 
 Whatever plan we adopt, we must be careful not to open the stomacli 
 befoi'e pretty firm adhesions have been formed. This mistake I saw
 
 224 IXTERCOLONIAL MKDICAL COXGRKSS OF AUSTRALASIA. 
 
 committed on two occasions, hotli cases jn-oving fatal within a few days. 
 Tiie exhansted condition in which these patients usually are before 
 operation, and their low vitality, render the process of inflammatory 
 adhesion slower than it would be in a healtliy individual. This same 
 state of exhaustion also makes the surgeon anxious to o[)en the stomach 
 at the earliest possible moment, in order tliat stomach feeding may be 
 commenced. To meet this difticulty, I would suggest the advisaliility of 
 injecting milk or other liquid nourishment into the stomach by means 
 of an aspirating syringe. The minute puncture made with the needle 
 is at once closed by the bulging into it of the mucous coat of the organ, 
 and all leakage is prevented. This injection may be commenced 
 immediately on the conclu.sion of the tirst stage of the operation of 
 gastrotomy, and repeated every few hours as may be thought necessary, 
 until firm adhesions have taken place. If rectal feeding be combined 
 with the plan of injection just described, the patient would be well 
 sustained until such time as it was thought to be [)erfectly safe to open 
 the stomach. The adoption of tiiis plan will also render unnecessary 
 that which English surgeons at any rate regard as very undesirable, 
 namely, immediate opening of the stomach. 
 
 PVLORECTOIIY. 
 
 Pylorectomy is only practicable when the [)yloric end of the stomach 
 is quite movable, and the lymphatic glands in the neighbourhood are 
 iniaffected by the disease. When these contra-indications exist, duodenal 
 or jejunal gastrostomy should be performed. Indeed, there is a growing 
 tendency to sulistitute one or other of these operations for pylorectomy, 
 in all cases of malignant disease of the pyloriis. 
 
 COXTUSION AND RuPTURE OF THE IXTESTIXES. 
 
 The difficulty of diagnosing simjile contusion, from rupture, is great. 
 The symptoms of shock are undistinguishable from those of collapse 
 from loss of blood. In simple contusion, it is manifest that delay is 
 desirable, as the patient may recover without any operation, if the 
 injury be not so severe as to lead to subsequent sloughing of the bowel. 
 In rupture, delay will probably be fatal. 
 
 The history of the injury may sometimes give us a clue. Should the 
 abdomen become universally tympanitic, we know tliat gas has escaped 
 into the peritoneal cavity, and that rupture has taken place. Emphy- 
 sema of the subcutaneous cellular tissue also, from escape of gas into 
 that structure, at a part where the bowel is uncovered by peritoneum, 
 will give us the same information. As far as I can ascertain, not a 
 single case of recovery, after lai)arotoniy for ruptured intestine, has taken 
 place. There are prol)ably two reasons for this, exclusive of shock — 
 First, that in consequence of the difficulty of making a correct diagnosis, 
 the operation has been too long delayed ; and secondly, that in con- 
 sequence of bruising of the bowel beyond the actual site of rupture, 
 necrosis is apt to occur, with extravasation of the intestinal contents. 
 Pi-obably the best practice in all cases of rupture, except those situated 
 very high up in the alimentary tract, is to estal)lish an artificial anus, 
 thus avoiding the risks of extravasation, and affording the bruised 
 bowel l>elow the anus absolute rest, and a better chance of escaping
 
 LAPAROTOMY. 225 
 
 necrosis. Enteroytouiy also occupies so inucli less time than suturino', or 
 i-esection, that it obviates the risk of a prolonged operation- — a most 
 important matter in the cases we are considering, where shock is so 
 cons])icaous a feature. 
 
 I cannot 1)Ut think that putting aside shock, the tendency to sul)- 
 sequent gangrene of the gut, in the cases in which the l)Owel has been 
 sutured and returned, explains the remarkal)le difference in the mortality 
 of laparotomy for this lesion, and that for stabs and pimctured wounds 
 of the intestine, where the recoveries are about 66 per cent. 
 
 Gun-shot Wounds of the Abdomen Involving the Viscera. 
 
 Much difference of opinion has been expressed as to the prourietv of 
 probing gun-shot wounds of the abdomen which may possibly invoh e 
 the underlying viscera. When done carefully, and l)y an experienced 
 hand, I can see no objection to such a proceeding. A'aluable informa- 
 tion as to the direction the missile has taken thi-ough the abdominal 
 cavity may be acquired — for that direction will u.snally be the same as 
 that of the tiack through the abdominal parietes. Further, I see no 
 objection to laying ojjeu the track if it be not very extensive, and so 
 ascertaining with certaint}^ whether the peritoneum has been punctured, 
 and also obtaining some definite information as to the })robable track of 
 the bullet through the ])eritoneal cavity. 
 
 When the direction of the missile renders it probable that one of the 
 fixed viscera (and in this class I include the large intestine) has been 
 injured, incision directly over the site of the o)'gan will ])robably be the 
 best. On the other hand, when that direction would indicate that the 
 movable viscera, and especially the jejunum and ileum, have been 
 involved, then I think the median incision should be chosen. If it be 
 impossible to ascertain the probable direction, then also, the linea alba 
 should be selected. 
 
 Perforating ulcers of the bowel, when due to foreign bodies, gall 
 stones, or Viurns of the skin, demand immediate lapai'otomy, if the 
 diagnosis can be made. In typhoid and tuberculous ulcers we have, in 
 most cases, to deal with patients already greatly exhausted by the 
 disease, and with a large tract of intestine, if not actualh^ involved 
 in ulceration, yet in a condition which renders healing, after a plastic 
 operation, most unlikely to occur. Under such circumstances success 
 cannot be expected. When ])erforation occurs during convalescence, 
 and especially when it occurs in those cases of mild typhoid, which my 
 old teacher, Dr. W. H. Walshe, used to call "peripatetic," then 
 laj^arotomy will afford the patient a fair chance of recovery. 
 
 In perforation of the appendix vermiformis, we are beset with the 
 difficulty of deciding whether we have to deal with actual perforation of 
 the appendix, or with a typhlitis. Could we, with certainty, differentiate 
 these conditions, our proper course of action would be clearly defined. 
 Early operation in cases of perforation is our duty, whereas the vast 
 majority of the cases of typhlitis will get well under judicious medical 
 treatment alone. By judicious, i mean the absolute avoidance of all 
 purgatives, witli rest, and liquid nourishment in very small quantity. 
 Late operation may be ne(-ded in some cases of perityphlitis, owing 
 to suppuration in the cellular tissue of the iliac fossa. When this does 
 occur, the retro-peritoneal ojjeration should be performed. In all other 
 
 Q
 
 226 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 cases, when operation is required, incision directly upwards from about 
 the middle of Poupart's ligament will usually afford the readiest access 
 to the aifected parts. 
 
 Since writing the above, I have read the report of a discussion intro- 
 duced by Dr. Bull, of New York, at the Medical Society of London, on 
 the surgical aspects of typhlitis and perityphlitis. Dr. Bull opened the 
 abscess extra-peritoneally in ten cases, and they all recovered. He 
 advocates the use of the exploratory needle to determine the presence of 
 pus. Dr. Bull, Mr. F. Treves (of London), and Dr. Weir (of New 
 York) expressed the opinion, that in all cases in which abscess forms, 
 there is perforation of the appendix. 
 
 Dr. Bull concluded his paper with the aphorism, that the risk of 
 operation was less than the risk of waiting. 
 
 Intussusception. 
 
 It is, I think, clear that the great fatality, which has until within 
 the last twelve months followed the operation of laparotomy for 
 intussusception, has been due to the fact that it has been put off until a 
 late stage of the disease — that, in fact, it has been looked upon as a 
 proceeding to be adopted only as a last i-esource. I entirely agree with 
 Mr. A. E. Barker, of University College Hospital, London, who 
 contends that, as in an ordinary case of hernia we are always prepared 
 to operate upon the failure of the taxis, so in intussusception, when 
 failure has attended the efforts at reduction by inflation, injection, and 
 inversion of the body, we should be prepared at once to do laparotomy. 
 The longer we wait, the more surely will the case become one of 
 " strangulation," instead of being, what it is in the early stage, one of 
 "incarceration." Strangulation existing, reduction of the invaginated 
 portion of gut will be probably im])0ssible. To trust to the possible 
 recovery of the patient by the perilous process of sphacelation, and 
 casting oft' of the strangulated intestine, is unjustifiable. The recent 
 remarkable diminution of mortality, which has attended abdominal 
 section for intussusception since this rule has been followed, gives strong 
 support to the justness of Mr. Barker's view. 
 
 Chronic Intestinal Obstruction. 
 
 Division of adhesions or bands, enterostomy and resection of the 
 intestine, are the methods which have been ordinarily adopted for the 
 relief of chronic intestinal obstruction. Mr. Lawford Knaggs has 
 proposed a fourth method, namely, union of the gut above the obstruc- 
 tion with some portion of the tract below it, the part of the bowel 
 involved in the obstruction being left in situ. 
 
 When adhesions are extensive, and it is found impossible to separate 
 them, or where the cause of the obstruction cannot be discovered, 
 enterostomy will probably be the best ])rocedure, Mr. Lawford Knaggs' 
 method, just mentioned, being followed if the obstruction be high up in 
 the small intestines, so as to obviate the escape externally of the 
 contents of the upper part of the tract, and the rapid wasting and death 
 by inanition, which such loss invariably brings about. The exhausted 
 condition of the jiatient also may bo so great that a rapid operation is 
 necessary, and then enterostomy will be the best method.
 
 r.APAKoroMY. 227 
 
 Mr. Lawsoii Tait deprecates any pi'olongecl search being made for 
 tlie cause of tlie ol)Struetion, and ))ractises enterostomy in a lar"e 
 number of cases of obstruction. Whatever may be the e.x;planatii)n of 
 the way in which enterostomy cures, practically it is found that 
 evacuation of the intestinal contents, and the resulting relief of distension, 
 do, in many cases, remove the obstruction, and it becomes possible to 
 close the fistula subsequently without any riiturn of the symptoms, the 
 lumen of the l)owol being apparently (|uite restored. 
 
 Absckss of Liver. 
 
 In abscess of the liver, incision through the i-ight linea semilunaris, 
 stitching the capsule of the liver to the wound in the parietal 
 peritoneum, or if there be no need to hurry, stuffing the wound with 
 carbolised or sublimate gauze to excite adhesion, opening and drainage, 
 constitute the plan ordinarily and successfully adopted. I siiould not have. 
 alluded to it, but to point out that sometimes, owing to the position of 
 the abscess, it is found difficult to secure free drainage. When this is 
 likely to be the case, the suggestion of Kartulis should be borne in 
 mind, namely, that of re-secting portions of one or more ribs. The 
 manifest disad\antage attending this ])lan is, that the diaphragm will 
 frequently have to be cut through, and if there be no adhesions, there 
 is danger of the pus entering the pleural sac. Tn one case of hydatid 
 cyst of the liver which came under my oljservation, and which was 
 treated in this way, infection of the ])leural sac actually occurred. 
 
 Stitching together the diaphragmatic and costal pleura^, if possible, 
 before opening the abscess or hydatid cyst, and thus shutting oti' the 
 pleural cavity, would probaljly obviate this danger. 
 
 Tumours of the Kidney. 
 
 The battle of the lumbar and abdominal methods, for the removal of 
 kidney tumours, is still unsettled. Mi'. Knowsley Thornton strongly 
 advocates the abdominal method ; Mr. Morris is a warm supporter of 
 the lumbar. In course of time when we become capable of more precise 
 diagnosis, we shall probaljly tind that tumours of a certain size, nature, 
 and position, will be best removed by the one method ; whilst tumours, 
 presenting the opposite characters, will l)e best dealt with l>y the other 
 method. 
 
 Tlie lumbar method, avoiding as it does all interference with the peri- 
 toneal cavity and its attendant risks, naturally disposes us to select it if at 
 all practicaljle, especially if our experience of abdominal surgery has not 
 been large. On the other hand, it has special I'isks of its own, and 
 the most serious of these, and a necessarily fatal error is, that of 
 removing the only kidney which the patient possesses, or the only one 
 which has functional activity. The abdominal method enables us to 
 examine the opposite kidney to that upon which we ju'opose to operate, 
 and thus to avoid a most lamentable mistake. Recenth', in witnessing 
 the post-mortem examination of the body of a medical man, whose case 
 I had had sevei-al opportiinities of observing from his boyhood, the risk 
 of which I am now siteaking was strikingly demonstrated. For some 
 years he had had a pyelitic swelling on the right side, of calculous 
 origin, no tumour having been noticed on the left side. We found the 
 left kidney completely saccular, all renal secreting tissue having dis- 
 
 Q 2
 
 228 INTKUCOLONIAL MEDICAL COXORESS OF AUSTHALASIA. 
 
 appeared. The tumour on the right side consisted of the dilated pelvis 
 of the kidney, with saccuhir dilatation of a considerable part of the organ 
 itself, whicli however, still had a large portion of its excretory structure 
 iinattected — manifestly, this kidney was the only one that had been 
 doing any work for some years. Had removal been proposed, and 
 the lumbar method selected, the surgeon would certainly have operated 
 on the right kidney, and thereby cut short the patient's life. Still more 
 recently, another illustration of the advantage of the abdominal method 
 came under my observation. An hydatid tumour of the right kidney 
 was diagnosed, and although its most prominent and accessible part was 
 in front, still, as it could be pushed well back into the loin, the surgeon 
 ])roceeded to opei'ate from the lumbal' i-egion. The ascending colon was 
 found to be so closely and firmly attached to the tumour, that it was 
 impossible to incise the latter without risk of injuring the bowel. A 
 laparotomy at the right semi-lunar line was then made, and at once the 
 surgeon came upon the cyst wall, which he stitched to the parietal 
 wound, opened, evacuated the daughter cysts, and introduced a drainage 
 tube. It is true that, during the progress of the lumbar operation, it 
 became doubtful whether the tumour was connected with the kidney at all ; 
 liut the possibility of mistake as to the exact seat of the growth is another 
 argument for the abdominal method. Where there is a hydro or P3'0- 
 ne[>hrosis bulging into the loin, no doubt the best plan is to incise and 
 drain from that site. Subsequently, should removal be required, and 
 the tumour have become shrunken, lumbar ne])hrectomy may be practised, 
 if there is reasonable probability that the opposite kidney is so\ind. 
 Should there be any doubt aljout this, or the tumour be still of large 
 size, abdominal section should be performed, both kidneys examined, and 
 either the trans-jjeritoneal of Terrier, or the retro-peritoneal method 
 of removal, be adopted. The cut end of the ureter may either be attached 
 to the parietal wound, or preferably in some cases brought out through 
 a puncture in the loin, and stitched to the skin in that situation. If 
 after oi)ening the abdomen in any case, it be found that removal 
 from the loin offers the greatest advantages, a hand in the abdominal 
 cavity, steadying the kidney, will much facilitate the proceeding. 
 
 Myoma of the Uteuus. 
 In the treatment of fibroids of the uterus, five jilans are open to us, 
 exclusive of the electrolytic. Each of these will be appropriate in certain 
 cases: — 1st, treatment by drugs ; 2nd, removal of the appendages; 3rd, 
 enucleation ; 4th, hysterectomy ; 5th, ligature of the pedicle, and return 
 of the stump, as in ovariotomy. The last mentioned will only be 
 api)licable in the case of pedunculated tumours, and then but rarely. 
 The medical treatment cannot be considered here, but I may say in 
 passing, what perliaps some surgeons are apt to forget, that much may 
 often be done by dieting, especial!}' al)stention froni animal food and 
 alcohol, and also by the aid of drugs. In a large number of cases, no 
 other ti'eatment is recpiired. Removal of the ajipendages has been fre- 
 (juently practised for intra-mural bleeding or [)ainful myomata. It is 
 often found to be impossible of execution, owing to the large size of the 
 tumor, and the imi)Ossibility of bringing the ovaries to the surface. In 
 cases also in which the fibroid is found to be undergoing cystic degenera- 
 tion, removal of the appendages has proved useless. When practicable, 
 
 I
 
 LAPAKOTOMY. 220 
 
 tliis ]'>roceetling sliould lio practised in ])reference to enucleation or 
 liysterectoniy, as involving less risk to life. It is of importance to ap])ly 
 the ligatures as close as possible to the uterine wall, and thus to diminish 
 the blood su)>ply as far as practicable. I have witnessed two cases of 
 intra-peritoneal enucleation of fibroids of the uterus, and the proceeding 
 was in both cases a formidable one. In one, as many as fifty pairs of 
 Ka4)erle's forceps were in use at the same time, comjiressing the mouths 
 of bleeding vessels. Only when the fibroid is extra-mural, and eitlior 
 non-pedunculated, or with a very broad and short pedicle, is enucleation 
 likely to be attem])ted; and the large raw and readily absorbing sui-face 
 which is left, constitutes a risk wliich is ])robably greater, in most cases, 
 than that incurred in })eiforming hysterectomy. Provision for very 
 complete drainage is also necessar}'. The oidy case illustrating the 
 fifth method of dealing with fibroid which I have seen, was one of 
 ]\Ir. Thornton's, the pedicle being of good length, and neither broad nor 
 thick. The temptation to treat it like the pedicle of an ovarian cyst was 
 too great to be resisted. It was transfixed with a double thread tied in 
 tlie usual way, and the tumour cut awaj'. The cut edges of the peritoneum 
 around the stum]> were drawn together b}' the glover's stitch; the stump 
 itself was allowed to drop back into the jjelvis ; the abdominal wound 
 was completely closed, no drainage tube being used ; the patient made 
 H perfect I'ecovery. Rarely will the condition of the pedicle be such as 
 to permit of its being treated in the manner just mentioned ; its 
 shortness, fieshiness, and vascularity forming usually insurmountable 
 obstacles. When, however, it is practicable, the advantages which it 
 afi"ords are manifest, and should not be lost sight of. 
 
 The fourth mentioned method, is that of complete hysterectomy. 
 Hemoval of the uterus and the tuuiour has been practised with much 
 success by Dr. Granville Bantock, to whom in England is due in large 
 measure the established position which the operation has acquired. 
 There are two accidents which may occur in the performance of the 
 operation, and which need to be carefulh^ guarded against — one is, 
 the wounding of the bladder ; and the other, division of one or both 
 ureters, which are often closely applied to the surface of the tumour. I 
 have several times seen the bladder in great danger of being included in 
 the wire of tlie serre nceud, and in one case the fundus of that organ was so 
 included, and cut away. The simple expedient of keeping a catheter in 
 the bladder, whilst the wire is being adjusted and tightened up, will 
 serve to prevent such an untoward accident. If we bear in mind the 
 fact that the ureters are liable to injury during the operation, we shall 
 be little likely to danuTge them. Such an accident, if unrecognised, 
 would a.ssuredly foul the peritoneal cavity. The open end of the uterine 
 cavity, or canal of the cervix, should be thoi-oughly clean.sed by some 
 antiseptic application, then the cut edges of peritoneum should be 
 drawn together over the tO}) of the stuuip by a continuous suture, in the 
 same manner as the mouth of a bag is closed by a string. The area of 
 cut surface is thus reduced, septic infection is less likely to occur, and 
 .shrivelling of the stump itself is favoured ; shreds of dry antiseptic 
 gauze foi-m the best dressing. The application of some powerful styptic 
 or antisej)tic to the cut surface of the uterine stumj) is, 1 think, 
 ilangerous. T'here is always risk of some of it passing down by tiio 
 feide of the stump into the peritoneal cavit3\
 
 230 INTERCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 It may surprise you to hear tliat I have nothinp; more to say respect- 
 ing the removiil of ovarian cystomata. A good deal of what has been 
 already said applies largely to ovariotomy, but that operation is so well 
 understood, and has been so well nigh brought to perfection, that I think 
 it unnecessary to occupy your time, already too much trespassed upon, 
 in discussing it. I shall only say that to a wider-spread knowledge of 
 tlie ill results of tapping — ill results often shown by the formation of 
 adhesions, and by infection of the peritoneum with jiapillary growths — 
 to a more precise diagnosis, and to a more com])lete asepsis, we must 
 look for a still greater reduction of the already small mortality. 
 
 UPON THE TREATMENT OF SO-CALLED TROPICAL 
 ABSCESS OF THE LIVER BY FREE INCISION AND 
 STITCHING OF THE ABSCESS-WALL TO THE LIPS 
 OF THE PARIETAL WOUND. 
 
 By Joiix Davies Thomas, M.D. Lond., F.R.C.S. Eng. 
 
 I have ventured to invite the attention of the Members of the 
 Congress to the histories of three cases of abscess of the liver, whicli 
 are here briefly reported, partly because, at any rate in my experience, 
 this disease is rare in the southern parts of Australia, and partly 
 because, to the best of my belief and knowledge, the treatment adopted 
 in these cases is rarely, if ever, carried out in India and other tropical 
 countries in which the disease in point is Aery common and fatal. 
 
 For the notes of the following case, I am indebted to Dr. Toll, of 
 Port Adelaide, under whose care the patient in question was during the 
 A\hole of his serious illness. The detailed notes of the case have 
 unfortunately been lost, and those recorded here are, on that account, 
 somewhat incomplete. My personal knowledge of the case is limited to 
 an examination immediately before the operation, and to the perform- 
 ance of the operation itself, in company with Drs. Toll and Lendon : — 
 
 Case I. 
 
 W. B. B., aged 28, was admitted into the Port Adelaide Hospital on 
 Octol^er 2, LS87. The patient had lately returned from the Kimberley 
 goldlields, Western Australia, and during his residence there he had 
 suHered great privations, and had had several attacks of ague. After 
 an illness of several weeks' duration, he came under the care of Dr. 
 Toll. At this time he complained of feverishness, j^ain in the hepatic 
 region, incessant vomiting, cough, and profuse night-sweats. His 
 temperature ranged from 99° to 103 . 
 
 Upon examination, the \i\ev was found to ])e greatly enlarged in 
 area ; there was considerajjle l)ulging in the hepatic region ; there was 
 also troublesome cough without expectoration, and with no evidences of 
 cardiac or pulmonary disease ; vomiting was almost incessant. 
 
 C>n Octoljer 2, F saw the })atient in consultation with Dr. Toll, when 
 we arrived at tlie conclusion, that there was an enormous aljscess of the 
 li\(M' present. The correctness of the diagnosis was contirmed by the
 
 TREATMENT OF SO-CALLED TROPICAL ABSCESS OK THE LIVER. 231 
 
 introduction of an aspiratoiy needle in one of the lower interspaces in 
 the x'ight axillary line ; it was also decided that immediate operation 
 was called for, in order to anticipate a speedy rupture probably into the 
 lung. An incision was made over the fifth intercostal space, tlie pleura 
 was opened, and the diaphragm was found not to be adherent to the 
 costal pleura near the wound. It was then cautiously di^■ided to the 
 extent of about two inches, when the surface of the liver showed itself, 
 tltere beiny, as far as could be ascertained, no adhesions beween the 
 diaphragm at this spot and the surface of the liver. An exploratory 
 needle was tiien inserted into the exposed liver tissue, and pus was 
 reached innnediately. Two strong curved needles were now passed so 
 as to transtix the wall of the abscess in two parallel lines about two 
 inches apart ; Ijy means of the needles, two stout loops of aseptic silk 
 were carried through the abscess wall, so as to loop it up tirmly against 
 the edges of the parietal incision ; the wall of the abscess was then 
 divided to the extent of about three inches, and the escape of pus into 
 the peritoneal and pleui-al cavities was prevented by bringing the liA'er 
 surface tirmly up to the sides of the wound. An enormous quantity of 
 thin blood-stained pus, amounting probably to several pints, escaped ; 
 the cavity of the abscess was gently but carefully cleansed with sponges 
 introduced by long forceps, ttc. ; a large drainage-tube was carried 
 to tlie bottom of the cavity, and the usual antiseptic dressings were 
 applied. The entire operation was carried out under strict antiseptic 
 precautions, including the use of the .spray. 
 
 For several days after the operation, pyrexia, cough, and perspirations 
 continued ; the dressings were changed twice daily, the drainage-tube 
 being removed occasionally to be cleansed. About the 16th day, the 
 drainage-tube was finally removed, and on the 21st day, he was 
 discharged from the hospital ; ten days later, the wound had entirely 
 closed. When admitted into the ho.spital his weight was 9st, when 
 discharged lOst 71b, and when he was last heard of, he was at the 
 goldfields of the Transvaal "in .splendid healtli," and weighing 14.st 91b. 
 
 Case II. 
 
 W. J. D., aged 38, labourer, was admitted into the " Alexandra " 
 "Ward of the Adelaide Hospital, on September 22, 1888. Born in 
 North America, he has visited uiany parts of the world, and has often been 
 in tropical latitudes ; two years of his life were passed in a ship oft' the 
 China coast, but for many years past he has lived in Australia. 
 Twelve years ago he had an attack of dysentery which lasted for three 
 weeks, and ten years .since he seems to have had a mild febrile illness, 
 for which he was treated at the Adelaide Hospital for about ten days. 
 He dates his present illness about eight weeks back, when pain referred 
 to the lower end of the sternum, the right hypochondriac region, and 
 the right shoulder, came on. A fortnight prior to his admis.sion into 
 the Hospital, he thinks that he caught cold, at any rate, he began to 
 spit up blood daily, and he estimates that he has since continued to 
 expectoi'ate every day about half-a-pint of blood-stained matter. 
 
 On examination, he was found to lie a somewhat spare man, ana*mic, 
 and of .sallow complexion. There was distinct bulging in the right 
 hypochondriac region ; the interco.stal depressions at the lower part of 
 the right chest were obliterated, and the subcutaneous \-eins in this
 
 232 INTERCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 region were unusually evident. In the riglit nipple and parasternal lines, 
 dulness commenced at the fourth rib, and thence extended vertically 
 downwards to a point about two inches below the costal margin. Tn 
 the riglit axillary line, the upper line of dulness was at the level of the 
 nipple ; posteriorly, resonance was deficient everywhere below the spine 
 of the scapula, whilst absolute dulness appeared two lingers' breadth 
 below the scapular angle. Over the entire right lung, the respiratory 
 murmui' was weak, but not otherwise altered in front ; posteriorly, the 
 respiratory murmur was not only weak, but was accompanied by a 
 coarse, sub-crepitant rale, possibly friction. Vocal resonance and 
 fremitus were practically normal. On the left side of the chest nothing 
 abnormal could be discovered, except a slight displacement of the apex 
 beat to the left ; there was present also a double basic murmur. In 
 the right hypochondriac and epigastric regions there was a distinct 
 tumour, which projected moderately ; its surface was smooth, elastic, 
 but not fluctuant. Jaundice was absent. No discoverable enlarge- 
 ment of the spleen. An exploratory puncture in one of the lower 
 interspaces yielded blood-stained pus. 
 
 September 2Ttli, 1888. — Operation by Dr. Davies Thomas, assisted 
 by Drs. Way and Lendon. An incisioii about three inclies long was 
 made a little above the sixth rib, and parallel to it ; at its posterior end 
 another incisioii about an inch and a Iialf in length was made at right 
 angles to the former one ; both were carried down to the rib. When 
 bleeding had ceased, a piece about two inches long of the sixth rib was 
 excised ; the periosteum, however, having been previously stripped oft". 
 Some slight difficulty was encountered in the removal of the piece of 
 rib, in consequence of the existence of anchylosis between the tifth and 
 sixth rib, for a small space at the place of operation ; no reason for 
 the anchylosis was discovered. The costal pleura was now exposed, 
 but had not been opened. An exploratory needle was inserted into the 
 abscess, in order to obtain full assurance that it lay at the bottom of 
 the wound ; this being satisfactorily ascertained, two strong curved 
 needles, firmly set in handles and armed with doul^le loops of strong 
 aseptic silk, were passed through all tlie intervening structures deeply 
 into and through the abscess, so as to include about two inches of the 
 wall ; the needles themselves were then withdrawn, leaving two loops 
 of silk by which the abscess could be firmly brought up to the pai'ietal 
 wound, and held there by an assistant. Tlie loops of silk were inserted 
 parallel to each other and to the edges of the external wound ; the wall 
 of the abscess was then freely incised between the loops of silk which 
 lay about an inch apart. Thick tenacious pus escaped slowly from the 
 large opening made, and the cavity of the abscess was cai-efully cleansed 
 by antiseptic injections, and the cautious use of sponges introduced by 
 means of strong forceps, etc. As adhesions were found to exist between the 
 surface of tlie liver over the abscess, and the parietal pei'itoneum over the 
 diapliragm, and the pleura, it was not necessary to use many sutures for 
 the pui'pose of securing the wall of tlie abscess to tlie parietal wound, 
 but as a measure of precaution, two were passed through the wall of 
 the abscess and the over-lying liver, and the lips of the external wound. 
 The original opening into the abscess cavity was found to have been 
 made at about the middle of the cavity, and as I considered it 
 unfavoui'al)ly situated for drainage, I made a counter-opening in tlie
 
 TKKATMEXT OF SO-CALLED TROPICAL AUSCESS OP THE LIVEU. 23."J 
 
 eighth interspace, in tlie axillary line, and inserted a drainage tu])t; 
 in each opening. The wall of the abscess was rough and irregular, and 
 the interior was partially divided into an upper and lower segment, by 
 a kind of ridge of liver substance. The operation was performed 
 mider the usual antiseptic precautions, including the use of the spray 
 The dressing consisted essentially of a pad oi wood wool enclosed in 
 antiseptic gauze. 
 
 It would be tedious to report in detail the subsecjuent histoiy of the 
 case ; it will suffice to state that the temperature fell at once to 
 normal, and remained so ; that the cough and expectoration, which 
 before the operation was incessant, ceased ; that the pad was changed 
 twice daily for four days, after which one dressing sufficed for eacli 
 day ; that on the fifth day the sutures were removed, and that the 
 drainage tubes were dispensed with, the upper one on the 14tli day, 
 the lower one on the 19th day. 
 
 Finally, it is repoi'ted that on the 28th day, the wounds had entirely 
 healed, and the physical signs in the right lung were iiormal. 
 
 Case III. 
 
 I am indebted to the kindness of my colleague, Dr. Way, for per- 
 mission to publish this case, and to Dr. Aitken, the House Physician 
 of the Adelaide Hospital, for the notes appended : — 
 
 G. T., aged 38, at present and for some years jjast a miner, but 
 formerly a sailor, was admitted into the Adelaide Hospital, on 
 Oct. 23, 1888, under the care of Dr. Way. He complained of diarrhoea 
 and dysentery of six weeks' duration ; this was associated with 
 abdominal pain and occasional vomiting. He had sustained a compound 
 fracture of the left leg eight months previously, and from this he had 
 hardly recovered when his present illness befell him. For two years 
 past he has lived in the Barrier Gold Fields District. 
 
 Upon examination he was found to have an enlargement of the liver, 
 the dimensions of which were as follows : — In the right nipple line 
 from the fourth interspace, as far as two inches below the right costal 
 margin ; in the median line from the cardiac dulness, to about two 
 inches above the umbilicus ; in the right axillary line, the upper line 
 of dulness was at the sixth rib ; and behind in the right scapular line, 
 the dulness began at the eighth rib. There was slight bulging of the 
 lower interspaces over the hepatic region, but no redness of the skin or 
 fluctuation. Jaundice was absent. An exploratory puncture in the 
 seventh interspace, in the right axillary line, yielded pus near the 
 surface. 
 
 November 2, 1888.- — Operation by Dr. Way, assisted by Dr. Thomas. 
 Incision, with re-section of a piece of the eighth rib in the right 
 axillary line ; pleural cavity opened, there being no adhesion of the 
 diaphragm ; loops of silk passed through the diaphragm and aliscess 
 wall ; the latter was then freely incised, the contents evacuated, the 
 edges of the incision in tlie wall stitched to those of the parietal wound, 
 and the cavity was carefully cleansed. 
 
 In this case. Dr. Way made an opening and inserted a drainage tub<^ 
 for the pleura in the seventh interspace, about two find a half inches 
 away from the opening into the abscess, the oliject being to prevent 
 infection of the pleura by the discharge from the abscess during the
 
 234 INTEHCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 after-treatment. The opening into the pleura at the site of the original 
 incision was closed by stitching up the wall of the abscess all I'ound 
 the edges of the parietal cut. 
 
 Tlie subsequent history of the case may be briefly stated. On the 
 eighth day the sutures were removed ; on the eleventh, the pleural 
 drain was dispensed with, as no discharge came through it. Until the 
 eighth day, the tempei-ature rose to about 100° in the evening, and 
 then fell to normal. 
 
 At present, November 14th, tlie patient n ay fairly be I'egarded as 
 convalescent. 
 
 CONGENITAL PHIMOSIS AND ADHERENT PREPUCE. 
 
 By Geo. Talbot Woolley, M.R.C.S. Eng. 
 
 Hon. Surgeon, Castlemaine Hospital. 
 
 Before going into tlie technical details of my paper, I cannot help 
 asking my professional brethren, and especially those with large 
 midwifery practices, to pay a little more attention to the formation of 
 the infant, especially with reference to the penis, and to instruct the 
 nurse how to act, in case all is not as it should be, and to utterly ignore 
 any stupid opposition which may be met with, either on the part of the 
 parent, or the nurse ; for I find that the greatest ignorance exists 
 amongst the parents and nurses, as to the proper formation of a baby 
 boy's foreskin. 
 
 In almost every instance, on a medical man being informed that the 
 infant is feverish, fretful, and always crying, he, as a rule, suggests that 
 there is something wrong with the diet, and that the little one is 
 sufiering from the wind, or some other popular complaint of infancy, arid 
 various suggestions are made, without any material benefit ; but if you 
 enquire more closely, you will often find that the child wets his napkin 
 almost incessantly, that his penis is almost perpetually in a state of 
 erection, and that the watei-, which is sometimes very high in colour, 
 stains the napkin yellow ; and if you look, you will find that the prepuce is 
 so tight that it is impossible to see tlie lips of the meatus, which, wlien 
 they are exposed, will be found to he in a state of congestion. In such 
 cases, measures should be adopted to gradually stretch the orifice of the 
 prepuce, and see if there are any adhesions, and if there are, the morbid 
 conditions will be commensurate with the extent of the adhesions and 
 the age of the child ; for it will be i-emembered, that at a very early age 
 the glanduhe odorifera; begin to secrete a quantity of badly smelling 
 caseous material, and this being, by the adhesions, prevented from being 
 washed away, has to find a habitat for itself, and gradually, but surely, 
 buries itself in the surface of the glans penis, or the under surface of 
 the prepuce, and sets ujj a definite form of constitutional disturbance; 
 tlic origin of which I generally have had to arri\e at by a series of 
 negative deductions, until T began gradually to recognise symptoms 
 peculiar to this condition.
 
 CONGENITAL PHIMOSIS AND ADHERENT PREPUCE. 235 
 
 In (Munuerjiting tliese symi)toiiis, 1 would like to dniw marked 
 attention to one, wliicii to my eye is pathognomonic of this disease, 
 \-iz., an expression or aspect of tlie face, more noticeable in children of 
 from two to eight years of age, which gives it a peevish or peaky look ; 
 the skin has a shiny, dry, cracked look about it, and there are generally 
 some sores about the nostrils and cornei's of the mouth, which are quite 
 typical and ditterent from the eotiuHon herpes following cold ; and so 
 great an impression has tliis eharaeteristic face made upon me, that T 
 rarely, if ever, make a mistake in my diagnosis. The child is generally 
 ill, feAerisli, with bad appetite and fui-i/ed tongue, and passes urine very 
 freipiently, which is sometimes thick and milky, and .sometimes of a 
 \ery high colour ; lie is generally in pain about the lower part of his 
 abdomen, but is not able to give you any definite account of his 
 condition. In order to illustrate the many and various phases of this 
 condition, T will shortly describe a few typical cases which luiAe come 
 under notice during the last few years, cases which illustrate some very 
 serious conditions, and point to the great importance of every medical 
 man insisting that the foreskin of e\eiy baby boy, whom he has under 
 his charge, can be easily put back, all adhesions broken down, and the 
 tilth cleaned out. 
 
 Child, jet. 3 years, had been under treatment for over twel^'e month-s 
 for double hernia, worms, consumption of the bowels, and various other 
 complaints, and was gradually getting worse. Got rapidly well after 
 having prepuce, which was contracted, forced back, xevy extensi^■e 
 adhesions broken down, and about a teaspoonful of sebaceous matter, 
 which had eaten into the glans, removed. 
 
 Child, mt. 2h yeans, treated for over three months for typhoid or 
 low fever ; cured immediately, on being cleaned out. 
 
 Child, a^t. 18 months, in same family in which three cases of virulent 
 typhoid were raging ; suddenly developed bad symptoms, almost identical 
 A\ith the others, when, in spite of the opinion of the parent that the 
 child had typhoid, I, led by the urinary expression, insisted upon 
 examining the penis, and found xevy extensive adhesions, and quite t^^■o 
 teaspoonsful of secretion. Immediate recoAei-y. 
 
 Boy, ;et. 8 years, passing almost pure blood per urethram for three 
 days, which entirely sul)sided, with all feverish symptoms, on having 
 adhesions bi'oken down, and foreskin cleaned out. Typical expression. 
 
 Boy, fet. 7 years, failing in health and losing use of both legs from 
 hips down, got quite well after having extensi\ e adhesions broken down. 
 iStrong facial expression. 
 
 Boy, set. 20 months, had Ijeen under treatment for intlannuation of 
 Ijrain, bowels and lungs. Got rapidly well on being cleaned out. 
 Condition partly found out 1)V habit of pulling prepuce.
 
 236 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 HE-8ECTI0N OF THE INTESTINE BY A NEW METHOD. 
 By H. WiDENHA.Ai Maunsell, M.D., Dunedin, N.Z. 
 
 Suigton to the Dianedin Hospital. 
 
 Witli antiseptic pvecaiitions, make an incision in the median line 
 sufficiently long to enable you to thoroughly search the bowels for the 
 wounded or diseased ])ortion of the gut. Having found the part to be 
 excised, bring it outside the abdomen with about six inches of healthy 
 gut on either side, pack well round with warm large flat aseptic 
 sponges. Clamp the gut in two places — from four to six inches above 
 and below the portion to be excised. 
 
 Neio Clamp for Bov^el. — Place a small flat sponge across the intestine, 
 about four or six inches from the part to be excised. Transfix the 
 sponge and the mesentery close to the gut with a strong safety-pin ; 
 pass the pin again through the sponge on the other side of the gut, 
 and clamj) the ])in. Better still, have two clam'ps prepared, ready for 
 immediate use, with the sponges sewn firmly to the arched portion of 
 the safety-pins ; the sponge should be sufficiently large to compress the 
 intestine against the pin, so as to effectually prevent extravasation of the 
 contents. 
 
 The advantages ai-e — its extreme sim])licity, its easy applicability, its 
 innocuousness, and its efficiency, as the pressure can be regulated by the 
 size of the sponge. 
 
 Neuber recommends a narrow elastic l)and to be passed through a 
 small opening made in the mesentery, close to the intestine, at a suitable 
 distance from each end of the ])iece of intestine to be removed, and tied 
 around the gut to prevent the passage of faices and flatus. I have tried 
 this method, and found that the bowel was injured by the ligature, no 
 matter what care was taken in applying it. 
 
 Sir William MacCormac, who wrote a very able paper on "Intra- 
 peritoneal Injury " for the Lancet, May 7, 1887, says he has abandoned 
 all artificial clamps, and relies alone on the pressure of the fingers and 
 thumbs of his assistants. I believe an artificial clamp to be necessary, 
 as an assistant's hands are always in the way, and must relax long 
 before the completion of a long operation. 
 
 When the entire circumference of the intestine is involved in the 
 wound, the bowel must be invaginated, so as to bring the i)eritoneal 
 surfaces into perfect contact all round, and suture them in that jjosi- 
 tion. 
 
 How is this to be accomplished? When Nature performs enterectomy 
 STiccessfuUy, she invaginates the upper portion of the intestine into the 
 lower, and when the jjeritoneal surfaces have united by adliesive 
 inflammation, the invaginated bowel sloughs ott" with impunity. Let 
 us co])y nature as closely as ])ossible.
 
 RE-SECTION OF TIIK IXTKSTIXI': HV A XEW .MKIIKH). 
 
 .3; 
 
 I will now, by a series of (lingraius, cndeiivour to demoiistnito the 
 dirterent ste[)s of my oi)eration. 
 
 Fio. 1. 
 
 Cut surfaces of both eucls of bowel brought together by two temporary sutures 
 with long ends left intact, aa. One at the mesenteric attachment of the 
 gut, and the other (exactly opposite) at the most distant portion of the 
 bowel from the mesenters'. 
 
 These temporary ligatvires are very im})ortant, as they secure the 
 proper relatice position <>/ the two cut ends of the gut, and facilitate their 
 subsequent invagination through the opening made in the lower segment 
 of the gut (see Fig. 5). If you examine the gut in a living animal, 
 you will find the blood-vessels pass into it from the mesenteric attach- 
 ment. These divide and subdivide, until they are lost in an invisible 
 anastomosis in that portion of the intestine most distant from the 
 mesentery. I pro])Ose to make an opening here in the lower segment 
 of the gut, through which the invaginated ends of the divided bowel 
 may be dragged by the temporary sutures, and when they are accurately 
 sewn together all round, they can be pulled back into their normal 
 position. The longitudinal slit in the lower bowel, which begins about 
 an inch from its transverse section, is brought together by a continuous 
 suture. By this simple device, the perfect union by suture of a 
 complete transverse section of the bowel, with its peritoneal surfaces 
 in exact ]iosition, and all the knots of the sutures on the inside, can be 
 accomplished.
 
 238 
 
 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 Fig. 2. 
 
 Longitudinal section (aboiit an inch and a half long) with tenotomy knife, of that 
 portion of lower segment of gut which is opposite to its mesenteric attachment. 
 
 This opening should be made about an inch from the severed end of the 
 lower bowel ; its length depends on the size of the gut to be invaginated. 
 In performing this part of the operation, ]nncli up the coats of the intes- 
 tine betw^een the linger and thumb, and transfix with a tenotomy knife. 
 
 Rimimniiiiniiiniiiiiii iiiiii i{ 
 
 INTERIOR OF UPPER 
 SEGMENT OF GUT 
 
 BliilTi 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 iTil 1 1 1 1 1 
 A ^ 
 
 ? 
 
 ( 
 
 [JiMii nmiHMiii iiillllll lllllllil 
 
 INTERIOR OF LOWER 
 SEGMENT OF GUT 
 
 lllllllllllllllllllllllllimn I MM I HI MIIIHIllllMIIIMMIIIIIlTllllllMIMIUM IIIMIIMIIIIIIIIIIIir 
 
 Fig. 3. 
 Longitudinal section of gut, sliowing a a, peritoneal coat; be, muscular coat; c c, 
 mucous coat ; d d, temporary sutures passed into bowel, and out through the 
 longitudinal slit made in lower gut ; f, mesentery.
 
 RE-SECTION OF THE INTESTINE BY A NEW METHOD. 
 
 239 
 
 Fig. 4. 
 
 Longitudinal section of intestine, showing the relative position of the diti'ercut 
 layers of bowel, invaginated through the longitudinal slit. 
 
 From this diagram, it may be seen that the ])eritoneal surfaces are in 
 accurate juxtaposition all round. While an assistant holds the ends of 
 the tem])orary sutures, tlie surgeon passes a straight needle armed with 
 stout horsehair through both sides of the bowel ; the horsehair is tlum 
 hooked up from tlie centre of the iuvaginated gut, divided and tied on 
 both sides. In this way, twenty sutures can be placed rapidly in 
 position with ten passages of the needle. The temporary sutures are 
 now cut off sliort, the l^owel pulled back. The longitudinal slit in tlie 
 lower bowel is closed with a continuous suture, and the mesenteiy 
 brought together with four or five interrupted sutures.
 
 240 INTKRCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Fig. 5. 
 
 Invaginated f,'ut, showing the two iieritoneal surfaces in jnxtapositioii all round. 
 A — Needle passed through both sides of the bowel, iiiti'odiicin;) ta-o sutures a 
 a time. 
 
 .Fig. G. 
 
 DiAORAM OF liETEACTED iiVT. 
 
 A -Line marking jun(;tion of both ends of bowel, the peritoneum well turned in, 
 and the .sutures ami knots all inside the gut, making an almost invisible air 
 and wutcr-tiglit joint. 
 
 ij — Longitudinal slit in bowel, sewn up with continuous .suture. 
 c — Mesentery united l)y interrupted sutures.
 
 liEVIEW OF THE RESULTS OF EXCISION OF IIAKD CllANCUK. 
 
 241 
 
 This oi>eration is applicable to any part of the large or small intestine, 
 and the pyloric end of the stomach may be excised in the usual manner 
 and invaginated through an opening in the centre of the anterior wall 
 of the stomach, sewn up from the inside, and then retracted to its 
 normal position. 
 
 Sutures for Bowel. 
 
 Fine silk is recommended in all the text books for sewing up the gut. 
 I find horsehair or tine silk-worm gut far the best. Silk sutures, when 
 wet, are very sloppy to work with. They swell up and cause suppura- 
 tion in their track. None of these disadvantages apply to horsehair or 
 
 silk-worm gut. 
 
 " A 
 
 Fig. 7. 
 
 AA — Temporary sutures, with euds intact, uniting cut surfaces of stomach and pylorus. 
 
 D — Longitudinal slit in stomach, made by pinching up its coats between the finger 
 and thumb, and transfixing with a tenotomy knife. Through this opening 
 the invaginated cut ends of the pylorus and stomacli are passed, when they 
 can be sewn up from the inside, and tlien retracted to tlieir normal position. 
 The longitudinal slit sewn up with continuous suture. 
 
 A ti'ansverse section of the intestine should never be sewn up with a 
 continuous suture, for the following reasons : — (1) The diameter of the 
 intestine is always varying. (2) As the stitches would not all cut out 
 simultaneously, they would form loops inside the intestine, which would 
 be liable to catch, or be dragged or torn out by the onward movement 
 of the contents of the bowel. 
 
 CRITICAL REVIEW OF THE RESULTS OF EXCISION 
 OF HARD CHANCRE. 
 
 By M. Crivelli, M.D. 
 
 Is syphilis a general disease from its beginning ? Does it commence 
 at the instant the virus is absorbed 1 Is the first symptom, the chancre, 
 the sign of an already general infection, or else is it a first local accident — 
 a focus from which the viru.s is propagated to the remainder of the 
 economy ? Briefly, does infection precede or follow the chancre 1 
 
 To resolve this question would be to resolve, at the same time, the 
 question of the correctness of the abortive treatment of syphilis, to 
 which it is intimately connected.
 
 242 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 If infection has already spread on the appearance of the chancre, and 
 if this symptom is merely its first manifestation, then ail abortive treat- 
 ments are wrong and useless, there being no advantage in destroying 
 chancre. Evidently, the infection must be local for a time, however short 
 that may be. On inoculation, the virus cannot be absorbed so quickly 
 as to attack at once the whole economy. But how long a timel How 
 are we to recognise the exact moment when, the virus beginning to 
 difiuse from the inoculation point throughout the system, abortive treat- 
 ment becomes useless ? These are questions which we cannot answer, 
 and which will only be decided on the day on which the key to the 
 phenomena may be found — that is, when the pathological microbe of 
 syphilis has been discovered. 
 
 Interesting works have already appeared, relating to this micro- 
 organism, by Aufrecht, Klebs, Lostorfer, Martineau and Hamonic, 
 Lustgarten, Hugo Marcus, &c., ifec, but the results have not been 
 sufficiently proved, and it is better to refrain from commenting on them, 
 and to wait for new discoveries. In 1857, Eicord said in his lectures on 
 " Chancre," " Syphilitic virus resemble all other s])ecies, whose effects 
 we see without being able to follow the method of their invasion and 
 irradiation in the organism. We see them acting, we recognise them 
 by the lesions they cause, but there ends our knowledge." 
 
 What Ricordsaid in 1857, is unfortunately true to-day, as far at least 
 as regards syphilis. 
 
 When syphilis first became known, means were sought to cure it, and 
 the method which was immediately adopted was that which consists of 
 destroying or extirpating the chancre on its first appearance, at a moment 
 when it could be supposed that absorption could not have had time to 
 take place. Thus we see cauterisation mentioned in the 16th century, 
 in the oldest known works on syphilis (Jean de Vigo, 1508, and Blegny, 
 1696). 
 
 In 1877, the question seemed to be settled, nothing had been said 
 about the abortive method for some time ; then a work by Auspitz and 
 XJnna, of Vienna (Vierteljahrsschrift fiir Dermatologie und Syphilis, 
 1877) was published during the year, and received great attention, 
 practically calling the whole subject in question. 
 
 It is interesting to learn how Auspitz was led to re-consider the 
 eradication of chancre, and to make fresh experiments by the abortive 
 method. He, with Unna, was then making a series of researches on the 
 pathological histology of syphilitic chancre, and on the alterations of 
 texture which precede and accompany the initial sclerosis. They sought 
 together to explain this more or less lengthy incubation of the primitive 
 ulceration, which only begins to become indurated after a few weeks. 
 Auspitz and Unna thought that the virus could enter into the organism 
 from the local lesion by all vessels, and not only by the lymphatics. 
 As for the swelling of the glands, it could not only be caused by the 
 progression of the virus from the iilceration to the nearest glands, but 
 also by a lymphatic, scrofulous, or tuberculous disposition. 
 
 Auspitz thought that, chancre being really a local lesion, the abortive 
 method should be looked on as a blessing, and he commenced to excise 
 chancres, having this time a therapeutic intent. 
 
 The observations of Auspitz, 33 in number, were minutely studied by 
 Dr. Leloir, of Lille. The result of this analysis Avas, that ten of the 
 patients presented undoubtedly symptoms of sy[)liilis, notwithstanding
 
 KKVIEW OF THE KESULTS OF EXCISION OF HARD CHANCRE. 213 
 
 the excision of clianci-e. Nine of these observations must be rejected as 
 being more than doubtful, the jnxtients having k^ft, or having been imder 
 treatment for too sliorfc a period ; this heaves 14 cases on which Anspitz 
 relies as ])roving his conclusions. Out of this 1-t, however, there arc 
 few which are absolutely convincing, as certain patients had previously 
 had chancre (?) Others had only been attended to for some four 
 months, Auspitz considering that a sufficient time; most authors, how- 
 ever, agree with Ricord, that a pei'iod of four months is not sufficiently 
 long to judge if syphilis has completely disappeared. Moreover, these 
 patients left to themselves, after being operated on, have been unwatched 
 for some considerable time, and there is nothing to prove that they did 
 not take mercury, thus retarding secondary accidents, or even causing a 
 total disappearance of any. 
 
 The folbrwing table shows the residts ohtaiaed by the authors in favor of, 
 '>/■ contrary to, the abortive method : — 
 
 Sigmund 
 
 Hueter . . 
 
 Kuzlinski 
 
 Auspitz and Uniia 
 
 Kolliker . . 
 
 Rydigier 
 
 Chadz.ynsld 
 
 Weisflog 
 
 Jullien . . 
 
 Bnmm and Eienecker 
 
 Ottmar Aiigerer 
 
 Lassar . . 
 
 Pick 
 
 Diday 
 
 Meyer 
 
 Uh'ich . . 
 
 Langenbeck 
 
 CouLsou . . 
 
 Thiry . . 
 
 Levfin 
 
 Caspary . . 
 
 Klmk . . 
 
 Zeissl 
 
 Zarewicb 
 
 Krowezinski 
 
 Gibier 
 
 Maiu'iae . . 
 
 Spillmau 
 
 Tomashewski . . 
 
 Kasori . . 
 
 Keyes 
 
 Berkeley Hill . . 
 
 Quinquaud 
 
 Terrilloy 
 
 Mauriac . . 
 
 Hallopeau 
 
 22 
 
 7 
 
 1 
 
 33 
 
 8 
 
 3 
 
 30 
 
 28 
 
 6 
 
 10 
 
 12 
 
 38 
 
 136 
 
 13 
 
 1 
 
 3 
 
 2 
 
 1 
 
 1 
 
 2 
 
 3 
 
 1 
 1 
 2 
 
 8 
 8 
 50 
 1 
 2 
 
 1 
 3 
 1 
 11 
 1 
 
 460 
 
 11 
 2 
 ] 
 
 14 
 3 
 3 
 7 
 
 28 
 1 
 5 
 
 5 
 19 
 
 102 
 
 Failures. 
 
 11 
 
 10 
 5 
 
 16 
 
 4 
 
 5 
 
 12 
 
 32 
 
 117 
 
 13 
 
 1 
 
 3 
 
 1 
 
 1 
 
 1 
 
 2 
 
 3 
 
 5 
 
 5 
 
 1 
 
 1 
 
 2 
 
 8 
 6 
 
 50 
 1 
 2 
 1 
 3 
 1 
 
 11 
 1 
 
 33i
 
 244 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 If to the above be added ten cases of excision, performed by the author of 
 tliis paper, in Paris and Melljourne, and barren of results, we have the 
 following totals : — Cases, 470 ; successes, 102 ; failures, 34;"). 
 
 If, however, account is taken of the large number of authors whom 
 ve have not quoted, owing to their not having given precise figures, who 
 utterly condemn excision and cauterization, the number of the 0])ponents 
 to the abortive method would be greatly increased, while the results 
 obtained by the partisans of this method should only be accepted with 
 great caution. Even when successful, no one has a right to affirm that 
 the operation is the certain cause of the abortion of syphilis. Cases in 
 fact have been known, in which manifestly Hunterian chancres have 
 not been followed by any secondary accidents. In my opinion, the 
 question is settled ; and bearing in mind the uselessness and deceit of the 
 aljortive method, I have never excised chancres, except when situated 
 at the end of the prepuce, which were consequently to be followed by 
 ugly scars. There is not a single one of the })retended successes that 
 can be admitted as having had an indis[)utable result. All are open 
 to serious objections, and should they be submitted to a rigid scrutiny, 
 little or nothing would be left in favor of the abortive ti'eatment of 
 syphilis. 
 
 To diagnose a Hunterian chancre is not always an easy matter. 
 More than one of the most renowned syphilographers could be cited as 
 having been obliged to recognise as insufficient the morphological character 
 of certain chancres, and to prudenth^ await secondary accidents before 
 pronouncing on the case. Could not the partisans of immediate excision, 
 or cauterization, have mistaken occasionally for Hunterian chancres 
 that ulcerative folliculitis, so frequently observed on the penis, and 
 wliich can be accompanied from various causes by a really inflammatory 
 induration '? 
 
 As for those authors previously mentioned, who pretend that they 
 have excised infectant chancres, which they had diagnosed four days 
 after their appearance, their ol)servations are of no value, and are 
 contrary to all the most authorised and classical opinions on the 
 incubation of syphilis. 
 
 Amongst the cases which are accounted as successes by the partisans 
 of the abortive method, some are found in which the patients have ])re- 
 viously had chancres. It is a question as to whether these were 
 Hunterian, and if the authors have not excised as initial sclerosis one of 
 those ulcerations of the penis which cause so many errors of diagnosis, 
 when one does not know about the antecedents of the patient. 
 
 Moreover, the time during which the patients were under observation 
 after the operation, has been in most instances too brief. Ilicord speaks 
 of six months, Auspitz of four, but cases can be found where secondary 
 accidents have appeared twelve months after the first appearance of the 
 chancre. Even the conditions of this period of observation seem to lack 
 the necessary strictness required for the affirmation of a scientific fact, 
 INTost of the patients were not retained in hospitals ; as soon as excision 
 liad been perfonned and healed, they returned to their homes, and only 
 interviewed the doctor several months after. (Syphilitic symptoms may 
 have appeared, and disappeared, during this tiuie. However attentive 
 these patients may have been, the necessary knowledge to recognise and 
 judge these symptoms could not have been theirs.
 
 KEVIEW OF THE RESULTS OF EXCISION OP HAUD CHANCRE. 245 
 
 The following case will pi-ove how fallacious are the results of the 
 abortive method : — On the 2nd February, 1880, Dr. Ottmar Augerer, of 
 Wiirzburg, excised a chancre eight weeks after infection ; there were 
 no further traces of infection for months. The jintient was married on 
 the 7th October, 1880. All went well at the beginning, but on the 
 21st April, 1881, his wife miscarried at the sixth month of a foetus in a 
 state of putrefaction. The young woman was a member of a perfectly 
 liealthy family ; certainly, the disease did not come from her side. The 
 husband was then treated with iodide of potassium and hydrai'gyric 
 frictions. The wife became pregnant again, and miscarried a second 
 time on the 16th April, 1882, at about the seventh month. There has 
 never been any symptom of sy])hilis in the mother. Had the patient 
 never married, this case of excision would have been quoted as a positive 
 ])roof of the value of aVjortive treatment ; it proves, however, that a 
 j)atient should not he considered as cured, although showing no signs of 
 general infection. 
 
 Another class of authors exist who, though not upholding the certainty 
 of abortive treatment, contend that if excision of the chancre does not 
 avert sy})hilis, it causes, at least, the consecutive accidents to be of a 
 more benign nature. It is no inore claimed to destroy or avert syphilis ; 
 but even this simple weakening of the virus is hardly admissible, and 
 this ver}' slight advantage does not seem to be a result of this method, 
 which should be decisively condemned. For if the number of cases on 
 which the partisans of the abortive method rely be counted, it will be 
 seen that they are very limited. 
 
 The system is not only useless, but seems to be irrational. As a 
 result of the excision of a chancre, there is always a more or less large 
 and always very apparent scar ; while a Hunterian chancre, left to itself, 
 hardly leaves any. The inconveniences that can take place from these 
 large and indelible brands — "unexceptionable witnesses of a disease all 
 would wish to hide" — ought to cause the abandonment of this method, 
 which not only does not effect what its least sanguine upholders expect, 
 i.e., the attenuation of the virus, but is absolutely to be condemned as 
 an operation. 
 
 As it is impossible, even to an experienced eye, to diagnose the 
 differential nature of a chancre before the sixth day, and as the glands 
 at this time are already generally tumefied, the partisans of excision, to 
 be logical, should not only excise the chancre and inguinal glands, as 
 ])erformed by Bumm and Rienecker, and which is not sufficient, but also 
 excise the glands of the iliac ])it, an operation which is im]jracticable. 
 
 I think that I have established now that all experiments made up to 
 date to avert syjihilis have been unsuccessful. The great majority of 
 negative results is conclusive, while out of the few successful cases, 
 some should not be accepted without great reservations, and the others 
 cannot stand a severe examination. It can thus be aftirmed, that 
 excision and cauterization are not abortive treatments of sy])hilis. All 
 trials to grapple directly with chancre are useless, because as .say Ricord, 
 Rollet, Fournier, and the great majority of French syphilogra])hers, to 
 whose 0})inions everyone should submit : — " 8y])hilis is a general disease 
 from the first, of which the first numifestation, chancre, shows itself 
 after an incul)ation of about twenty days, when the general economy is 
 already infected and saturated."
 
 246 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 This affirmation is sujiported both by clinical observation and experi- 
 mentation, which agree perfectly. The best proof that can be given of 
 the wortli of initial sclerosis, as demonstrating genei-al infection, is 
 inoculation. Everyone knows that the effect of inoculating a non- 
 sy[)hilitic person, from a Hunterian chancre, is to produce a cliancre ; 
 that the same, inoculated on a per.son constitutionally syphilitic, has no 
 effect ; and that this same chancre, inoculated on the bearer of it, gives 
 no results. These are facts which have been so often verified, that they 
 are admitted by everybod3^ 
 
 In conclusion, it can be stated that the method of averting confirmed 
 sj^philis has not yet been discovered, and that the best abortive treatment 
 of syphilis (if it can be so called), is still the administration of mercury 
 at as early a stage of the disease as possible. 
 
 OBSERVATIONS ON THE PRACTICE OF CYSTOTOMY. 
 
 By Alex. MacCormick, M.D. et Ch. M. Edin., M.R.C.S.E. 
 
 Hon. Surgeon, Prii;C3 Alfred Hospital, Sydney. 
 
 I may state, at the outset, that I use the term cystotomy in its widest 
 acceptation, that is, a section of the bladder for any purpose whatever. 
 I purposely avoid the nse of the time-honoured term lithotomy, as 
 a inisnomer, for we do not cut the stone, we cut the soft parts and 
 remove the stone. I venture to plead for greater accuracy in our 
 terminology. 
 
 Some justification for attempting a more accurate use of terms, is, 
 I think, to be found in the fact tliat, with an increased variety of 
 0})erati\'e procedures in connection with the urinary organs, there lias 
 arisen a necessity both for general terms to express the broader, and 
 pai'ticular terms to express the more particular features of such 
 operations. Now cystotomy is manifestly a good general term, hitherto 
 unwari-antably restricted in its interpretation ; while lithotomy, though 
 sacred by usage, is, as I have said, a misnomer, and does not express 
 the special features of any operation. 
 
 I may venture to indicate how I think consistency and utility in 
 nomenclature might well be attained. 
 
 I think the term cystotomy ought to be used as a general term as I 
 have above defined it, while if a special term to signify cutting for stone be 
 required, tlie term lithectomy would be preferable. Lithectomy could 
 then be further specialised as cysto-lithectomy, and asnephro-lithectomy, 
 according to the site of the calculus ; or according to the site of the 
 operation, as supra-pubic cysto-lithectomy, median perineal cysto- 
 lithectomy, and lateral perineal cysto-lithectomy. 
 
 In taking as the subject for my pajier the practice of cystotomy in 
 its wider sense, I make no pretence of treating it exhaustively. Its 
 scope is too wide to be adequately treated in any single paper such as 
 this. At first, indeed, it was my intention to take up the subject of 
 supra-pubic cystotomy alone, but, at the request of our Secretary, I have 
 included some remarks upon the subject of cystotomy in general.
 
 OBSERVATIONS OX THE PRACTICE OF CYSTOTOMY. 247 
 
 Few of its departments ai-e better fitted to exhibit the advance of the 
 science and art of surgery, than tlie surgery of the bladder. It is not 
 here chiefly that the triumphs of antiseptic surgery are so marked, 
 though, no doubt, it has contributed largely to the result ; but, 
 independently of antiseptics altogether, there has been a widening of the 
 area, so to speak, of surgical interference, and an ever-increasing variety 
 of procedure. 
 
 I shall avoid long tables of statistics, and will try, as much as 
 possible, to base my preference for the adoption of any o[)erative 
 method upon anatomical and physiological grounds. 
 
 Varieties of the Operation. 
 
 Looking at a vertical mesial section of the body, it immediately 
 becomes manifest that there are two safe routes into the bladder — one 
 above the pubes and the other below, through the ])erinieum ; or through 
 the rectum in the male, or the vagina in the female. By safe, I mean 
 gaining access to the interior of the organ without })assing through the 
 peritoneum. The rectal operation has been given up by surgeons of the 
 present day, on account of the persistence of fistula afterwards in a 
 great many cases, although ])lenty of room is gained by this method. 
 Of vaginal cystotomy, I shall not here speak. 
 
 Practically, there are only three operations now practised on the 
 male to obtain access to the interior of the bladder, (1) supi'a-pubic, 
 (2) lateral perineal, (3) median perineal. I think these three operations, 
 with a little modification according to circumstances, will meet all 
 requirements. The median operation, as practised at the present day, 
 is more an external urethrotomy than a cystotomy, as the bladder itself 
 is not incised. 
 
 Choice op Operation. 
 It is an exceedingly difficult matter to lay down definite rules for the 
 choice of an operation, in any case of bladder trouble where cystotomy 
 has been decided upon. Many operators have a favourite method to 
 which they will submit all patients, but this is not fair to the patient, 
 nor is it fair to the method selected, for each operation has some special 
 advantages, and special disadvantages, according to circumstances. 
 
 Supra-pubic Cystotomy. 
 
 The position of the wound in this operation is said to be a faulty one, 
 from the point of view of general surgical principles, on account of the 
 l)ad position for drainage, but this is the worst that can be said of it. 
 To show that the track of the wound is limited by fasciie, though not so 
 eff'ectually as in the low operation, I shall refer to the arrangement of 
 the transversalis fascia in the front wall of the abdomen, to which 
 Braune, in his "Atlas of Topographical Anatomy," has drawn particular 
 attention. He shows that the transversalis fascia, opposite the semilunar 
 fold of Douglas, splits into two layers — an anterior and a posterior. — 
 (See also Liverpool Med. Ghir. Journal, Jan. 1885.) 
 
 The anterior layer passes down behind the rectus abdominis, and is 
 attached to the upper border of the pubes towards its posterior aspect. 
 The posterior layer when traced downwards is seen to be carried to the 
 superior aspect of the bladder by the urachus, and becomes continuous
 
 248 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 witli the recto-vesical fascite and the capsule of the prostate- Of the 
 correctness of the above description, I liave satisfied myself by careful 
 dissection. These two layers of fasciae enclose a space which is called 
 the porta vesicae of Ketzius, or the pi"e-vesical space, and it is into this 
 space, and not into the sub-peritoneal space, that the bladder rises when 
 distended. In the operation of supra-pubic cystotomy, it is this space 
 that is entered; and here the bladder can be opened to a considerable 
 extent in the middle line, without the operator running any risk of 
 wounding the peritoneum, or even of opening the sub-})eritoneal space, 
 so long as the incision is confined to the middle line, and does not extend 
 backwards beyond the urachus. 
 
 I may mention here an interesting fact, pointed out by Mr. Harrison, 
 viz. : — " When there is a fracture of the pelvis, with extra-peritoneal 
 rupture of the bladder by a fractured pubic ramus, it is evident that the 
 urine will be discharged into the pre- vesical space ; and, sup])osing the 
 bladder to be drained by a perineal incision, this incision will be very 
 unlikely to drain the space of its contained urine, which will remain 
 mixed with blood, and in contact with the fractured bone." — (" Surgical 
 Disorders of the Urinar}' Organs," p. 28.) 
 
 Dr. Weir, of New York, reports a case illustrative of this, where he 
 drained the blaxlder through the perineum, after making an incision 
 above the pubes. — (^New York Medical Record, March "iOth, 1884.) 
 
 Mode of Performing the Operation on the Adult. 
 The hair having been shaven off the pubes, and the skin rendered 
 aseptic, anesthesia is jiushed to complete relaxation. Then a red 
 rubber catheter is introduced into the bladder, and the urine drawn ofif. 
 The bladder is now to be gently distended with a solution of boro- 
 glyceride (1 in 40). If fermentation is going on in the bladder, it ought 
 to be gently washed out with boro-glyceride solution before finally 
 injecting it. The quantity to be injected should be between nine and 
 ten ounces for an adult, and from half an ounce to two or three ounces 
 for a child, according to the age. In distending the viscus, I prefer 
 Thompson's bladder syringe to any other, on account of the exact way iu 
 which you can gauge the amount of resistance. The catheter having 
 been removed, the penis is tied with a small piece of elastic tubing, A 
 rectal bag shovild then be greased, and introduced into the rectum just 
 beyond the internal sphincter, and then distended with warm water 
 (10 or 12 ozs.) An incision of sufiicient length, according to circum- 
 stances, is made in the middle line in front, stopping at the symphysis 
 pubis. The thin pale line, corresponding tothelinea alba, is then looked 
 for, and the incision deepened along this line between the edges of the 
 recti with as little teai-ing as possible. The edges of the recti being 
 gently held asunder Ijy retractors, the anterior layer of the transversalis 
 fasciffi is exposed, and should be pinched up with forceps near the lower 
 end of the wound, and incised, and then the deposit of fat in the pre- 
 vesical sjjace will be exposed. Next, by means of the left index finger, 
 with the pulp uppermost, the fat and the reflection of tlie peritoneum 
 should be pushed upwards out of the way. A sharp hook or a loop of 
 silk should be made to fix the bladder to the anterior wall of the 
 abdomen in the ui)per part of the incision. Then an incision is made 
 into the bladder large enough to admit the index finger with which to
 
 OBSERVATIONS ON THE PRACTICE OF CYSTOTOMY. 249 
 
 examine the interior of the organ, and to judge of the requisite Icngtli of 
 incision in the bhidder wall that may be necessary. Here, I think, it is 
 of the greatest importance to disturb the tissues in front of the bladder 
 as little as possible. The soft tissues behind the pubes should not be 
 interfered with; and, above all, the bladder should not, when it collapses, 
 be pushed before the examining finger, and its fascial connections 
 disturbed, because, if this be done, it is evident that the chances of 
 extravasation will be much increased as the two layers of the trans- 
 versalis fascia will be extensively separated. If the cystotomy is being 
 done for stone, it can be placed in the most favourable position, and 
 removed with a pair of forceps, taking great care not to injure the 
 bladder wall, or to bruise or tear the edges of the bladder wound ; it is 
 always better to enlarge the wound with the knife than to tear it with 
 the finger. The most suitable kind of forceps are a pair of " lithotomy 
 forceps," with a lock like midwifery forceps, and the blades should be 
 applied in the same way as in obstetric practice, taking great care not to 
 include the wall of the bladder. The parts should be then well washed 
 with boro-glyceride solution. 
 
 The question now arises as to whether the bladder wound should, or 
 should not, be sutured. I think everyone will agree to suture the 
 bladder, if the urine and viscus itself be fairly healthy. The best suture 
 to use is fine catgut, and the best method of suturing is Gussenbauer's 
 or Lembert's. The sutures should be ])laced close together. The 
 superficial wound is then closed, and a drain put in the lower part 
 of the wound, down to the bladder wall. It is very difiicult to sew up 
 an extra-peritoneal wound or rupture of the bladder, so as to render it 
 watertight. In an intra-})eritoneal wound or rupture, the smooth serous 
 surfaces can be brought so accurately together as to render the wall of 
 the bladder perfectly watertight ; but in the foi-mer case, it is much safer 
 to provide a good drain for any urine that may leak through. In any 
 case, where the bladder wound is at all large, I think it is good practice 
 to suture it carefully, and if the mucous membrane be unhealthy, or 
 fermentation is going on in the urine, to leave room for a drainage tube 
 at the lower end of the wound. A catheter in the urethra, unless in an 
 exceptionally tolerant subject, is not advisable. In the case of adults 
 with very unhealthy urine, I should be inclined to use a method 
 described by Dr. Keyes, of New York, for draining the bladder through 
 the perinseum — {Journal of Cutaneous and Genito-Urinary Diseases, July 
 1887, Xew York.) He uses a large red rubber catheter, and ])asses 
 thi-ough its lumen a piece of twine, bringing it out at the eye, and then 
 with a needle he passes the twine in through the eye again, and out 
 through i)oint of the catheter, until a knot, previously ])laced on it, 
 catches. The part of the twine hanging from the ti]) is then threaded 
 into the eye of a silver probe, which is turned up at the point ; then, as 
 in the operation for median cystotomy, the membranous part of the 
 urethra is incised, making just enough room for the catheter to be 
 drawn through. The probe is pushed through the incision along the 
 knife into the groove of the staff, in the membranous part of the 
 urethra, and then into the bladder, and is caught through the supra- 
 pubic incision, and by the aid of the string, the catheter is pulled into 
 the bladder, the string is cut short and withdrawn, when the catheter 
 can be fixed at the proper length inside the bladder.
 
 250 INTERCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 I have performed tliis operation (siipra-pubic cystotomy) four times 
 within the last two years. The first case was that of a boy seven years 
 of age, on whom I performed tlie lateral perineal operation on 
 December 23, 1886. On making the usual incision, and passing the 
 finger into the bladder, I found a stone, very rough, and as I consider, 
 very large for a boy of his age. On passing the forceps, I had no 
 difficulty in seizing tlie stone, but I judged, from the position of the 
 handles, that the blades were sejmrated to such an extent as to be likely 
 to cause a great deal of tearing if extraction were attempted ; thei'efore, 
 I considered it safer to withdraw the forceps. I had then to choose 
 between crushing the stone or removing it above the ])ubes. I decided 
 on the latter method. I got one of my colleagues to pass the index 
 finger of the right hand into the bladder through the perineal incision, 
 and with it to push the anterior wall of the viscus up behind the pubes 
 against the lower part of the rectus muscle, so as to push the anterior 
 wall of the bladder up into the pre-vesical space. I then made an 
 incision as for supra-pubic cystotomy. I did not see the peritoneum at 
 all, and I found the finger a most convenient and effective guide. On 
 opening the bladder, I kept it forward with blunt hooks. The stone 
 was removed, the forceps being much aided by the finger in the bladder. 
 I sutured the bladder carefully with catgut, put a drain in the lower 
 part of the abdominal wound, and left it in for forty-eight hours, the 
 bladder being drained through the lateral incision. The abdominal 
 wound healed by first intention, and the patient made an uninterrupted 
 recovery. 
 
 In young or thin people where, for some reason, after the lateral or 
 median perineal oj)eration, it is deemed necessary to open the bladder 
 above the pubes, the finger of an assistant acts as an admirable guide, 
 and by judicious pressure on the anterior wall of the bladder, he can 
 push it uj) into the pre-vesical space as reatlily and as effectively as if the 
 bladder and rectum were distended. 
 
 My three remaining cases were those of children of one and one-sixth, 
 two, and two and a half years respectively. In these three cases, the 
 operative procedure was the same, and the supra-pubic method was 
 chosen in the first case on account of the youth of the patient ; in the 
 second and third cases, on account of the size of the stone, which was 
 first measured bi-manually with one finger in the rectum and the other 
 on the front wall of the abdomen. The bladder in the first case was 
 injected with about one ounce of fluid ; in the second and third, with 
 two ounces. The bladder wall was not sutured. A drainage tube was 
 used in the superficial part of the wound only, and the upper part of 
 the abdominal wall was sutured. The drainage tube was always removed 
 in forty-eight hours ; and in the first case, although urine trickled along 
 the drainage track for the first two days, it did not prevent union by 
 first intention in the greater part of the wound, which was completely 
 healed in ten days. In the other two cases, the wound healed in twenty- 
 one and eighteen days respectively. In neither of these cases did I use 
 a rectal tampon, but instead, I got an assistant to push the bladder 
 upwards and forwai-ds gently with his right index finger in the rectum. 
 In the case of children, I consider it is quite unnecessary to use rectal 
 distension, as it is more likely to cause injury to the rectum, and it may 
 even thrust the bladder to one side, and the rectum itself thus present in
 
 OBSERVATIONS OX THE PRACTICE OF CVSTOTOMV. 251 
 
 the al>doniinal wound ; and, furthermore, the finger can give the operator 
 great assistance in the removal of the stone, by making jjressure from 
 below.— (Vide " Deutsche Zeitschrift fiir Chirurg.," Bd. •28th, 1 ct 2 Hft.) 
 I have made reference to the use of the l)i-nianual, or recto-abdominal 
 examination, under deep aniestliesia, in the diagnosis of stone, especi- 
 ally in children. This method of examination has not hitherto received 
 sufficient recognition in the literature of the suV)ject. I have been in 
 the habit of practising it for .several yeans, with the greatest advantage. 
 Thu.s, I have been enabled to detect a calculus not bigger than a split 
 pea in the bladder of a child of fourteen months, upon whom I was 
 unaV)le to pass the smallest sound. Another great advantage of this 
 method is the information which it elicits as to the shape and dimen- 
 sions of the stone. 
 
 Indications for Supra-Pubic Cystotomy. 
 
 (1) For stone in very young children. — I think the supra-pubic 
 method is the best operation in very young children. I advocate it on 
 two grounds, as being {<(), the best operation anatouiically ; and (A), the 
 safest. 
 
 (a) In regard to the anatomy of the bladder in the child, I think 
 there is a tield open for further investigation. The be.st descrii)tion of 
 it that I have found, is in Dr. Symington's " Atlas of the Anatomy of 
 the Child." 
 
 S3'mington gives a vertical mesial section of a male child at birth, and 
 the amount of urine in the bladder was estimated at one drachm. The 
 orifice of the urethra, in this case, was at about the level of the upper 
 border of the pubic sym])hysis. [n front, the bladder extended 
 forwards and upwards, in contact with the symphysis and the anterior 
 abdominal wall, against which it lay, until within one centiuietre of the 
 umbilicus. The anterior surface of the bladder was entirely uncovered 
 by pei-itoneum, and there was no tendency to the foruiation of a 
 jieritoneal pouch between the bladder and the anterior aV)dominal wall. 
 Posteriorly, the peritoneum i-eached as low as the level of the urethral 
 orifice. 
 
 In all the sections of a child at this age, the orifice of the urethra was 
 at the level of the upper border of the pubic symphysis. Whether the 
 bladder was empty, or distended, its anterior surface always lay in close 
 contact with the anterior abdominal wall — this relation corresponding 
 more than in the adult, with its tubular tlevelopmental character. The 
 anterior surface was entirely uncovered by peritoneum, and was of a 
 triangular shape, tlie base of the triangle being at the pubes, the apex 
 towards the umbilicus, and the lateral boundaries corresponding to the 
 hypogastric arteries. The bladder, in all cases, lay in contact with the 
 lower two-thirds of that part of the anterior abdominal wall between the 
 umbilicus and the sym[)hysis ])ubis. 
 
 In a section of the body of an infant, three and a half months old, 
 Symington found that the uncovered part of the bladder corresponded 
 to about a quarter of the distance between the umbilicus and the pubes 
 with the bladder empty. In an infant, seven months old, where the 
 bladder contained one ounce of urine, the uncovered part of the bladder 
 occupied nearly half the distance between the umbilicus and the 
 symphysis.
 
 252 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 In boys of from four to six years, he found tliat when the bladder was 
 empty, its relations to the peritoneum differed in the contracted and 
 relaxed conditions. When contracted and empty, the peritoneum came 
 down behind the .symphysis. When relaxed and empty, the membrane 
 was reflected on the bladder above the symphysis. When distended 
 with from two to three ounces, the distiince between the reflection of the 
 peritoneum and the .symphysis was over two centimetres. 
 
 From a perusal of these facts, it will be seen, that in the child the 
 jDeritoneum covers the bladder more extensively towards its base than in 
 the adult, and therefore, the distance between the base of the ])rostate 
 and the reflection of the peritoneum is I'elatively less. The facts, also, 
 make clear the relation of the anterioi' surface of the bladder to the 
 anterior wall of the abdomen and to the peritoneum. Another very 
 important point displayed in the sections is the small capacity of the 
 infantile bladder. In an infant, seven months old, the bladder was 
 pretty fully distended when it contained only one ounce of urine. 
 
 In Holmes' "System of Surgery," Sir Henry Thompson says, that the 
 most frequent cause of death in children, after lateral perineal cystotomy, 
 is ])eritonitis, due presumably to injury to the peritoneum during 
 extraction. Xow, I hold that this would be much less likely to happen 
 in the supiu-pubic operation. 
 
 (b) If we look at the statistics given by Sir William MacCormac, 
 and published in tlie British Medical Journal of March 19tli, 1887, 
 where he collected all the cases of supra-pubic cystotomy he could find 
 in London and the ])rovinces, from January 1885 up to that date, we 
 find thirty-three cases of this operation in children under fifteen years 
 of age, with no death; in Mr. Twynam's paper, in the October number 
 of the Australasian Medical Gazette, last year, we find a list of twenty- 
 eight cases of fifteen years and under, with one death. Assendelft has 
 done the high, or supra-pubic operation, one hundred and two times, 
 with two deaths. 
 
 If we comjjare these statistics with the statistics of the lateral opera- 
 tion, as given in Holmes' "System of Surgery," we find that, for 
 children .sixteen years and under, the death-rate is about one in sixteen. 
 So that, judging from these statistics, tJie high operation is much the 
 safer one in young children. 
 
 Still, I would not advocate its performance in all cases of children 
 under fifteen, because, after five years of age, with a small stone, I do 
 not know of any easier or more rational operation than the lateral. 
 But if the stone be of such a size as to require a large incision into the 
 parts at the base of the bladder, and any roughness in the handling, I 
 think the supra-pubic route the safer. The size of the stone, at this 
 period of life, can be very easily determined by the bi-manual examina- 
 tion, and then the operator should weigh in his mind the difficulties, 
 and give the benefit of the doul)t in favour of the supra-pubic. 
 
 Up to December 1886, I liad not thought much about supra-pubic 
 cystotomy in children, and I was always in the habit of doing the 
 lateral operation; the results were always favourable, and beyond a 
 little delay in getting into the bladder of a fat child of two years of age, 
 I never had any difficulty or com))lication; but I am sure that one not 
 practised in the lateral })enneal operation, and who practises antiseptics 
 carefully, can more easily and safely gain access to the bladder above the
 
 OBSERVATIONS ON THE PHACTICE OF CYSTOTOMY. 253 
 
 pubes than below, in. cliiklren of five years and under. I know of 
 several unpul)lislied eases, below this age, in which the perineal opera- 
 tion had to 1)0 abandoned, and a still greater number of cases in which 
 considerable difficulty was exi)erienced, and time spent, before the 
 interior of the bladder was reached. Passing over the difficulties and 
 complications that may occur during and immediately after either 
 oi)eration, we must not forget the after-effects of tiie two operations. 
 In the high operation, the only bad after-effects that may occur in 
 children are, a tendency to hernia and the possibility of a fistulous 
 opening, both of which chances are very remote. But, after the perineal 
 operation, there are the chances — (1) Of incontinence of urine (I have 
 seen several cases of this, and I think it is always due to an over- 
 stretching of the sphincter vesicte, from an insufficient incision). (2) Of 
 impotence. (3) Of sterility. (4) Of fistula. 
 
 CONX'LUSIONS. 
 
 (1) I would advocate the supra-pubic operation for stone in all 
 children under live or six years of age ; between six and sixteen, I should 
 be less decided in my choice, but should, if the stone were of a con- 
 siderable size, prefer the supra-pubic. I think, however, that it would 
 be much better to perform lithola|-axy for small stones in children, if 
 one had suitable instruments, but I would limit this operation to very 
 small stones. 
 
 (2) For large stones in adults. — No one will dispute the great 
 advantage and safety of the high operation over any other method in 
 cases of very large calculi in the adult ; neither will any one dispute the 
 advantages of the lateral perineal in any case of small stone where a 
 cutting operation is decided upon. In this field of practice, litholapaxy 
 has come to rival the lateral perineal so much so that, according to Sir 
 Henry Thom])son, all calculi that cannot be crushed ought to be too 
 large to be safely removed by the jjerineal roitte, and therefore ought to 
 be removed by the supra-pubic route. He even states that the high 
 operation is, in his opinion, preferable to crushing for calculi, which, 
 though not of the largest size, are extremely hard. Most surgeons have 
 not the dexterity in crushing that Sir Henry Thompson has accjuired, 
 and although most men can crush a small stone with perfect safety, I 
 have seen very disastrous results at the hands of very good opei-ators in 
 attempting to crush a large stone. According to Sir Henry Thompson's 
 dictum, a stone is small, medium-sized, or large. A medium-sized stone 
 is one which measures about one inch in each of two of its smallest 
 diameters, anything below this is a small stone, and anything above is a 
 large stone. Any calculus one inch or less in its two smallest diameters 
 no one would hesitate to crush, but stones above this, except in the 
 hands of very good manipulators, would be more safely removed by a 
 cutting operation. The pi-ostatic urethra itself can be dilated to nearly 
 one inch, without much risk of injury, and the incision of the prostate 
 would give three-quarters of an inch more room, so that a stone one and a 
 quarter inches in each of two of its smallest diameters could be removed 
 by the lateral perineal route without any tearing of parts, so that I still 
 hold that in the hands of judicious operators the lateral operation ought 
 to retain a place. Sometimes in cases of small stone, it may be desirable 
 to perform cystotomy, as in patients of a phosphatic diathesis with
 
 254 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 intense purulent cystitis, so as to allow the bladder rest by a thorough 
 drainage for a few days. Such cases are better treated by a lateral 
 perineal cystotomy. 
 
 (3) For tumour of the bladder. In cases of tumour of the bladder, 
 supra-pubic cystotomy has achieved very wonderful results ; but as 
 there is generally a very considerable amount of doubt in these cases, as 
 to the nature and attachments of the growth, a niedian perineal 
 cystotomy in the first instance would clear up all doubt, provide a good 
 drain, and in no way interfere with the subsequent supra-) )ubic 
 cystotomy, if the case could not be dealt with through the perineal 
 opening. Here, Thompson's sound will be of the greatest advantage 
 as a guide to the high incision, and to ^Jush up the bladder wall. 
 
 (4) For enlarged prostate, with chronic cystitis. Supra-jnibic 
 cystotomy has been performed by Thom])Son and others in cases of 
 enlarged prostate with chronic cystitis, where instrumentation had 
 become very troublesome. By McGill, of Leeds, it has been performed 
 with the object of removing portions of the enlarged prostate. He 
 reports three cases in which the results were very satisfactory. AVhen 
 cystotomy is performed to ]n-ovide for a permanent drain, I think most 
 surgeons would prefer, when possible, to drain through the perineuui, 
 when, if necessary, portions of the prostate could be removed. 
 
 (5) For foreign body of an irregular shape, that cannot be broken up 
 or extracted by a lithotrite. 
 
 (6) Oases of impassable stricture for catheterisation from within 
 [British Medical Journal, No. 1, 1S84). 
 
 (7) In cases of anchylosed hip joint. 
 
 (8) In deformed pelvis, from rickets. 
 
 (9) For some cases of encysted stone. 
 
 (10) In cases of pyo-nephrosis, where there is doubt as to which 
 kidney is diseased, this operation might be performed as a ])reliminary, 
 in order to decide which ureter was discharging pus cr blood, before 
 any more heroic ]»rocedure, in the way of nephrotomy or nephrectomy, 
 should be decided on. In some such cases, of couise, the endoscope 
 might render exploratoiy cystotomy unnecessary, but in other cases, the 
 amount of pus or blood )night obscure the examination by that 
 instrument. 
 
 Median Perineal Cystotomy. 
 
 This operation in the adult is the easiest and safest route to the 
 interior of the male bladder, but it has the great disadvantage of giving 
 only a small opening. I will describe the operation as I practise it. 
 The i)ati(!nt, having been ana3sthetised, and a median staff passed, is 
 placed in the lithotomy position. The staff being held by an assistant, 
 the surgeon passes the foi-efinger of the left hand into the rectum, and 
 places its tip, with the pulp upwards, where the staff enters the apex of 
 the prostate, so that he can feel the groove tin-ough the intervening 
 tissues. Then, taking a long narrow bistoury in the right hand, he 
 plunges the knife, with the back downwards, into the tissues of the 
 perinseum, half an inch in front of the anus, through the raphe, and 
 exactly in the middle line. With the finger in the rectum, he avoids 
 wounding that viscus, and guides the knife into the groove of the staff 
 at the apex of the prostate, and with a sawing motion, incises the floor
 
 OBSERVATIONS OX THE PKACTICE OF CYSTOTOMY. 2oO 
 
 of the membranous urethra for fully lialf an inch close to the apex of 
 tlie prostate. The knife is then withdrawn, and at the same time is 
 made to cut upwards to give sutiicient room, avoiding the bulb if 
 l)Ossible, so as to lessen the amoxint of haemorrhage. A Wheelhouse's 
 goi-get, passed into the groove of the staff, is guided by it into the 
 bladder, and over this the left index hnger of the oi)erator can easily 
 enter the bladder under ordinary circumstances. By making bi-manual 
 examination, the whole of the inner wall of the bladder can be brought 
 into contact with the examining finger. 
 
 Dolbeau, who made careful dilatations of the prostate and neck of the 
 bladder experimentally wdth a dilator, has shown that the neck of the 
 bladder cannot be distended to a diameter greater than twenty to twenty- 
 four millimetres, without producing lesions of it, and of the prostate ; so 
 that no stone more than four-fifths of an inch in diameter can be 
 removed by forceps without laceration. — (" Ashhurst's International 
 Cyclop, of Surgery," vol. VI., j). 258). 
 
 The great field for this operation, however, is not for the removal of 
 calculi, but for the purpose of exploring and draining the bladder. 
 Considered from an anatomical point of view, it is perfectly correct ; it 
 cuts no important structure, there is no haemorrhage if the incision is 
 not made to wound the bulb, and the drainage is perfect. This opera- 
 tion is very useful as a preliminary to any of the other operations in 
 any doubtful case of bladder trouble. I have i)ointed out above its 
 advantages as a preliminary to the supra-jjubic. Mr. Harrison points 
 out how more room can be gained, if necessary, by passing a curved 
 probe-pointed bistoury into the bladder, along the pulp of the finger, and 
 then cutting with it downwards and outwards to the prostatic capsule, 
 and enlarging the wound in the same direction as the knife is with- 
 drawn. I think it is everywhere admitted, that this is the easiest and 
 safest way of entering a bladder for the purpose of exploring it. In 
 obscure diseases of the bladder wall, it will become more common, not 
 only for the purposes of diagnosis, but for the purpose of treatment. 
 Through it the bladder can be thoroughly drained, and put at complete 
 rest, as can also the urethra, so that the mucous membranes get time 
 to recover ; just as in the female, where dilatation of the urethra for the 
 purpose of exploi-ing, when no cause is found for the bladder trouble, 
 often cures the disease completely by paralysing the sphincter and 
 giving the viscus rest. 
 
 I have performed median cystotomy twice for chronic cystitis, which 
 had persisted for years, and each time with great benefit to the patient. 
 Besides for the purposes of exploring, removing tumours of the prostate 
 and bladder, draining the bladder in cystitis, and of prostatectomy, 
 Mr. Harrison practises this operation, in a somewhat modified form, for 
 certain cases of irritable stricture, where instrumentation is apt to be 
 followed by a great deal of febrile excitement, and where an internal 
 lu-ethrotomy alone would be dangerous. His intention is thus to stop 
 all danger of sepsis, or urethral fever, by keeping the urine from contact 
 with the diseased urethra. Let me quote a case, to show the advantages 
 which followed complete removal of urine from contact with a raw or 
 diseased urethral mucous membrane : — 
 
 C. P., aged 26, was admitted, suffering from an organic stricture of 
 the bulbous portion of the urethra. The stricture was the result of
 
 256 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 gonorrhoea, wliicli lie had contracted when he was about 16 years of age. 
 It had been dilated to the size of a No. 7 on several occasions, but 
 always recurred very rapidly. With some difficulty I succeeded in 
 getting a whalebone bougie into his bladder, and this was followed by a 
 severe rigor. To make the history short, sutfice it to say that after a 
 great deal of trouble, I succeeded in dilating gradual]}^ to the size of a 
 No. 9, but after almost every operation he had a rigor, even after the 
 gentlest handling. He was discharged from the hospital, with instruc- 
 tions to come regularly to have an instrument passed. This he partially 
 neglected to do, and soon had to be admitted again for further treatment. 
 He being so subject to rigors, 1 determined to perform internal 
 urethrotomy, and in addition, to drain his bladder tlirough the perinseum. 
 His stricture being still large enough to admit a Thompson's urethrotome, 
 I divided the constricted part completely along the floor of the urethra, 
 passed a large median staff, entered the urethra at the apex of the 
 prostate, as in median perineal cystotomy, next passed a probe into the 
 bladder as a guide for a No. 12 gum elastic catheter, which I used as a 
 drain, draining the urine by means of a tube into a vessel by the side of 
 the bed. The patient escaped all constitutional distui'bance after the 
 operation. At intervals of three days I passed a large sound through 
 the divided stricture, and washed out the urethra from the front with 
 antiseptic solution. At the end of three weeks, the bladder drain was 
 removed, and in a short time the urine flowed through the natural 
 channel. The patient left the hospital with Nos. 12 and 14 soft 
 catheters (English scale), which he was instructed to have passed at 
 intervals of fourteen or twenty-one days. I saw him nine months after, 
 when he described himself as being more comfortable than he had been 
 for ten years. He has since married. 
 
 The advantages claimed for this operation are : — (1) Avoidance of 
 grave constitutional disturbance ; (2) Avoidance of risk of extravasation ; 
 (3) The stricture is more pliable after, and less liable to contract. 
 
 Lateral Perineal Cystotomy. 
 
 This classical operation has not been changed in any essential respect 
 since the days of Cheselden. It is one of the best planned operations in 
 surgery. Although its scope has been greatly limited by the practice of 
 litholapaxy, and the supra-pubic operation, I hope there will still be a 
 })lace left for it in the future. 
 
 An able, brilliant, and kind-hearted old surgeon of my student days 
 was used to express his ideas about Heaven in the following words : — 
 " Heaven is a place wheie all the good i)eople are cutting the bad people 
 for the stone." 
 
 As I have already said, I make no pretence of travelling over the 
 whole field of the practice of cystotomy. The subject is an exceedingly 
 important one, for I suppose few operations can claim to do more in the 
 way of relieving human suffering, when judiciously carried out. I have 
 only to thank you for the courteous attention wdiich you have given to 
 my observations on this subject.
 
 suPKA-i'umc Li'nioTOMY. 257 
 
 SUPRA -PUBIC LITHOTOMY. 
 By J. Tremearne, M.R.C.S. Eng. 
 
 Tlie safest and most effective method oi operating for stone has lieen 
 lately a subject of contention, f<ir ^vhilst a large nvunber a])i)rove of 
 lateral lithotomy only, there is an increasing number who favour the 
 supra-pubic cystotomy. 
 
 The evidence already recorded from different ])arts of the world fully 
 sustains the opinion, that when the bladder has to be cut into for the 
 removal of large stones, of two or three ounces or more (wjiieh cannot 
 be crushed), the opening should be made above the pubes. My limited 
 experience inclines me to the belief that whenever cystotomy is necessary 
 for encysted calculi, tumour, etc., the supi-a-jjubic operation is preferable 
 to the i)erineal. In judging these two great operations, the results as 
 well as the dangers should be noted. 
 
 The death rate, so far as recorded, is lower in lateral lithotomy than 
 in supra-])ubic, but this is scarcely a fair guide, as the rule generally 
 followed has been to j>erforni the high operation on patients advanced in 
 years, and suffering from large stones, the woi'st cases in fact, where 
 probably diseased prostate or some other complication exists, which would 
 necessarily entail fatal results if the latei'al operation was attempted. 
 
 We may arrive, however, at some idea of the advantage of one opera- 
 tion over the other, in cases where the bladder has been cut into above the 
 pubes, when it might have been through the perinseum, and vice versd. 
 
 In August 1877, I cut into the bladder, above the pubes, after 
 performing the lateral perineal operation for a boy of ten years old. A 
 calculus tilled the bladder and projected it forwards, so that it felt large 
 and hard like a cricket ball at the lower part of the abdomen. Nothing 
 could be done through the jjerineal opening, but with the addition of 
 that above the i)ubes, it was easy to break up, and clear out the bladder 
 thoroughly. After the operation, oidy a few drojis of water escaped 
 through the abdominal opening, but not any after the third day, and by 
 the seventh, the abdominal wound was healed. Urine ceased to come 
 through the perineal opening on the twenty-seventh day, and the wound 
 healed shortly afterwards. The abdominal opening in this case would 
 have been quite sufficient had it been a little larger, and that it was 
 absolutely necessary for the removal of the calculus, was quite evident. 
 
 In the case of J. C, a sharebi'oker, aged 47 (reported in the Australian 
 Medical Journal, for July 1883), all the usual symptoms of stone were 
 present, and he was compelled to pass water every hour. He had been 
 badly affected by spasmodic asthma for 18 months, and could not lie 
 down, but slept sitting in a chair at night. After an unsuccessful 
 attempt at crushing, the supra-pubic operation was i)erfornied, and a 
 cystine calculus of 2| ounces in weight removed, as well as small bits of 
 cystine gravel. A tube was put into the wound, and allowed to remain 
 for a week, and the usual means of drainage adopted. Shortly after its 
 removal, the opening (juickly closed and healed. Five weeks after the 
 operation, the patient had increased 30 lbs. in weight; and asthma, whicli 
 pi'eviously distressed him, had neai'ly disappeared. 
 
 Robert F., aged 45, a big, burly, red-faced, and very nervous man, with 
 hsemorrhagic diathesis, had the .supra-pubic operation performed two 
 years ago. A stricture affected the greater part of the urethral canal, 
 
 s
 
 258 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 which was so sensitive, that on attempting to introduce a sound, violent 
 rigors came on and prevented its being properl}^ treated. The symptoms, 
 however, became so urgent, that it was decided to opei'ate, as stone of 
 some kind had been felt in the bladder. Through the unusual amount 
 of fat, and bleeding from the incision, many minutes elapsed before the 
 anterior wall o£ the bladder was seen projecting forwards on the point 
 of the catheter, when it was liooked up, cut into, and a calculus removed 
 about one and a-half inches in length. Another stone, somewhat 
 smaller, was found embedded in the upj^er and front part of the bladder. 
 This might have been missed had the bladder been cut into from below. 
 The incision into the bladder caused profuse haemorrhage, although the 
 ])lexus of veins in front was not wounded. During the night, two 
 assistants, one on each side of the bed, held the wound compressed 
 between the foi-efinger in the bladder, and the thumb on the outside of 
 the abdominal wound, and thus almost entirely commanded the bleeding. 
 A great amount of blood was, however, lost during the tirst twenty-four 
 hours, but afterwards recovery was rapid, and within three weeks he 
 was quite well. The stricture was dilated at the time of the operation, 
 and gave no further trouble afterwards. Had the lateral operation 
 been undertaken, I believe the bleeding from the bladder could not have 
 l)een controlled so effectively as it was through the supra-pubic opening. 
 
 Edward C, aged 30, was operated on in July 1887. A stone (which 
 was found afterwards to weigh exactly one ounce) could be detected 
 readily, and might have been removed by crushing or cvitting. He had 
 previously made up his mind to have the high operation and no other, 
 attempted. The opening above the pubes had closed, and he was up 
 and well eight days afterwards. 
 
 Lateral ]ierineal cystotomy has been performed only six times in the 
 Creswick Hospital. Three of these were young boys ; one, 5 years old, 
 died the same night ; another, aged 3 years, has now — seventeen years 
 after the operation — involuntary micturition, and impotence ; while the 
 third is the case mentioned, where the supra-pubic incision was combined 
 with the lateral. One of the adults, W. B., aged 26 years, had the stone 
 removed, but the perineal wound could never be healed, and he remained 
 until his death, twelve months afterwards, with a iistulous opening. 
 
 John N., aged 36 years, had for six months frequent and severe 
 attacks of bleeding from the bladder. ISTothing definite could be 
 detected (although he was several times under chloroform) except a 
 slight roughness at the top of the bladder. Lateral cystotomy was 
 jterformed in 1877, when a small stone was discovered to be deeply 
 encysted in the wall of the bladder. It was not easily removed, as the 
 fistulous opening leading to the stone w*as only one-eighth of an inch in 
 diameter. Little bleeding took i)lace at the time of the operation, but 
 several sudden bursts occurred afterwards, and on threeor four occasions 
 death from syncope was apprehended. Had the supra-pubic o})eration 
 been performed, the bladder could have beeii examined more thoroughly, 
 and means used to check what nearly ended in fatal hajuiorrhage. 
 
 John O'S., seen in September 1878, had all the symptoms of stone in 
 an aggravated form. There was an opening in the perinfeum, through 
 which urine constantly dribl)led. He stated that lateral lithotomy was 
 })erformed on him two months before, and a stone over an inch long 
 removed, but the wound had not healed, and his pain, relieved only for
 
 SUPRA-PUBIC LITHOTOMY. 259 
 
 a few (.lavs, had returned more violently than ever. A stone, 1^- inch 
 long by 1 inch across, could be readily made out in tlie bladder, and 
 after several attempts with a powerful Jithotrite, was removed by crush- 
 ing, when the wound healed. It would have been impossible to miss 
 this calculus had the bladder been opened from the front. 
 
 Thomas J., aged 19, was seen by me only once, about an hour before 
 his death, when a distinct projection was noticed over the pubes. After 
 his death, T made a post-mortem examination of the body. A stone lay 
 in a pouch in front of, and nearly as large as, the bladder itself, causing 
 an ai)pearance of the bladder like an hour glass. The opening from the 
 • bladder into the pouch was only sufficient to admit a No. 2 catheter into 
 the cavity, so that a sound passed through the urethra into the bladder 
 detected nothing. The calculus could have been removed easily by the 
 supra-pul>ic operation, but in no other manner. 
 
 Comparison of the Two Operations. 
 Supra-inihic. 
 
 (1) Cutting into the l)ladder from above the pubes may be attempted 
 by a novice with but little fear, as long as he keeps in the centre line of 
 the abdomen. 
 
 (2) There is no danger of wounding important parts, except the 
 reflection of the ])eritoneum over the upper and front part of the bladder, 
 but the peritoneum will rarely be seen if the rectum and bladder are 
 distended (as Sir H. Thompson advises), and even if wounded, it seems 
 of no great consequence as long as the accident is noticed, and 
 immediately attended to. In boys, the anterior fold of the ])eritoneum 
 is higher, on account of the abdominal position of the bladder, and no 
 distension of the rectum is necessary. Of 478 cases collected by 
 G. Dallas, and mentioned in the Eacydopcedia of Surgerf/, in 13 the 
 peritoneum was wounded, and with a fatal result in one only. 
 
 (3) The bladder is opened from the front, which is its safest aspect ; 
 some veins over the bladder bleed freely when divided, but they can be 
 plainly seen and cutting them avoided. 
 
 (4) The opening can be made as large as necessary for any stone or 
 tumour to be removed. The bladder can be examined more satisfac- 
 torily, and an encysted calculus or morljid growth (vvhicli might not 
 have been detected through the ])erineal ojtening), removed. Haemorr- 
 hage can be controlled without difficulty, as no arteries would be divided ; 
 the bladder can be readily washed out, and the wound treated anti- 
 sejjtically. There is no fear of tistula, incontinence of urine, wounds of 
 rectum or i)rostate gland, impotence, or any other of the risks of the 
 ])erineal incision. Although extravasation of urine is mentioned as one of 
 the dangers, it has been rarely, if evei-, reported as occurring, and by 
 draining the wound both extravasation and septic poisoning are pre- 
 vented. The bladder can be kept free from any accumulation of urine 
 or pus, and the patient's body dry, by adopting the syphon principle. 
 Some threads of candle wick, aV)Out two yards long, are doubled in the 
 middle, and the fold pushed through the wound down into the Vjladder as 
 far as it will go. The ends of the upper portion of the threads com- 
 municate with a liottle of fluid (solution of ])erchloride of mercury, 1 in 
 5000), raised above the level of the wound, whilst the lower portion 
 passes across the |iatient's 1)ody, and ends in a vessel ]:»eneath the bed. 
 The solution runs down along the thit-ads and through the wound, 
 
 s 2
 
 260 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 carrying off all ]iuriilent matter with urine, as soon as either appear in 
 the bladder. The wick, except abont an inch or two in the lower part of 
 the wound, is covered with india-rubber tiil)ing ; and waterproof sheeting, 
 with a small hole cut in the centre (to allow of the passage of the wick 
 into and out of the bladder opening), can be placed over the abdomen. 
 
 Lateral. 
 
 (1) In cutting through the periuieum, considerable skill is required; 
 the incision may not be low enough, or too low, or too much inwards, &c. 
 
 (2) The urethra may not be opened as far back as it should be. The 
 artery of the bulb, the jjudic artery or the I'ectum, may be wounded, or the 
 prostate cut through. The prostate may be torn from the membranous 
 portion of tlie urethra, a misfortune which sometimes happens when 
 children are operated on, in the attempt to get the finger into the bladder. 
 
 (4) There is but a limited amount of room for grasping and removing 
 a stone, or morbid growth, and for examining the bladder. 
 
 (.5) The ditticiilty of controlling secondary lifBuiorrhage; 
 
 (6) The chances of incontinence of tirine, wounds of rectum or prostate 
 gland, impotence, &c. 
 
 TWENTY SUCCESSFUL CASES OF SUPRA-PUBIC 
 CYSTOTOMY. 
 
 By Henry O'Hara, F.R.C.S.I. 
 
 Senior Surgeon, Alfred Hospital, Melbourne. 
 
 In February 1887, the House Surgeon at the Alfred Hospital 
 published in the Australian Medical Journal, the notes of my first case 
 of supra-pubic cystotomy. The operation was performed successfully 
 for the removal of a large oxalate of lime calculus, and I claimed for 
 the operation, that it was the first recorded in Australia. I was so 
 struck with the wonderful results obtained by the lithotomists of the 
 old world, in their revival of supra-pubic cystotomy, that I determined 
 to perform that operation whenever a suital)le case should present itself. 
 
 I had removed several large and small calculi by the lateial method, 
 both in private and hospital practice, with varying success; and I always 
 felt, that in jierforming ]ierineal section, one was working at a great 
 disadvantage (more jiarticularly in cases of enlarged prostate gland), and 
 how helpless one necessarily was in arresting the hemorrhage that 
 might occur in the region of the prostatic plexus. 
 
 The pressure that is usually apjilied, in the form of a " plug," not 
 only prevents the flow of urine through the wound, but itself very soon 
 becomes a source of septic mischief, and holds foetid material for the 
 prostatic veins to take up. Where chronic disease of the bladder is the 
 result of the long continued irritation, caused by a stone within its 
 walls, I hold that it is as necessary to give free exit to its contents, as is 
 the drainage of a purulent cavity in any other region of the body. If, 
 therefore, in the removal of a stone from the bladder, I find that no 
 vesical trouble exist, I allow the wound to heal as speedily as possible; 
 but on the other Jiand, where a collection of putrid urine has accumu- 
 lated for a length of time— a semi-paralysed bladder having merely rid 
 itself of overflow — I keep a portion of the wound in its walls open witli 
 a drainage tube, until I have satisfied myself that the mucous lining has
 
 TWEXTV SUCCESSFUL CASKS OF SUPRA-PUHIC CYSTOTOMY. 261 
 
 regained its noi'uial condition. During the operation, the peritoneum in 
 this region can \>e kept up with very gentle traction. Tlie anterior wall of 
 the bh\dder is its thickest and strongest part, and therefore, more likely 
 to Ileal best. 
 
 In children, the anterior bladder wall is quite uncovered by i)eritoneum, 
 although tlip bladder lies high up in the abdomen. Its posterior wall is, 
 however, covered by peritoneum down to the level of the prostate gland. 
 The blood-vessels, sup[)lying the parts anterior to the Ijladder, are not of 
 a formidable nature. 
 
 In my tirst operation, December 8, 1886, I took two ste})s, which at 
 that time were laid down as im])erative, viz., inflating the rectum, and 
 suturing the divided walls of the bladder ; and experience has since 
 taught me that neither step is necessary — in fact, that both are some- 
 times harmful. I can quite realise how a partially diseased bladder 
 would tear (when the knife was applied to it), from the intense pressure 
 of a rectal bag. I cannot see any advantage in filling the bladder to 
 bursting-point, and I never inject more than six ounces into it m3'self. 
 It can be kejit well away from the peritoneum, if the catheter or sound 
 is properly held in i^osition. 
 
 The sutures, I consider, only retard the healing process, causing 
 sloughing of the parts, and I do not think there are any authenticated 
 cases where no urine escajted through the wound, after the operation 
 had been completed. I have quite discarded the use of sutures. 
 
 Having had the pubes shaved, and 6 ozs. of some antiseptic fluid 
 injected into the bladder, I make an incision from two to three inches in 
 length in the median line, commencing about one inch above the pubes. 
 This incision is carried down to the bladder. I then introduce my finger 
 into the wound, and guided by the sound inside, I feel for the anterior 
 superior asjiect of the bladder. Having seizevd the wall in this position, 
 I make an opening through it about one inch, so as to admit my finger. 
 If the stone be a large one, the incision can be lengthened to suit the 
 operator. The stone is now grasped with a lithotomy forceps, and 
 extracted, and the patient j)ut to l)ed. 
 
 jVIy reasons for making the incision so high up are, because it is less 
 likely to be encroached upon by the urine, if that fluid be drawn off 
 every two hours for a few days; and also, because the superior surface 
 of the bladder is more likely to be healthy, being further away from 
 the part where the stone has been lodged. And I find it a good plan 
 to hav'e the patient's bed raised at the head, so as to have him lying on 
 an inclined plane. 
 
 Should a stricture of the urethra co-exist with stone, the operation of 
 internal urethrotomy can be done at the same time as the lithotomy. 
 
 I did Teevan's operation in three cases, with good i-esults, leaving a 
 drainage tube in the bladder to drain off the urine while the urethral 
 wound was healing. 
 
 In conclusion, I must express my delight at the results of supra-pubic 
 cystotomy in chronic cystitis, where incrustations form on the bladder wall. 
 It is not my intention to occupy your valuable time with the notes of 
 every case. I have made out a tabulated list, giving the age of patient, 
 the complication (if any) co-existing, the duration of time from date of 
 operation until healed, and the result when healed. The shortest cure 
 was 9 days, in a Chinaman at the Alfred Hospital, and the longest 236 
 days, the patient's bladder being in a very diseased condition.
 
 262 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
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 264 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 NOTES ON LATERAL SPINAL CURVATURE, WITH 
 SPECIAL REFERENCE TO TREATMENT. 
 
 By G. Affleck Scott, M.B., CM. Edin., Maryborough, Victoria. 
 
 Tliis subject seems to me worthy of attention (1) Because the 
 complaint is so common. (2) Because it is so often not noticed, so 
 often not considered, and so often left to nature's own treatment, or 
 nature's own neglect. And yet it causes a great deal of discomfort 
 and ill health, a good deal of pain, and ill severe cases, sometimes 
 complete invalidism and occasionally death, and the effects will probably 
 be still more marked on posterity. I have been surprised to see 
 how much lateral curvature there is in our country districts, often 
 very slight, certainly, and frequently discovei'ed only when examining 
 the chest for other reasons, but always sufficient to justify treatment, 
 preventive and curative. 
 
 The object of treatment is to restore the vertebral column to its 
 normal shape, and to prevent its re-assuming the abnormal. Removing 
 the cause is, of course, the preliminary step ; treatment being followed 
 out as indicated. Drawing or writing in bad position, inequality in 
 length of limbs, etc., will require to be remedied. 
 
 Preventive treatment, as regards the spine itself, we need not fully 
 discuss here. The chief points seem to me to be : — 
 
 (1) Gymnastics for girls as well as boys. 
 
 (2) Free natural movement and exercise to be allowed to children. 
 
 (3) Give young gii-ls no corsets, and older girls very light ones. 
 
 (4) For shop girls, and all young people who have to stand much, 
 allow sitting down whenever possible. This is an important point, and 
 seldom, if ever, attended to. 
 
 (5) Introduce a reform in the system of teaching writing. This is 
 looking forward, i)erhaps, too much, but it is sometimes well to be 
 radical. It is impossible to sit over a desk, as at ju'esent taught, with 
 the paper straight before one and write in the orthodox slope, without 
 great risk to spinal rectitude. It is suggested to abolish the slope 
 altogether, and let us all be taught straight or back hand. But why 
 should not the paper be placed at an angle of 45° towards the left side, 
 that would still allow an orthodox sloiie, and the spines would be 
 grateful, wliatever the caligraphist might be. It would be a question 
 whether the latter method would tend to give us Laputan inclination of 
 the eyes. But either of the two reforms would be better than the 
 present system of endeavouring to induce spinal curvature in the writing 
 class. 
 
 The cause being removed, the next question is, whether to allow the 
 vis medicatrix to complete the cure, or to take its place ; the former 
 course is, perhaps, usually followed, but considering the number of cases 
 seen, and seen too in a pretty advanced stage, its adoption is repre- 
 hensible ; l)esides which, the curvature is, of itself, a predisposing cause 
 of further curvature. 
 
 Having premised then that .sometliing be done, we have a bewildering 
 number of difi'erent modes of action recommended, ranging from 
 ab.solute rest to extreme exercise ; from making instruments do all the 
 treatment, to discarding instrumental support altogether. In severe
 
 ox LATKUAL SPINAL CURVATURE. 265 
 
 cases we may, perhaps, simply follow out Noble Smith's instrumental 
 treatment, wiien instrumental treatment is necessary; that we leave, as 
 we are discussing cases of medium severity. Sayre's jacket deserves 
 notice. As a curative agent it cannot act, but in cases of caries, where 
 movement is to be prevented, it makes an admirable splint, and by 
 giving rest, allows nature to cure the cai'ies, but the curve remains 
 in statu quo. It is recommended in very advanced cases, where there is 
 no hope of improvement, and where prevention of further deformity 
 only is aimed at. Such cases, also, I cannot dogmatise upon, but should 
 think them excessively rare ; besides which, the jacket ])revents the use 
 of what muscle there is left, and Smith's apparatus should answer at 
 least as well even in the worst cases. 
 
 Heavy instruments of all kinds, of which several have been invented, 
 have all the same drawback, besides putting too heavy a yoke upon the 
 patient. 
 
 But instrumental treatment is only necessary in severe cases, which 
 are comparatively rare. The slight and medium cases (Vjy far the more 
 nuuiei'ous class), may be treated without spinal supports at all, and 
 among all the different instructions, th*^ matter is much simplified if we 
 rememljer that the kernel of the treatment is to make the muscles which 
 have allowed the deformity undo the deformity — and then prevent 
 return of the deformity. Cases where the muscles are inca])able of so 
 doing, come under the head of severe cases, re(juiring instruments, but 
 they are probably not so numerous as supposed. 
 
 The two I'equisites in muscular treatment are rest and action: — 1. 
 Action {a) of one set of muscles more than the others, to undo the 
 ileformity ; and {h) general, to keep the body in tone. 2. Rest [a) of 
 these same muscles, to prevent fatigue which would leave their last 
 state worse than their first ; (/>) of the body generally, to prevent general 
 fatigue. It seems very simple, and the beauty of it is, that it is as 
 simple as it looks. No fixed rules could be laid down as regards either 
 rest or action, the amount of which must be regulated according to ertch 
 individual case — amount of curve, strength of muscles, strength of body 
 generally. &c., but the princiide is easily laid down. 
 
 1. As Regards Rest. 
 Its advocates have gone all lengths, even to lying down — if I mistake 
 not — in bed, for long periods up to one or two years. The failure of 
 this need excite no surjn-ise. Two debateable points arise : — [a) 
 Whether the amount of rest should be regulated by the patient's 
 feelings — the system of resting when tired — or whether a fixed daily 
 time should be set. As a rule, I should certainly say the latter. A 
 j)atient is a highly unreliable mechanism, and nine out of ten would not 
 rest till over-tired. The time fixed would, of course, vary ; in moderately 
 severe cases, probably two hours twice a day would answer well. 
 (6) Whether the supine or prone position should be adopted. The 
 supine presses too much on the spinal column, besides having the great 
 disadvantage that each motion of the head, as also the act of rising up 
 again, tends to roundness of the shouldei-s, which is an evil. The prone 
 position avoids these evil.s, but only if supervised ; otherwise, there is 
 risk of roundne.ss of shoulders, as I have seen occur. The great 
 advantage of the prone position is, that every movement of the head is
 
 266 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 beneficial ; but if the head droop, as it often does, the result is to do 
 passively, what movements in the supine position do actively, i.e., 
 produce round shoulders. Verral's couch admits of this, and a well- 
 padded or cushioned couch is pex'ha])s preferable, with no special 
 mechanism, where tlie cushions are arranged so that at rest, the head 
 will not bow the back ; and during movement, allow of beneficial action 
 on the curve. Finally, the patieiit should have a chair, whose back fits 
 the lumbar curve, to sit in at any time when fatigue is threatened, besides 
 the fixed daily time of recumbency in the prone position. This, then, 
 fulfils the requisites as regards rest ; as regards other restrictions, in an 
 ordinai'y case very few are necessary. Tennis is allowed by some 
 surgeons, but I think the quick strokes in all attitudes and positions 
 a risk, and should forbid it. Riding, j)robably, has little efifect either 
 vay, and may be allowed ; and ordinary work, except stooping at a 
 table, Avriting, or even drawing, need not be forbidden if the evil 
 position be not taken up. 
 
 All this is, however, only precautionary against over action, and in 
 no way cures the curve. That is done by the second muscular requisite, 
 viz., action. 
 
 2. Action. 
 
 Noble Smith's work, and the article in Heath's " Dictionary of 
 Surgery," give good directions as to exercises which may be performed, 
 and which it would be tedious to recapitulate. We might note, 
 however, the evil of acting upon the dorsal muscles on the concave side 
 of the curve, in the hope of thereby undoing the curve. Use them, 
 and the result is as seen in Fig. 1. Certainly, the spines of the verte- 
 brae come into the middle line, but the rotation will be increased, and 
 the deformity of ribs and scapula made worse. The action required 
 is exactly the converse — traction on the spinous processes of the 
 vertebras from the convex side of the curve, so as to undo the rotation. 
 To effect this, I follow Noble Smith's plan, modified, I think, by 
 Chiene : — Patient sits on a chair with pelvis fixed by band round chair, 
 then with I'ight arm crossed in front of breast and left arm behind 
 back (in right dorsal curve, of course), with the hands holding hand- 
 pieces fixed to elastic bands attached as seen in the Fig. 2, traction is 
 made upon both elastic bands at once, beginning with two or three pulls 
 once a day, and gradually increasing the number as required. Ordinary 
 4-inch elastic bands answer well. The mode of action is seen by 
 reference to Fig. 2. The pelvis being fixed, each contraction of right 
 arm acts upon muscles from sternum to arm and arm to spine on right 
 side, and draws vertebral spine in a direction away from the middle line, 
 but iindoing the rotation ; also, the left arm contractions tend to diaw 
 sternmn in tlie direction of arrow, towards the left, thus also heljdng 
 to undo the deformity caused by the I'otation. The result bears out 
 Smith's remarks on the subject. 
 
 But now, with difiidence, I touch a farther note on the treatment, not 
 having had the advantage of extraneous help, M'hich I should be relieved 
 to get ; as however much we admire heterodox theologians, a heterodox, 
 and especially a youthful hetei-odox practitioner, is justly viewed very 
 critically. My fathers will, I know, be lenient, and my brethren 
 courteous.
 
 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. * 266
 
 267 * INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 Fiq. I. 
 
 To shew result on Vertebrae of acting on muscles on concave side of curve. 
 
 a. Lateral Ciu'vature per se. h. Same after such action ; Spinous Process approaches 
 middle line but rotation is increased. 
 
 Fig III. 
 
 CL. ' 'J ^"- 6. 
 
 To shew result on Vertebrae of acting on muscles on convex side. 
 
 a. Curvature as before. 6. After action, rotation undone, but Spinous Process not 
 
 brought nearer middle line.
 
 ON LATERAL SPINAL CURVATURE. 267 
 
 We are usually left at this point, but it seems to me that to stop here 
 rejieats precisely, though in a lesser degree, the error we have already 
 condemned. When we concluded tliat something should be done Vjeyond 
 simply removing the cause of curvature, we considered the vis medicatrix 
 insufficient of itself. We have now reached a })oint where we have, by 
 treatment, undone the rotation — at least, to some extent — but the lateral 
 curvature remains untouched, and we leave the vis medicatrix to correct 
 it. This same vis seems to me to want help here, too, and it was this, 
 as well as the incompleteness of the treatment already described, which 
 caused me to enquire as to whether nothing more could be done. 
 
 The object of treatment is, as said, to undo rotation, and to undo 
 lateral curvature. And I submit, that the vertebral column is not one 
 individual, but it is a congregation of 25 separate individuals, who can 
 all move separately, as well as together. We have seen the error of 
 trying to cure curvature by dragging the spines to the middle line, and 
 we have seen how the opposite is the rational ti-eatment. But the effect 
 of the rational treatment is seen in Fig. 3, the rotation is undone, but 
 the vertebra remains as far from the middle line as ever ; and, as it is 
 not our object to end with a spinal column, showing an example of 
 lateral curvatiire without rotation, there must be some movement of the 
 vertebra as a whole towards the middle line. Now, if we can effect thi.s, 
 as well as the undoing of the rotation, and especially if we can get the 
 two processes to go on simultaneously, a great advantage will be 
 gained. 
 
 If a patient be sitting up — or even lying down, though this to a lesser 
 extent — any exercise, such as we have already discussed, acts at a 
 disadvantage. If you press a number of discs one against the other, to 
 move any one of them is ditficult ; and if you wish to move a dorsal 
 vertebra, to do so with tlie cervical and dorsal sitting upon it above, and 
 the dorsal and lumbar giving counter jiressure below, is not an easy 
 matter, but if you can free the vertebra from its ovei'-aflectionate 
 neighbours, and leave it a little elbow-room, it becomes easy. 
 
 The two advantages seem to me to be combined in the method of 
 utilizing the old-fashioned extension process by hanging, plus the use of 
 electricity. 
 
 The method of extension has unqualified condemnation from most 
 surgeons, and, if it means the old fashion of making of the patient a 
 pendulum, justly so; but there are extensions and extensions. The 
 objections are — (1) That it puts too gieat a strain on the cervical 
 portion of the spinal column. (2) That the ligaments, and perhaps 
 muscles, get stretched by extension, become relaxed when the extension 
 is taken off, and fall back into a worse position than before. 
 
 As regards the first objection, I submit that it depends entirely how 
 nnich extension you exert. If the arms be supported also, and if the 
 extension be only sufficient to have the patient's heels just off and the 
 toes just on the ground, the good desired is obtained, and no risk to the 
 cervical region incurred. 
 
 As regards the second objection, I beg leave to differ. The muscles 
 do not get stretched, nor do the ligaments. The ligaments on the convex 
 side of the curve are stretched without the extension which, in fact, 
 relieves their tension. The ligaments on the concave side are not tense 
 enough, and the straightening of the spine only makes them so ; and the
 
 268 IXTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 amount of extension sufficient for our i)ui'i)Ose does not come within 
 measurable distance of risk of stretching ligaments or muscles. 
 
 For extension, 1 do not use a tripod, but had a tetrapod made; the 
 head pad fixed from a pulley in the centre, but the arm pads separate. 
 I have arm-}nt bands attached to pulleys on opposite legs of the 
 apparatus, which allow of the arms being separately raised or depressed, 
 as well as different direction of muscular contraction as desired. 
 
 Noble iSmith says that extension needs to he very powerful to have 
 any effect. "To illustrate this fact," he writes, ]jage 10, Ed. 1888, 
 " let us take a stout piece of copper wire, or a thin iron rod, and bend it 
 to represent the spine. Then hold each end with the fingers or with 
 ])incers, and endeavour to straighten it by stretching it lengthways. The 
 difficulty is great, we are working at a mechanical disadvantage, and 
 })robably will find it impossible to pull it into a straight line ; but 
 support each end, and press laterally with a finger against the curve, and 
 with much less expenditure of force, the desired effect will be produced. 
 This fact is of course not new, and no one would have thought of trying 
 to straighten the wire in any other way than by lateral pressure, but the 
 argument has not to my knowledge been hitherto api)lied in discussing 
 the treatment of the spine." 
 
 But, while diffident about disputing authority so great, does not 
 the argument seem fallacious? This copper wire or iron rod is 
 one bodv, it cannot represent the spine, which is many members, 
 and what may be jiredicated of the one, is not necessarily true of 
 the other. Suppose we laid out a string of beads or a piece 
 of elastic, curved to represent the spine, no one would dream of 
 straightening that by lateral pressure, or in any other way than by 
 extension. Not, of course, that a string of beads could represent the 
 spine ; it would be difficult to find a mechanical arrangement which 
 would represent the muscles, ligaments, discs, articulations, bones, &c., 
 which are factors in keeping the form of the spine, but the beads may 
 throw a doubt on the validity of ai-guing that what an iron rod does, so 
 also does the spine. Besides this, practically, 1 think we find that slight 
 extension has a very decided effect. Place a patient erect but not 
 extended, and ajiply the electrodes of an ordinary Faradic battery (mild 
 current) over the rhomboids, and feel the motion of the spines; then 
 extend slightly, and api)ly the electrodes again, the difference in response 
 i<s most marked ; so much fur rotation. Repeat the same a few times, 
 and the lateral curvature improves quite noticeably. 
 
 I therefore contend, that by combining extension with Faradism (or 
 galvanism), you (1) give the required correction to the lateral curve, and 
 (2) relieve the pressure of the vertebrpe upon each other, and by ajjplica- 
 tion of the electrodes to any muscle or set of muscles required, much 
 more easily undo the rotation of each and all of the offending vertebras. 
 
 Friction, stimulating liniments, douches, massage, and gymnastics and 
 other e.vercises, such as are detailed in the work spoken of, are tiseful 
 adjuncts, besides general Faradisation of the dorsal muscles. 
 
 If the treatment b(! carried out carefully, and not entrusted to anyone 
 else, I think it will be found that the risks sjwken of have no real 
 existence, and that the improvement in most cases will be more decided 
 than by other methoils. [Two ca.ses, treated with success by Dr. Scott's 
 method, are then related.
 
 THE MANAGEMENT OP TRAUMATIC HEAD CASES. 269 
 
 THE MANAGEMENT OF TRAUMATIC HEAD CASES, 
 WITH A VIEW TO THE PROPHYLAXIS OF IMME- 
 DIATE AND REMOTE MORBID SEQUELS. 
 
 By A. J. W. Pettigrew, M.R.C.S. 
 
 As the necessity foi-, and the benefits of, any means of prevention 
 \ised ill the medical art, are least conspicuous when they are most 
 successful, it is necessarily difficult or im])ossible to determine their 
 exact value ; isolated cases can discover nothing, however closely 
 observed. 
 
 The experience, however, of a considerable number of head injuries 
 of various grades of severity, in the treatment of which the strict 
 precautionary measures which are routine in my practice were adojjted, 
 induces me to believe that the mortality from these causes may be 
 materially lessened ; while it is distinctly the case within the scope of 
 my own observation that, iinder the employment of the system I indicate, 
 the number of early and complete recoveries from these injuries has 
 undergone a marked increase. 
 
 The sources from which the remai-ks I have the privilege of offering 
 you are mainly drawn, iire notes extending over some thirteen years, and 
 recording fully any case of cranial injury of any interest that has been 
 available to me for observation during that period. 
 
 I desire to be understood as aftecting nothing more than to briefly set 
 forth the results of a practical application of familiar and recognised 
 principles of treatment, which, as I conceive, are too frequently entirely 
 iffnored. In dealing with the cases under consideration, I refer more 
 particularly to those cases of little or no objective severity, and accom- 
 panied on the part of the patient, after recovering from the immediate 
 effects of the injury, with but little sense of illness. The following may 
 be cited as typical : — A young man, strong and healthy, has a fall or 
 blow on the head, from which he suffers some slight degree of concussion 
 — as, for instance, some mental confusion, giddiness, inability to stand 
 or walk, lasting a few moments or minutes, or longer. After a few 
 hours' rest, he resumes his work and continues at it, though without 
 having recovered his usual sense of perfect health ; this lasts say for 
 ten days (a very usual period of latency), when he is rather suddenly 
 attacked %vith severe head sym})toms, and obliged to desist. All the 
 signs of active cerebral irritation rapidly supervene, and in this condition 
 he presently dies ; post-mortem may be found a few small flat coagula 
 adhering to the membranes, an ounce or two of red serum, but the brain 
 substance perfectly sound in every part, no breach in the surface or 
 ruptured blood-vessel discoverable to the most careful washing and 
 examination ; or recovery may in time ensue, complete, or more 
 frequently with more or less permanent or long persistent mental or 
 bodily disablement, or with both. It is during this period of latency — 
 the interval between the injury, and the accession of serious head 
 symptoms— that an opportunity occurs of saving from ill consequences, 
 perhaps, a fatal issue, a crippled nervous system, or a host of minor 
 miseries. It may be suggested, ])erhaps plausibly enough, that the 
 surgeon is seldom consulted at this time ; I think, however, that
 
 270 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 experience shows it to be otherwise, and that he commonly sees the case 
 early, summoned usually before the alarm and confusion of some 
 accident has subsided. Should the patient be found to have sustained 
 any degree of concussion (the extent to which consciousiiess is involved 
 affording a means of gauging its severity) at this stage, however favour- 
 able appearances may be, the case, I apprehend, must be regarded as a 
 serious one, and should be treated as such, the patient being at once 
 removed to his home and to bed, and quiet and rest of mind and body 
 insisted upon and maintained for a ])eriod of at least ten days, though 
 if there be freedom from symptoms, he need not of necessity be kept in 
 bed throughout this time. Should, however, there be any headache, 
 mental confusion, shakiness, irritability, or other evidence of nervous 
 derangeuient — the bowels, of course, having been attended to, while 
 anything approaching purgation is to be avoided as depressing and a 
 cause of disturliance and discomfort, and certainly not derivative — the 
 ])atient should be put upon the bromide of potassium in doses, say of 
 fifteen grains, frequently repeated. Should there be no improvement in 
 headache, irritability, &c., five-grain doses of chloral hydrate may be 
 added — a most ethcient combination to this end. Should there be any 
 rise of temperature, as there commonly is in these circumstances of a 
 degree or so, drop doses of tincture of aconite may be given with this 
 mixture ; diet, of course, to be in liarmony wi^h the treatment. The 
 wetted cloth to be found on the head of every patient with cerebral 
 syuiptoms is pi'obably useless, while the circumcrauial pressure afforded 
 by a handkerchief tied with moderate tightness is often most comforting. 
 Should, however, the case be one of greater severity, and the primary 
 disturbance of a more formidable character, it may be conjectured that 
 some intra-cranial structural damage has been sustained, and not 
 uncommonly there may be reason to suspect that the upper part of the 
 cord has been injuriously involved in the concussion — often a most 
 perplexing complication from the unlooked-for and unaccountable natui'e 
 of the functional perversions occasionally induced thereby. The reaction 
 will now be longer delayed, and when it does come about, overstep the 
 normal level and, without remission, merge, if uncombated, more or less 
 gradually into a condition full of danger to the patient. The headache 
 becomes increasingly severe ; delirium soon api)ears without any 
 decrease in the headache —unlike, in this respect, the headache and 
 delirium of systemic fever ; intense irritability, and restlessness, light 
 and sound intolerable, scalp hot and having a feeling of tumidness, 
 temperature perhaps 102° or 103°, pulse not frequent nor hard, but 
 having a p)eculiar thrill, and giving the sense that it is morbidly 
 inhil)ited, vision clouded —this often an early symptom. The ophthalmo- 
 scojie will, in most cases, reveal a double optic neuritis, the disc appearing 
 vascular throughout, the cup being entirely obliterated, and the sliarp 
 definition of the edge of disc lost, the nasal side usually being first 
 affected ; and I can conceive that from these appearances much might 
 l)e learned of the state of the parts inside the cranium, and beyond 
 reach of our inspection. The case may now rapidly pass on to coma, 
 signs of compression, and death ; the brain in these circumstances being 
 very susceptible of the effects of pressure, though wonderfully tolerant 
 of it when slowly developed. This state of affairs must be met early, 
 before active congestion passes on to inflammation, by prompt and
 
 THE TREATMRNT OF THE SAC IX HERNIOTOMY. 271 
 
 effective measures. Position in bed is important ; it should be such as 
 otFers least resistance to the performance of the circulation as a wliole — 
 that is, with the head and shoulders slightly raised, the back of the head 
 to be much on the same level as scapular region. A free operation of 
 the bowels should be secured as early as possible, the head shaved, cold 
 apjilied by any of the many means in use ; it is not necessary, nor perhaps 
 desirable, that it should be intense in degree, but all-important that it 
 shoukl be maintained, and not intermittent. Moderate heat should be 
 applied and maintained along the cervical spine, small doses of tincture 
 of aconite and chloi-al hydrate being given at frequent intervals ; anil I 
 think it will be found that cases not having an invincible tendency to 
 go to the bad, or having some necessarily fatal element in them, will 
 respond favourably to treatment conducted on these lines and carefully 
 watched. 
 
 I may fitly conclude this paper by quoting the familiar aphorism 
 usually attributed to Hippocrates, and endorsed by many great names 
 in surgery — " No case of head injury is too slight to be despised, or too 
 severe to be despaired of." 
 
 THE TREATMENT OF THE SAC IN HERNIOTOMY. 
 
 By K. R. KiRTiKAR, Surgeon H.M. Bombay Army. 
 
 The operation for the removal of the sac in incisions for strangulated 
 hernia, is not a strictly new one. It used to be practised by surgeons 
 of former generations. But with the recent advances surgery has made in 
 dressings, and especially in the control of haemorrhage, by the u.se of the 
 haemostatic forceps, the attempt to remove the sac of the hernia ]ieed 
 not be considered one that would necessarily endanger the life of the 
 patient, or increase the risk of the operation. Every surgeon who 
 recommends the removal of the sac, in our own day, advocates the strict 
 use of the antiseptic method of dressing. In my own humble opinion, 
 the operation has no danger, if the dissection is carefully done. The 
 extensive, freshly dissected surface, which the operation leaves behind, 
 is rather an advantage, moreover, inasmuch as the parts, in healing, 
 Ijecome firmly united by fresh poured lymph, which effectually destroys 
 the smooth track of the former hernia, and ensures a '■* radical " cure. 
 Some surgeons advocate the mere removal of a portion of the neck of the 
 sac, or the removal of an inch of the serous membrane, an inch or half an 
 incli below the neck of the sac, leaving the Ijody of the sac intact. This, 
 I opine, is not a safe proceeding, at any rate, in a country like India, 
 where, we know, hydrocele is so common. Hero, in leaving the body of 
 the sac, we produce a sort of a sac — another tunica vaginalis, where, 
 possibly, by some error in the absorptive and secreting process of the 
 confined serous membrane, a hydrocele may be produced. I think, 
 thei'efore, the removal of the sac in toto, an inch or half an inch from 
 the neck of the sac dounward, is the best course. The neck of the sac 
 should 1)0 sutured by transfixion, as high as possible, to pre\ent pouch- 
 ing and a recurrence of a hernia. Half an inch or an inch would be 
 allowable, as on healing and cicatrising, the parts retract, and would
 
 272 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 thus leave no bagging. My experience is not much, but guided by tlie 
 experience of others, T have performed the operation successfully, not 
 only in uncom])licated hernia, but in cases witli elephantiasis. It is too 
 early yet to determine whether, in the men from whom I have removed 
 the sac, there is a return of the hernia. T have briefly summarised the 
 cases in which I have performed the operation. They are as follows : — 
 
 Case I. 
 
 G. K., a middle-aged man, Hindu, admitted into hospital on 13th 
 July, 1886, with strangulated hernia (direct scrotal), right side. The 
 hernia was of long standing, and this man had been wearing a truss for 
 nearly five years. Occasionally the hernia came down — tvvo days ago it 
 did so, but could not be returned. Size as large as an ostrich es:g, 
 tense and painful ; stercoraceous vomiting. Taxis has been tried outside 
 hospital, but without avail. Ice has been put on for the last two hours. 
 Pulse 100. No fever. 
 
 Operation. — The parts are shaved, and covered with a towel dip])ed 
 in perchloride of mercury solution (1 — 1000), and curbolic lotion 
 (1 — 100). The patient was placed under chloroform, and an incision 
 was made in the long axis of the hernia, commencing a little 
 above the position of the external ring. After going through the 
 different layers of fascial and cellular tissue, the jjeritoneum was o])ened 
 into. About four ounces of blood-tinged serum escaped. No attempt was 
 made to reduce with the sac unopened. A linger was jiassed up to the seat 
 of constriction, which lay at the upi)er part of the external ring, and a 
 slight nick was made with the hernia knife passed over the index finger 
 of the left hand, cutting upward and inward. This I'elieved the tension 
 of the conjoined tendon, and the bowel, a large coil of the small intestine 
 (ileum), was free. It was next pulled down gently, and examined at the 
 seat of constriction, where there was the usual congested condition at 
 the seat of strangulation. Here and there there was- just a sliade of 
 peritonitis. The bowel was washed with equal parts of mercury perch- 
 loride and carbolic lotion, and i-eturned into tlie abdominal cavity. The 
 sac was next divided half an inch below the external ring, and the 
 scrotal portion was carefully dissected- The jiroximal end of the sac 
 was also dissected out all round for about a quarter of an inch, and a 
 suture (double catgut) passed by transfixion through the centre of the 
 cut ends, tying a knot on each side. The parts were washed with 
 mercurial lotion, and iodoform freely aj)]ilied to the cut and dissected 
 parts. A draining tube was inserted into the parts under the skin, and 
 the edges of the wound brought together by silver sutures. Iodoform 
 applied to the sutured surface, and a pad of boric cotton and oakum was 
 placed thereon, secured by a firm spiral bandage. Opium allowed, 
 thirty drops of the tinctui'e every four hours, and iced water to drink for 
 twenty-four hours. Bits of ice to suck to allay thii-st. No food. 
 
 On the following day. — No rise in temperature. No motion. Pulse 
 80. No pain. No tenderness of abdomen. Dressings not removed for 
 a week. On the third day, the ))atient was allowed iced milk to drink. 
 Tincture of opium twenty drops, thrice daily. No solid food was allowed 
 during tlie first week. On the fifth day, the patient passed a few 
 scybala. He was allowed an enema of castor oil and rice congee, which 
 brought away a large mass of scybalous matter. On the 8th day, the
 
 THE TREATMENT OF SAC IN HERNIOTOMY. 273 
 
 skin wound had healed by first intention, having been treated tlu-ough- 
 out antiseptically. 
 
 Case II. 
 
 G. M., a middle-aged Hindu, admitted into hospital on 10th Sejit., 
 1886, suflfering from strangulated hei'nia of left side, direct inguinal, of 
 the size of a small cocoaniit ; it had been down more than forty-eight 
 hours. Taxis had been tried without benefit. The man was allowed to 
 remain with the ice bag on for three hours before he came to hospital, 
 but there was no sign of the hernia being influenced by it. The parts 
 were shaved, and covered over with a towel, steeped in perchloride of 
 mercury and carbolic acid lotions. 
 
 Operation. — The man was placed under chloroform, and an incision 
 made in the long axis of the tumour, right over the external ring. The 
 sac was opened, and the index finger passed xipward in the direction of 
 the constriction, which lay at the upjier and outer aspect of the con- 
 joined tendon. A nick was made by means of the hernia knife — the 
 knife being passed over the left index finger. The direction of the cut 
 lay slightly upward and outward. There were no adhesions anywhere. 
 The coil of intestine (jejunum) was 2iow loose. It was pulled down 
 gently and examined. It was very dark, but not " dead." There was a 
 large quantity of dark red fluid, about six ounces, in the sac, and the 
 peritoneum was injected. The parts were carefully Avashed with 
 mercuric lotion, and returned into the abdomen. The sac was dissected 
 out, and the cut ends of the sac secured, as in the case cited above, with 
 the same mode of dressing and after-treatment. The man was sent out 
 of hospital, cured, on the Gth October, 1886. 
 
 Case III. 
 
 N. K., an aged Hindu, male, over 70 years, not a very strong 
 looking man, was admitted into hospital on 20th July, 1887. Patient 
 has a strangulated hernia (scrotal direct) of the left side. The hernia 
 has been down nearly twenty-four hours. Has the history of having 
 suffered from strangulated hernia of the right side, for which he was 
 successfully operated upon. Taxis has been tried, in the present instance, 
 with no benefit. The hernial tumour is of the size of a cocoanut of 
 ordinary size. Ice has been tried, but without avail. The man was 
 therefore put under chloroform, and with the precautions mentioned in 
 Case No. I., the operation was performed. The sac was opened, 
 without making any attempt to reduce the l)Owel. The constriction, 
 which was at the external ring, was relieved by making a few nicks over 
 the tense fibres, with the ])ointed end of the scalpel, guarding the bowel 
 with the index finger of the left hand — this procedure being not 
 sufficient to reduce the bowel, the nicked spot was again invaded by the 
 hernia knife, and a cut was made upward and inward. The cut was about 
 a quarter of an inch, just enough to let the bowel sli}) in easily. Before 
 the bowel was finally returned into the abdominal cavity, the constricted 
 ])arts were examined — tliere was a dark rim, but the damage was repar- 
 able. On oj)ening the sac, a good deal of red-tinged serous fluid escaped. 
 There was a good deal of injection of the sac ; in some parts slight 
 opacity of the serous membrane. The sac was carefully dissected out. 
 The incised parts and the protruded part of the bowel, which consisted 
 
 T
 
 274 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 of two coils of the ileum, with the great omentum and mesentery 
 drawn into the sac, were washed with the mercuric chloride 
 lotion ; the cut ends of sac, near the external ring, were secured 
 by a double ligature of carbolised catgut, and iodoform was rubbed 
 well into the dissected parts. A drainage tube was introduced, 
 and the edges of the skin of the scrotum and abdomen brought 
 together by silver wires. Boric cotton and oakum pads were 
 put on, and secured by a spiral bandage. Iodoform dusted over the 
 sutures. The patient was allowed nothing but iced water for the next 
 twenty-four hours. Milk and ice allowed on the third day after the 
 operation. Opium, thirty drops of the tincture, every four hours. On 
 the third day, the patient passed a few scybala ; he was therefore 
 ordered a soap and warm water enema. The pulse was 80. No rise of 
 temperature. No pain. No abdominnl symptoms. The dressings were 
 clianged every three days, it having been found that the patient, an 
 inveterate snufF-taker, constantly put his fingers, soiled in snuff, into the 
 di'essings and scratched the wound. (Query — Did the snuff act as an 
 antiseptic dressing'?) It evidently made no difference in the after pro- 
 gress and treatment of the case. The wound healed steadily without 
 much suppuration. The skin, notwithstanding the old age of the man, 
 and feeble vitality, healed chiefly by the first intention, and only a few 
 drops came away by the drainage tube, whicli was removed in twelve 
 days. He was discharged on 6th August, on the seventeenth day after 
 admission into hospital, with the incision all but healed, there being just 
 a point, where the lower end of the drainage tube rested on the skin, 
 discharging a little pus. 
 
 Case IV. 
 
 J. B., a Parsee, male, aged nearly 60, in poor health ; has suffered 
 for the past twenty-five yeai's from elejihantiasis of the scrotum, com- 
 plicated with double hernia. The size of the scrotum is twice that of an 
 ordinary cocoanut. . The tumour is riddled with sinuses, here and there 
 discharging thin ichorous pus, smelling offensively. He came under my 
 observation in the Thana Civil Hospital, in August 1885, for symptoms 
 which seemed to simulate strangulated hernia of the right side. He 
 had been accustomed to a truss which he wore right over the elephantoid 
 mass, invading the right groin. In reducing his hernia, he had no 
 diittculty usually. One morning he felt very sore about the seat of the 
 hernia, where the pad of the truss, which was of brass — a heavy country- 
 made article — pressed on the scrotal tumour. By afternoon there was 
 distinct tenderness, and the man was uncomfortable. He had, conse- 
 quently, not dared to meddle with the hernia; had not attempted to push 
 it up ; and, moreover, he left off wearing the truss. The following day 
 the symptoms were very urgent. He had vomiting, which, coupled with 
 a tender irreducible swelling in the vicinity of the external ring, with 
 a history of former reducible hernia, excited the suspicion of the case 
 being one of strangulated hernia. There was, however, no stei'coraceous 
 vomiting. Tiiere was a good deal of restlessness and constitutional 
 disturbance, with a certain amount of fever (101°) ; pulse 110, very 
 feeble. It was decided to put the man under chloroform and determine 
 the nature of the complaint. I could in no way be sure that I had to 
 deal with an uncomplicated case of strangulated hernia ; yet the
 
 THE TKEATMEXT OF SAC IN HERNIOTOMY. 275 
 
 possibility of there being a strangulation of the bowel struck rne as the 
 most feasible way of accounting for the local symptoms and the con- 
 stitutional disturbance. The bowels had not moved for two days. I at 
 once decided to cut down upon the swelling without Siny hesitation, to 
 know the nature of the disturbance, and to remove any strangulation if 
 there Avas any. The parts were washed with mercuric perchloride 
 solution, after they were shaved, and an incision three inches long made 
 right over the tumoui-, which now occui)ied a spot midway between the 
 external ring and the lowermost part of the scrotum, taking advantage 
 of a sinus in the sci'otuni. Cutting step by step, I came across the 
 tunica vaginalis, and the testicle beneath. The tunica vaginalis was 
 distended, inflamed, and full of purulent serous matter, with a tinge of 
 blood here and there, with a coil of intestine (ileum) imbedded in it, and 
 adherent to the tunica vaginalis. Thus my way was clear. There was 
 a sort of a pseudo-strangulation of the bowel, which had got caught in 
 the congenital hernial sac, now in a state of inflammation. There was 
 no strangulation proper at the internal or external ring, nor at the neck 
 of the sac ; for there was really speaking no neck, as on passing 
 the finger along the cord, it went freely into the abdominal cavity 
 through a widely patent internal ring. I carefully separated 
 the coil of intestine from the mass of the disintegrating j^roducts of 
 inflammation, which seemed to me to have originated in, and extended 
 from, the sinus ; which, along with several others, had riddled the 
 scrotal tumour in the close vicinity of the right testicle. The bowel was 
 freed from its entanglement, and, although slightly injected, was 
 returned into the abdominal cavity. I scraped a good portioia of the 
 tunica vaginalis, and where possible dissected portions of it ; washed 
 the parts with mercuric perchloride lotion, and rubbed in iodoform 
 freely. A drainage tube was introduced after the healthy portion of 
 the sac had been secured by a double ligature, thus trying to efl:ect a 
 radical cure for the hernia. The dressings used were oakum, over a 
 large pad of boric cotton. The after-treatment of the case consisted of 
 daily dressings. The man was kejjt on iced water, or bits of ice to suck, 
 for the first twenty-four hours; milk, jellies, soup, and arrowroot 
 congee allowed a fortnight after the operation. 0})ium was prescribed 
 a grain every third hour for tlie first five days, and then every sixth 
 hour for another five days. The bowels acted for the first time on the 
 sixth day after the operation, hardened fascal matter being j^assed. 
 Enemata were given every other day for a week subserpiently. The 
 parts healed near the ring, and efiectively plugged the inguinal canal ; 
 but the elephantoid mass remained as a sinus for about two months. 
 Under iron tonics the man improved, but the sinuses caused a great 
 deal of trouble. The patient was recommended an operation for the 
 removal of the whole of the elephantoid scrotum, but he would not 
 consent. The immediate effect of the operation was to put a stop to all 
 constitutional s3-mptoms — the fever went dowai, the pulse regained its 
 normal quality, and tlie man had relief. 
 
 Case V 
 A male, middle-aged Maratha Hindu, convict in the Thana District 
 Gaol, came under my obsevation in September 18S8. He had an 
 elephantoid scrotum as big as the largest sized cocoanut, complicated 
 
 T 2
 
 276 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 with a hernia of the right side. There were sinuses in the scrotum. 
 In this case, the elephantoid degeneration had attacked the prepuce and 
 skin of the penis also, as far as the pubes. Having on one occasion 
 shown symptoms of the sinus extending to the sac of the hernia, whicli 
 was reducible, guided by my former experience, I at once explained 
 the nature of the case to the patient, and asked him to consent 
 to an operation for the removal of the elephantoid growth from 
 the penis and scrotum, and for the radical cure of the hernia. He 
 readily consented. He was put under chloroform, after the necessary 
 preparations. The preputial afiection was first removed by a careful 
 dissection, afterwards the hernia was reduced, and the scrotum and penis 
 were held tightly by an elastic tube, spirally fastened round the waist, 
 to lessen haemorrhage. Then with an oval sweeji, the scrotum was dis- 
 sected off the perineal surface ; the bleeding points were secured by the 
 haemostatic forceps. The testicles were next separated from the 
 elephantoid scrotal mass, by a careful dissection begun over each 
 spermatic cord, holding that in hand as a guide for the dissection of the 
 testicle. The portions of the peritoneum forming the hernial sac on the 
 right side were next dissected iip to the external ring, after removing 
 the elastic tube. I then left only half an inch of the sac beyond the 
 external ring. I went on securing the bleeding vessels by catgut 
 ligatures as they were cut ; the cut ends of the hernial sac were next 
 secured by a transfixing double ligature. This hernial sac was partially 
 inflamed in the close vicinity of the sinus, which was burrowing in the 
 elephantoid tissue. The parts were well washed with mercuric 
 perchloride lotion, and rubbed over with iodoform freely. The testicles 
 were brought together and covered up with flaps of healthy skin secured 
 from the scrotum before making a clean sweep of the affected mass. 
 Silver wire sutures were used in the median line to secure the flaps, and 
 a drainage tube introduced, extending from the root of the penis to the 
 perinfeum. The after-treatment consisted of opiates and iron tonics, 
 good food, and dressings every third day. The first dressings were 
 removed after a week, and consisted of boric cotton and oakum. The 
 penis became gradually covered over with healthy granulation tissue, 
 and within a fortnight there was firm union of the scrotal flaps, with 
 very little pus or constitutional disturbance. 
 
 The last two cases have a special interest about them, inasmuch as 
 they combat a complication of hernia, which simulates strangulated 
 hernia ; and moreover, they .show that it does not in any way endanger 
 the life of a patient, or add to the risk of an operation for relieving true 
 strangulation, or the pseudo-strangulation of secondary inflainmations, 
 resulting from the degeneration of unhealthy tissue in close proximity.
 
 A CASE OF DIFFUSE SUPPURATIVE PERIOSTITIS OF THE TIBIA. 277 
 
 A CASE OF DIFFUSE SUPPURATIVE PERIOSTITIS OF 
 THE TIBIA, TERMINATING IN RECOVERY ALMOST 
 WITHOUT NECROSIS. 
 
 By Jos. C. Vehco, M.D. Lond., F.R.C.S. 
 
 Honorary Physician, Adelaide Hospital. Honorary Medical Officer, Adelaide 
 Children's Hospital. 
 
 C. G., set. 83% years, male. He was taken ill on Sept. 11, 1888, with 
 pain in the left ankle, and a " bilious attack." It was treated by the 
 mother as a sprain ; but the leg grew worse, and by the 17th, the 
 swelling had extended to the knee. On that date. Dr. Poulton saw it ; 
 and on the day following, the child having been put under ether by 
 Dr. Way, he incised the leg, and found the tibia bare in its whole 
 length. 
 
 On the 24:th, the case was transferred to my care (as Dr. Poulton had 
 kindly taken my practice dui'ing an illness). There were then three 
 incisions along the front of the left tibia — one just above the ankle, a 
 second in the middle of the leg, and a third a little below the tibial 
 tuberosity — varying from one to two inches in length, the higher ones 
 being the larger, and gaping widely. A di-ainage tube passed from the 
 upper wound by the inner side of the tibia, through an incision in the 
 calf ; while a fifth incision in the back of the leg, in the lower })art, 
 corresponded to the lowest one in front. After the blood-clot had been 
 removed by poultices and suppuration, the tibia was plainly seen in all 
 three anterior wounds quite white and bare, and insensitive to the 
 probe, which could be passed along the bone from one wound to the 
 other. 
 
 By Oct. 15th, the lower incision at the back of the leg had spontane- 
 ously closed, and the lower one on the anterior aspect. On Nov. 23rd, 
 as the drainage tube was quite blocked, I removed it with some difficulty, 
 and found it occluded by a piece of granulation tissue, almost cartilaginous 
 in consistence, and containing minute bony spiculpe. At the time, it 
 was supposed to be derived from the periosteum. I tried, with directors 
 introduced into the two front incisions, to move the tibia ; but it appeared 
 firm, though quite bare, white, and insensitive. 
 
 Nov. 1st. — The incision over the front of the middle of the tibia had 
 gradually closed up and epitheliated, and the bone in the upper wound 
 was noticed to be of a pink colour, as though blood-.stained ; and when 
 a director was pressed ujion it. instead of bein.2; hard and dense, it was 
 softened somewhat, and allowed the point to crush into it. There were 
 no granulations on it. 
 
 Nov. 1.5th. — The previously bare bone was completely covered by 
 granulations springing from its surface, large and firm. The appearance 
 was different entirely from that presented by granulations gradually 
 extending inwards from the mai'gins of a wound, and covering over, but 
 not adhei'ing to, a dead bone. These evidently sprang up in situ ; nor 
 could the probe be made to touch bare bone anywhere. 
 
 Nov. 28th. — The granulations were large and irregular ; no space 
 could be detected between the marsins of the wound and the bone.
 
 278 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 The epithelium was spreading inwards, and covering the osseous 
 granulations. 
 
 Dec. 4th. — The wound was almost completely healed over ; but two 
 minute apertures remained, out of which, with a probe, I lifted a 
 superficial piece of exfoliated bone, about three-quarters of an inch 
 long and the sixteenth of an inch wide, and two small immeasurable 
 scraps. 
 
 This is the only case, within my experience, in which, where there 
 was at first evidence of separation of the periosteum from the whole 
 diaphysis of a long bone, there was, eventually, complete recovery, 
 practically without necrosis. And for this reason, I think it worthy 
 the notice of this Congress. 
 
 In the last edition of Erichsen's " Surgery," page 2S0, we read, " as 
 the name ' acute necrosis ' implies, the disease almost invariably results 
 in more or less extensive death of the compact tissue. The extent of 
 the necrosis by no means necessarily corresponds to the area from which 
 the periosteum has been raised by the pus, for after this has been 
 evacuated, the membrane may adhere again, to a considerable extent, 
 and the connection between its vessels and those of the bone be 
 re-established. In a case lately in the University College Hospital, the 
 tibia was felt to be bare from one end of the shaft to the other ; yet, 
 after free incisions were made, no necrosis followed, except over an area- 
 of about one square inch near the lower end." 
 
 Again, from the British Medical Journal, for August 25th, 1888, we 
 learn that Dr. McEwen, of the Royal Infirmary, Glasgow, at the 
 annual meeting of the British Medical Association, cited and exhibited 
 the case of a child who had had suppurative periostitis of the whole 
 diaphysis of the tibia, the periosteum being completely stripped, except 
 a portion posteriorly, where the nutrient artery entered. The bone was 
 bare, and presented the appearance of white porcelain. Between the 
 periosteum and the bone a series of layers of sublimated gauze were 
 packed, thus separating the bone from its periosteum. This separation 
 was kept up for four weeks, the parts being dressed every forty-eight 
 hours, when they were observed. Two days after operation, the bone 
 presented a pinkish blush, except a small portion three quarters of an 
 inch in length, and half an inch broad ; this ultimately exfoliated. On 
 the 16th day, the bone was covered with granulations, as also the 
 periosteum. Four weeks after the operation, the bone was completely 
 enveloped by firm cartilaginous granulations, those of the periosteum 
 being soft and pulpy. The two layers were, for the first time, allowed 
 to come together, and they soon coalesced. This case shows that bone 
 is capable of living and growing, independently of its periosteum, if the 
 nutrient vessels are still intact. 
 
 There are some points for reflection, which arise out of a case such as 
 the one I record. 
 
 In the first jjlace, what shall the disease be called ? Its common name 
 is " Acute Necrosis." But this is evidently a misnomer. The bone 
 may be bare, white, and insensitive ; but it is not, therefore, dead ; and 
 consequently, to call it a necrosis, is to go beyond our facts. It may be 
 dead — it may not be. Nor, as my case proves, have we reason for pro- 
 nouncing the bone dead until at least six weeks have passed since first 
 the collection of pus was opened. In McEwen's case, the bone was
 
 A CASE OF DIFFUSE SUPPUKATIVE PERIOSTITIS OF THE TIBIA. 279 
 
 seen to be pink witliin two days of operation ; but in mine, not till six 
 weeks had elapsed. 
 
 Some would call it " Osteo-myclitis," but of this, there is even less 
 evidence ; for the condition of the marrow is even more hypothetical 
 than that of the bone itself. Besides, in my case the vitality of the bone 
 almost certainly depended on the normal state of the marrow, which was 
 able to maintain it in spite of the extensive or complete denudation of 
 periosteum. What is certain is the existence of a periostitis, ditfuse in 
 its extent, and suppurative in its character ; and diflfuse suppurative 
 periostitis is, to my mind, the correct name for the complaint. Some 
 call it infective ; but though I have had a case in which the infective 
 element certainly existed, it did not in this ; and consequently, the 
 pyjemic character is an accident, and not an essential, just as it may be 
 in a whitlow. 
 
 In the second place, this is not merely a matter of names. Names 
 involve ideas. If we call the disease necrosis, we are apt to regard the 
 bone as dead. If it be dead, it will not recover, and will require to be 
 removed. Hence, as a jirognosis, we are liable to assert emphatically 
 and absolutely that the limb can never get well, and that a subsequent 
 operation must be performed. And after this prophecy has been uttered 
 for six weeks in an ex cathedra style, and has been fortified by the 
 opinions of learned and experienced surgeons, we see granulations appear, 
 and have to modify our gloomy forebodings ; and nothing but the 
 unexpectedly satisfactory termination of the case sav^es the reputation of 
 the attendant and of the profession. Therefore, until the expiry of at 
 least six weeks without improvement, we should not be hopeless of an 
 apparent necrosis. May be, " it is not dead, but sleepeth." 
 
 There is one other consideration. If the bone is necrosed, it must be 
 taken out of its periosteal covering. One rule is, not to operate for its 
 removal until it can be felt to be free from its epiphyses. But does 
 every surgeon wait until he can move the bone about in its casing ? It 
 is not every bold spirit that can display that masterly inactivity wliich 
 sits down quietly by the side of a tibia for two months, and allows it to 
 stare him in the face. Has a living tibia ever been removed in mistake 
 for a dead one 1 Unless the bone is certainly free — not merely from its 
 periosteal sheath, but from its ei)iphyses — however bare or white or 
 insensitive it may be, it ought not to be extracted within a less period 
 than two months from the time it has been exposed. And this rule we 
 lay down for ourselves, not because recoveries of the apparently dead are 
 so connnon, but because nature has demonstrated that they are possible.
 
 280 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 ABSCESS IN THE LEFT MIDDLE CEREBRAL LOBE— 
 EVACUATION BY OPERATION — TEMPORARY IM- 
 PROVEMENT—DEATH. 
 
 Reported by J. C. Verco, M.D. Lond., F.R.C.S. Eng. 
 Physician to the Adelaide Hospital, South Australia. 
 
 And E. C. Stirling, M.A., M.D. Cantab., F.R.C.S. Eng. 
 
 Sui'geon to the Adelaide Hospital, South Australia. 
 
 The following case is considered worthy of the attention of the 
 Congress, as it presents .several points of interest in its diagnosis and 
 treatment, and as it is the first case of the kind (so far as known to the 
 reporters), which has occurred in Australia. Cei-ebral surgery is com- 
 paratively of so recent introduction, and is so beset with difficulty and 
 uncertainty, both in the localisation of the diseases demanding its 
 exercise, and in the diagnosis of their pathological nature, that every 
 contribution which will serve to throw a light upon these questions, 
 cannot fail to be both interesting and profitable. The case hei'e detailed, 
 while not so satisfactory to those recording it, as it would have been 
 had the jmtient recovered, has the advantage of the post-mortem 
 examination to confirm the localisation, and to indicate the succession 
 of events in cerebral suppuration secondary to ear disease. 
 
 H. \V., male, tet. 29, pointsman, was admitted to the Adelaide 
 Hospital on November 11, 1888, under the care of Dr. Verco. 
 
 The following history was obtained from his wife : — About four 
 weeks ago he began to complain of headache, chiefly in the left 
 temporal legion. On the 5th and 6th inst. the teeth on the left side 
 began to ache, and on the 7th he came home from his work with great 
 pain in the left temple, orbit and ear, and an aggravation of the 
 toothache. He was "raving," and saying he would dash his brains out. 
 He had had the left upi)ei' canine, and the left lower posterior molar 
 extracted in the morning, without any relief. On the night of the 
 7th, however, he slept well, and in the morning was able to go to his 
 work at o a.m. At ten o'clock he returned, seeming quite stupid, and 
 in great jiain with the teeth and head, and has remained in this 
 condition since. His wife lias not noticed any loss of power, nor does 
 she know of any previous illnesses, except that five years ago he had 
 some head trouble, which was relieved after a discharge of matter from 
 the ear — which one, is not known. 
 
 On admission, the following notes of his state were taken by the House 
 Physician : — He lies in bed with his hands to his head and groans as 
 if in pain, and sometimes holds his head and shouts; con)i)lains of 
 l)ain in his teeth ; when asked his age, he stares in an astonished 
 fashion, and says he doesn't know anything about it ; when told to put 
 out his tongue he opens his mouth widely, but does not protrude it ; 
 it is dry and fissured ; bowels confineil ; no vomiting ; no tenderness 
 of the scalj) ; ])upils equal, left 0[)tic disc seemed to be just a little 
 swollen ; special senses unaltered so far as can be ascertained ; no 
 aural discharge ; no paralysis of motion or sensation ; urine, no albumen
 
 ABSCESS IN Till} LEFT MIDDLE CEREBRAL LOBE. 281 
 
 nor sufjar ; two stumps in tho upper left jaw, belonging to the second and 
 third molars, were removed. 
 
 Seen by Dr. Verco on the 16th ; — Pulse GO, regular ; respirations 22, 
 irregular in time and depth ; ])artial paralysis of the right side of 
 the face ; left palpebral fissure smaller than ihe right ; after attempting 
 and failing, he succeeded in jirotruding the tongue, which tended 
 slightly to the riglit ; double optic neuritis existed ; there was a small 
 amount of moist discharge in each ear, necessitating cleansing prior 
 to examination. There was some difficulty in using the speculum, as 
 he was rather noisy, and the ears were manifestly very tender. As 
 far as could be determined, the membranes were absent in both ears. 
 There was marked aphasia, the answers being quite irrelevant, and 
 sometimes incoherent, though he evidently understood what was said. 
 The right hand grasjied thirty kilogrammes, and the left twenty-three. 
 Sensation to touch was very distinctly impaired in the right upper 
 and lower limb ; the hypa^sthesia was questionable about the right side 
 of the trunk. Plantar reflex was rather more marked on the left than 
 on the right side. 
 
 Nov. 17th. — He passed a noisy night, but at 7.30 a.m. he began to 
 quieten, and at 9 a.m. his condition was that of semi-coma. When 
 seen by Dr. Verco at noon, he was quite comatose, without sensation of 
 touch or motion, and not to be roused, with a freely perspiring skin and 
 dilated pupils, stertorous breathing, vei\y sluggish conjunctival reflex, 
 and with very difficult deglutition. About half-past two. Dr. Symons 
 examined the fundus oculi, and demonstrated the extent of the i)apillitis 
 to be equal to live dioptrics, and noticed a small htemoi'rhage in the left 
 disc at the lower and outer edge. Veins full, and rather too tortuous. 
 Divergent squint. He was transferred to Dr. Stirling for operation. 
 
 The diagnosis was an abscess in the tip of the temporo-sphenoidal lobe 
 of the left side. The circumstances which led to it were the following : — 
 
 The extreme pain in the dental branches of the left fifth nerve, in the 
 orbit, and about the ear, directed attention to its sensory root, with the 
 Gasserian ganglion lying on the tip of the petrous bone, the aphasia to 
 the left third frontal convolution, and the partial facial palsy to the 
 Eolandic area immediately above. The partial affection of sensation on 
 the right side of the body without paralysis indicated some aflection, 
 probably from pressure, of the gyrus hip[)ocampi, and the jiarts adjacent 
 on the under and inner surface of the temporo-sphenoidal lobe. An 
 abscess, therefore, in the tip of this part of the brain, pressing down- 
 ward upon the Gasserian ganglion, downwards and backwards upon the 
 gyrus liippooampi, itc, and upwards against the third left frontal 
 convolution and adjacent jiarts, would explain all the symptoms. The 
 optic neuritis would be quite in order : the history of four weeks' 
 temporal headache would support the diagnosis ; and the account of 
 head trouble years ago, relieved by aural discharge, would i-ender it 
 still more probable. Two circumstances were unfavourable. First, the 
 difficulty of certainly determining the exact condition of the ears, about 
 which, however, Dr. Giles coincided with Dr. Verco ; and next, the very 
 rapid march of events. The speedy onset and considerable degree of 
 aphasia, the progre.ss of the optic neuritis, and the occurrence, within a 
 few hours, of strabismus and deep coma — these pointed (if an abscess 
 existed) to its rapid increase in size, or else to the extension of the
 
 282 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 inflammatory mischief beyond tlie specific limits of the abscess into the 
 brain tissue around. 
 
 Dr. Stirling supplies the following notes of the operation, and sub- 
 sequent history of the patient : — 
 
 It having been decided on the morning of November 17 to operate 
 on the afternoon of that day, the patient's head was at once shaved, 
 well washed with soap and water and then with ether, after which it 
 was kept enveloped in a towel steeped in a five per cent, solution of 
 jDhenol. 
 
 The i^atient was semi-comatose, but complete narcosis was effected 
 according to the plan recommended by Mr. Victor Horsley, by the 
 subcutaneous injection of a quarter of a grain of morphia, after which 
 complete insensibility was easily maintained throughout the operation 
 by a very small quantity of chloroform. 
 
 It will be understood that the operation, and all subsequent dressings, 
 were performed with strict antiseptic precautions, including the use of 
 the spray. 
 
 The diagnosis being an abscess in the central part of the left temporo- 
 sphenoidal lobe, it was decided to expose the surface of the brain at a 
 spot corresponding to the junction of the posterior and middle thirds of 
 the middle convolution of that lobe ; and the spot fixed upon for the 
 trephine hole was at a point an inch and a half above and about half 
 an inch behind the external auditory meatus. This, Avith the skin 
 incision, was marked out with a coloured pencil. 
 
 The scalp incision, made vertically to the bone, defined a nearly 
 semi-circular flap, with a curve of about an inch and a half radius ; the 
 convex edge pointing upwards, and its highest point a little behind a 
 line drawn vertically upwards from the meatus. In making this 
 incision, care was taken not to divide any of the large vessels distributed 
 to that part of the scalp, and as a matter of fact, there was no vessel 
 divided which required ligature. 
 
 I desired to raise the whole of the soft parts with the flap, but I may 
 here remark tliat, misjudging the thickness of tlie temporal muscle, I 
 was not careful enough to do this quite cleanly in the first instance, and 
 a thin plane of muscle was left adhering to the periosteum, and was 
 reflected with that membrane by a crucial incision down to the bone. 
 A disc of bone, which proved of very unequal thickness, was then 
 removed from the region selected with a one inch trephine, and even 
 during its elevation a little pus was seen to ooze through the track of 
 the trephine at its lower i)art. On complete removal of the disc, this 
 appeared to well up through a small aperture in the dura mater, just 
 iinder the lovver edge of the bony opening. I was afraid at the time 
 that this aperture might have been due to accidental laceration of the 
 membrane with the trephine, though I was using the utmost care to 
 avoid such an occurrence. As will be seen subsequently, no such 
 aperture existed, and this pus which first flowed was entirely external 
 to the membranes. The dura mater bulged considerably, and was then 
 incised for about four-fifths of the circumference of the trephine hole, at 
 about a distance of one-sixth of an inch from its edge, the posteiior 
 branch of the middle meningeal vessels j)assing upwards and backwards 
 through the unincised isthmus of dura mater, and being tied with tine 
 tendon at the ojjposite margin.
 
 ABSCESS IX THE LEFT MIDDLE CEREBRAL LOBE. 283 
 
 On reflection of tlie flap of dura mater, the brain with its ])ia-matral 
 covering also bulged conspicuously, and the convolutions seemed 
 flattened, but there was no apj)eai'ance of increased vascularity, or of 
 any inflammatory aflection. 
 
 A little pus was seen to exude from under the dura mater in the 
 upper segment, but its source was not evident. 
 
 A very narrow tenotome was then passed A^ertically to the surface 
 into the bulging brain, for about two inches, and a fine director made to 
 follow in its track with all j)ossible gentleness. About a drachm of 
 normal pus immediately flowed along the groove. 
 
 As the brain still continued to bulge into the ti'ephine hole in spite 
 of this evacuation, it was thought that more pus must i-emain, and so 
 the tenotome, and after it, the director, was gently })assed in various 
 directions through the same external surface opening. From several 
 directions, but chiefly from a region lying in a direction forwards and 
 inwards, pus, together with some dark blood clot, flowed freely along 
 the groove of the director, and still more freely on gently dilating the 
 incised track with a pair of sinus forceps. This wus gently washed 
 away with a stream of corrosive sublimate solution (1 in 5000). When 
 pus would no longer flow, we reckoned that about an ounce to an ounce 
 and a half had been evacuated, but this estimate is liable to error. 
 
 Into what then seemed the main abscess cavity, lying at a depth of 
 about two inches, in a direction forwards and inwards, a small hydrocele 
 canula w^as passed, a gum catheter being substituted for the trocar. 
 Through this canula a flexible catheter was inserted, which served as 
 an irrigating tube for washing out the supposed cavity with the weak 
 corrosive sublimate solution. A piece of india-rubber tubing, about a 
 quarter of an inch in diameter, and about two inches long, was finally 
 inserted, and left for drainage. I should mention that no bleeding 
 whatever accompanied any of these pi'ocedures. 
 
 The flap of dura mater was left unsutured, and tucked away at the 
 lower pai't of the trephine hole, so as not to obstruct the tube. The 
 scalp flap was split by an incision, running parallel to the vessels, in 
 such a way that the anterior segment when replaced just cleared the 
 orifice of the drainage tube, and was accurately and closely sutured. 
 The ])osterior flap was also replaced in such a way that the drainage 
 tube emerged between the two scalp flaps, the rest of the trephine hole 
 being com])letely covered up by these. Underneath this posterior flap, 
 a small sized drainage tube was placed, passing from the i-egion of the 
 trephine hole, and emerging at the lowest margin of the wound in the 
 recumbent ])Osition. This arrangement was intended to hinder any 
 discharge from gravitating downwards, and collecting under the scalp. 
 Iodoform powder was dusted over the wound, and the ordinary gauze 
 dressings applied. On being removed to his bed after the operation, the 
 patient's condition was as follows: — Pulse 84, fairly good; breathing 
 somewhat stertorous; respirations 19 per minute. Pupils dilated, the 
 left more so than the right; reaction to light of both irides doubtful; 
 conjunctival reflex ))resent. Ptosis of left eye, and corresponding cheek 
 puffed out on expiration; left angle of the mouth "screwed up" on 
 being aroused, when he seems to understand what is said to him. 
 He can move his arms, the left freely, but the right to a slight degree 
 only.
 
 284 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 At niidnight the patient was rational, could answer questions, and 
 could move his right arm much better than before the operation. 
 
 Nov. 18, 7.30 a.m. — The tongue is dry, and cannot be protruded. 
 Left ptosis ; both pupils still widely dilated, especially the left ; right 
 iris reacts to light, the left not at all ; left eyeball almost fixed, with 
 slight movement, only outwards. He is drowsy and aphasic, but seems 
 to understand what is said to him. Pulse 96. Ordered hydr. subchlor., 
 gr. iij. At 10.30 a.m. the dressings were changed. There has been 
 no discharge of pus from the tube, which is patent. No bulging nor 
 protrusion of brain. 
 
 Nov. 19, 10.30 a.m. — He can move his right arm and hand, and 
 button his shirt with it. The ptosis of left eyelid continues, but he can 
 partially raise it with his occipito-frontalis. Both pupils dilated, with 
 same excess of left side. Reaction to light of right iris, none of left ; 
 slight divergent strabismus of left eye, which is immobile ; right eyeball 
 moves freely in all directions. 
 
 Nov. 20. — The tongue moist, furred ; cannot protrude it. Ocular 
 symptoms unchanged, but there is rather less facial paralysis. 
 
 Nov. 21. — -Tongue moist ; makes the effort to protrude it without 
 success. There is evidenth^ increased power in the right facial muscles, 
 and he can move the limbs on the right side, on which there is no loss of 
 sensation. 
 
 Nov, 22. — General condition the same, 
 
 Nov. 23. — On dressing the wound, there is evidently some discharge 
 of pus, but it is quite sweet. A rather larger drainage tube inserted. 
 
 Nov. 24. — Very restless and delirious during the night. Pupils 
 unequal, but the left is diminished in size, and the iris acts a little to 
 light; otherwise the paralytic symptoms ai'e apparently unchanged. On 
 the other hand, his mental condition is decidedly less favourable, as the 
 hebetude is markeiUy increased. In his restlessness this morning, he 
 managed to displace the bandages, and with them the drainage tube was 
 withdrawn, but they were replaced almost immediately by the house 
 surgeon. On dressing the wound early in the forenoon, there was found 
 to be a distinctly increased discharge of pus, which is however quite 
 sweet. Later in the daj'', at 4 }).m., he was found to have complete 
 paralysis of motion on the right side, and on removal of the drainage 
 tube, it was found to be full of oflensively-smelling and disintegrating 
 blood clot. On gently probing the depths of the cerebral wound with 
 the director, pus of the same character escaped along the groove. The 
 wound was well washed out, and a fresh tube inserted. 
 
 Nov. 25. — Has ])assed a re.stless night. Left pupil less dilated ; no 
 reaction of iris to light ; that of right eye acts. Facial paralysis more 
 marked ; incontinence of urine. Later, at 8 p.m., he was very drowsy 
 and lethargic. 
 
 Nov. 26. — Paralysis of right side, ])ersistent and marked, but he can 
 move tlie left leg. There is some difficulty in swallowing, some of the 
 fluid regurgitating. Makes no effort to protrude tongue ; incontinence 
 of urine. Endeavours to pull the bandages off. On dressing the 
 wound, pus mixed with blood and softened brain substance escapes 
 when the tube is removed. There is also some hernia cerebri. There 
 seem to be two distinct tracks leading into the interior of the brain — 
 one inwards and forwards, and the other more directly inwards or a
 
 885* INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Mim& H.yV^ 
 
 Drs.VePco & Stirling 
 
 DayoF 
 Treei.-jiril 
 
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 7 
 
 8 
 
 9 
 
 10 
 
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 TEMPEF^ATUf^E TAKEN AT 6 A.M, & 6 RM, /^ESPECTIVEL\<
 
 ABSCESS IN THE LEFT MIDDLE CEREBRAL LOBE. 285 
 
 little backwards, into either of which the drainage tul)e passes easily. 
 The former is that into which the tube has jireviously been placed, and 
 through which most of the dischai-ges have come. Depths of wound 
 washed out l)v irrigating through a flexible catheter. 
 
 Nov. 27. — Is veiy drowsy, and in about the same condition as yester- 
 day, but there is more discharge from the wound, which, however, is less 
 offensive. 
 
 Nov. 28. — Restless during the early part of the night, but subse- 
 quently slept quietly. There is still difficulty in swallowing, but he is 
 taking more than on the previous two days. Paralytic symptoms as 
 before. Does not speak, but seems to understand what is said. 
 
 Nov. 29. — Semi-comatose all night, scarcely stirring. Will drink a 
 little. Incontinence of urine. Bedsore commencing over sacrum. 
 Evidently sinking. 
 
 Nov. 30. — Comatose, with apparently complete paralysis of extremi- 
 ties. Sinking fast. Died at 11.40 a.m. 
 
 The temperature never rose above 101 "3°, until about 3G hours before 
 death, when it reached 104'-i°. 
 
 Post-mortem. — There was no general meningitis, but the left third 
 nerve was flattened, and involved in some lymjih in the subarachnoid 
 space at the base. There was no adhesion of the left temporo-sphenoidal 
 lobe to the dura mater over the petrous bone, but the membranes were 
 adherent to the brain substance at, and immediately around, the trephine 
 wound. The brain substance at this point was softened, of an almost 
 black colour, and foetid. From the external wound two tracks were 
 discovered, one passing almost directly inwards, thi-ough reddened and 
 softened brain substance, into the lateral ventricle, just at the junction 
 of the middle and posterior horn ; the other })assing inwards, forwards, 
 and towards the base, through soft dark brain tissue nearly to the tip of 
 the middle lobe, and into a cavity with a greenish-gray lining, which 
 communicated at one point by a small oi)ening with the lowest part of 
 the middle horn of the lateral ventricle, and also with a second small 
 cavity in the extremity of the temporo-sphenoidal lobe. The left side of 
 the brain for a considerable area around the seat of operation was 
 softened and reddened, but there was no adhesion to the dura mater, nor 
 any cff'usion of plastic lymph, except in the immediate neighbourhood of 
 the surgical wound. The left temj)oral bone was removed and examined. 
 The centrepiece of the trephine had been placed at a point one inch and 
 a half above the centre of the external auditory meatus, and half an inch 
 behind. On stri^iping off the dura mater, there was seen an eroded 
 surface of bone, of an irregularly lozenge shape, the long diameter 
 extending downwards and forwards along the line of junction of the 
 squamous and petrous portions of the temporal bone. The posterior end 
 of this eroded surface just touched the lowest point of the trephine hole. 
 Its width was about three quarters of an inch, half an inch of this Ijeing 
 on the upper surface of the petrous bone. Here there was a ragged 
 perforation running vertically into the substance of the bone. In the 
 groove for the lateral sinus, just after it makes its curve from the 
 horizontal to the vertical portion, that is on the posterior part of the 
 petrous bone, about half an inch from its supero-posterior edge, was an 
 irregular hole, one quarter of an inch V)y one eighth of an inch in size. 
 Probes put into these two perforations touched one another. On ojiening
 
 286 IXTEHCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 the tyini)auum internal to these apertures, it was found, like them, filled 
 with inspissated pus ; and on remoA-ing this, the walls were felt bare of 
 membrane. The malleus and incus were present, but water injected 
 into the external meatus flowed freely through this hole in the 
 tympanum, demonstrating the absence of the membrana tympaui. 
 From tlie u[)per {)art of the cavity of the tympanum, a probe passed 
 directly outwards, under an extremely thin shell of bone, and [)arallel 
 with, but above the meatus, to the perforations described on the upper 
 surface of the petrous bone, and also outwards, backwards, and down- 
 wards to the large perforation in the groove of the lateral sinus. 
 Inspissated pus lay between the dura mater and the skull, over the 
 carious bone on the upper surface of the petrous portion of the temporal, 
 but no perforation of the dura mater existed. There was no separation 
 of the dura mater at the back of the petrous bone in the groove of the 
 lateral sinus, nor was the sinus obliterated by ante-mortem clot. 
 
 Kemarks by Dr. Verco. — The symptoms on which tlie diagnosis was 
 based have been already briefly mentioned, and the incidents of the 
 operation ; and the post-mortem appearances confirmed it. There had 
 evidently l)een old-standing ear disease, as evidenced by the caries of 
 the temporal bone. This possibly existed five \'ears before, and was the 
 occasion of the head symptoms, relieved by the discharge from the ear. 
 It is scarcely possible that such extensive caries could have arisen as 
 recently as one month before admission. The amount of otorrhoea, 
 however, must have been very scanty, for not only were both the man 
 and his wife ignorant of its existence during his last illness, but the 
 house surgeon's note was positive against it ; and when I examined the 
 patient with the otoscope, it only existed as a little thickened secretion 
 in the deeper part of the meatus, somewhat blocking the speculum. 
 This caries had caused subdural suppuration over a limited area on the 
 upper aspect of the petrous bone, and the inner surface of the squamous 
 bone. The collection was, however, small, and at the post-mortem was 
 not noticeable until the dura had been stripped from the bone. 
 Simultaneous with this subdural sup})uration, which was altogether 
 inadequate to account for the cerebral symi)toms, there arose a localised 
 collection of pus in the substance of the temporo-sphenoidal lobe, about 
 its centre, rather towards its tip ; and this, by its pressure during its 
 unusually rapid increase, caiised the neuralgia in the dental branches 
 of the fifth, the aphasia, facial palsy, and hyppesthesia. The formation 
 of this abscess may have dated from the left temporal headache of five 
 weeks' duration ; though more probably this symptom was due to the 
 subdural temporal sui)puration, while tlie commencement of the central 
 suppuration just a little preceded the dental neuralgia of Nov. 5th. 
 This explanation presupposes a very rapid suppurative process in the 
 ])rain tissue, beyond what is generally observed in abscesses secondary 
 to ear disease ; but it accords with the unusually rapid march of 
 symptoms while under observation. The desperate condition of the 
 j)atient, within twenty-four hours after tlie first visit of the physician, 
 justified any operation that held out the barest possibility of life ; and 
 the considerable improvement after its performance vindicated the action 
 taken. The paralysis of the right arm and leg, noted when the coma 
 disappeared, was doubtless a pressure eftect, for after the operation the 
 power of movement was markedly restored. The hemiplegia, which
 
 ABSCESS IX THE LEFT MIDDLE CEHEBIiAL LOUE. 287 
 
 recurred later, was due to extension of softening into tlie internal 
 capsule. The paralysis of the left eye did not disappear ; the tliiixl nerve 
 was too much affected from the pressure antecedent to the operation to 
 admit of I'estoration of its function liefore the destructive softening attend- 
 ing cerebritis; this cerebritis, causing softening, was almost certainly the 
 Ccvuse of death. Whether it originated subsequent to the operation, or 
 whether it had begun before this was undertaken and afterwards s])read, 
 it is impossible to determine. Had not the lateral sinus been found 
 patent, and containing only a coloured post-mortem clot, the softening 
 might have been attributed, in great part, to phlebitis of this vessel, from 
 caries of the bone in its groove ; but it showed no signs of disease. 
 
 Kej[arks by Dr. Stirling.— After the ol)Sei'vations of Dr. Verco 
 (with which I entirely concur), and the report of the incidents of the 
 operation, there is little to l)e added from a surgical point of view. 
 The strong recommendation of Mr. Horsley induced me to reflect the 
 scalp by a semicircular flap instead of by a crucial incision ; but 
 whatever may be the advantages of the flap in allowing accurate 
 replacement, and firm and uniform pressure over the brain at the 
 bony vacancy, it certainly does nob seem to affoi'd the same facilities for 
 the fixing and exit of a drainage tube as the crucial incision. However, 
 by the arrangement adopted, it was possible to carry this out efficientl}^, 
 with fairly accurate replacement of the reflected scalp ; at no time, in 
 fact, was there any bagging of pus or hindrance to the exit of discharges. 
 The allusion to the inequality in the thickness of the skull at the part 
 trephined will be confirmed by the statement, that at the lower and 
 posterior part of the opening it was rather over a quarter of an inch in 
 thickness, while at the lower and anterior it was not quite a sixteenth 
 of an inch. The absence of bleeding from the incised brain has been 
 already mentioned. The strict antisepsis adopted throughout the opera- 
 tion and the subsequent dressings was effectual until the eighth day ; 
 and it is possible, that the putrefactive changes which were then observed 
 "were caused by the exposure, due to the accidental shifting of the 
 dressings by the patient's restless movements ; but, on the other hand, 
 it is probable that the rapid extension of the cerebral inflammation had 
 begun before this happened, and was, in fact, the exciting cause of the 
 restlessness which so soon culminated in coma and paralysis. 
 
 It must always be a matter of extreme anxiety and difficulty in such 
 cases to decide upon the time when the drainage tube may be safely 
 disj:)ensed with ; and I made every endeavour to act with judgment, by 
 gradually reducing the length and the calibre of the tube in conformity 
 with the amount of discharge. 
 
 After the marked imjjrovement that followed the operation for 
 several days, the result Avas of course disappointing to us, but in the 
 light of the post-mortem revelations, recovery must, from the first, have 
 been very doubtful. If we had been aware of the extensive necrosis 
 that existed at the squamo-petrosal junction, the proper course would 
 have been to enlarge the trephine opening downwards, and so to 
 permit of the escape of the pus in that locality ; bixt even then it is 
 scarcely possible to hope that, with disease of such ra]>id onset and 
 progress, a fatal result could have been averted. Still, under all the 
 circumstances of the case, we believe that we were fully justified in the 
 adoption of extreme surgical measures.
 
 288 INTEKCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 A FEW OBSERVATIONS ON SOME CASES OF CANCER 
 OF THE BREAST, WITH A TABLE OF FORTY- 
 SEVEN CASES. 
 
 By F. MiLFORD, M.D. 
 
 Lecturer ou Surgery, Sydney University. 
 
 In the year 1877, I read before the Medical Section of the Royal 
 Society of New South Wales, a short paper, which I called " Observa- 
 tions on some Cases of Scirrhus Cancer of the Mamma." This was 
 afterwards published in the Australian Practitioner. As the subject is 
 therefore not entirely unfamiliar to me, I trust I shall not bore you in 
 continuing a record of some few more cases. 
 
 That locality has a great influence on the prevalence of cancer, has 
 been shown by Haviland, who has searched the Registrar-Genei-als' 
 reports throughout England for the priuci[)al habitats of the complaint. 
 It is not known in the Arctic regions or Frigid zones ; is not common 
 in the Tropics ; but is more often found in large cities than in country 
 places. The investigation committee, who are using their utmost 
 exertions to become intimate with the Ijistory of cancer in England, 
 state they only know of one case originating in a person who has lived 
 1000 feet above sea level. They are of opinion that the character of 
 the soil and subsoil influence its presence. 
 
 I beg to show you a table compiled from the records of the Registrar- 
 General, showing the num):)er of deaths taking place in Sydney and 
 suburbs during the years 1880 and 1885 inclusive, and the proportionate 
 number of males and fejuales dying from cancer. 
 
 I lind that in the city of Sydney, 1 female dies in proportion to 42 -8.5 
 of deaths from other causes. In the suburbs, 1 dies in proportion to 
 58-53 from other diseases ; showing the much greater liability to the 
 disease in the town, than country. The average mortality of city and 
 suburbs among females is 1 to 50-7. The average mortality in males 
 in the city of Sydney is 1 to 64-9 ; in the suburbs, 1 in 81-7 — 1 death 
 in 73-7 cases of both town and country. The proportion is also thus 
 seen to be much greater in the city, among males, than in the country. 
 The proportion of deaths from cancer among females, during the six 
 years, is much greater than in males. While 1 female dies out of 
 50 with this complaint, 1 male out of 73 only succumbs, or nearly 3 
 females for 2 males. 
 
 In my 1877 paper, I stated that throughout New South Wales the 
 mortality among males and females was 1 in 59-5, In Sydney and 
 sui)urbs it was, during the years 1880 to 1885, 1 in 66*19. 
 
 It devolves upon us as guardians of the public health, if possible, to 
 devise prophylactic measures to prevent the attack of this complaint, and 
 it will undoubtedly repay us to ascertain what is the best mode of tx-eat- 
 ment after it is implanted in the living tissues. 
 
 There is little doubt that the disease is chiefly induced by injury to 
 the i)art, whether that be caused by constant irritation or sudden 
 violence. In inquiring the liistory of a patient — sliould we find that she
 
 OBSEIIVATIOXS ON SOME CASES OF CANCER OF TJtK BREAST. 289 
 
 has a oancerous inheritance and an eczematous rash, or a liard scar from 
 a wound, or nodule — the result of a blow, or has been in constant 
 intercourse with a cancerous ])erson — the question might arise, would we 
 bejustihed, as a j)rophylactic measure, in removing the breast? In any 
 case with a history of cancerous inheritance, I think it will be necessary 
 to recommend your patient to take the greatest care of tlie mannnary 
 glands, to prevent these being injured and exposed to sudden changes 
 and vicissitudes of the weather. Should a patient pi'esent herself to a 
 surgeon with a tumour in the breast, his first duty will be to ascertain 
 whether it be of a malignant character or not. Having satisfied him- 
 self it is a cancer, his next question should be, what is the best mode of 
 treatment? In our present imperfect knowledge of the disease, we are 
 still sure that if left uninterfered with, the disease will go on from bad 
 to worse, until death closes the scene. I am not aware of, nor do I think 
 there is, any record of a s]iontaneous cure of cancer. My nearest 
 experience is recorded in my 1877 paper, in the case of Ellen J., aged 
 40, who lived three years afflicted by the disease, and had early secondary 
 deposits in the lungs. 8he had an ulcerated hai-d scirrhus tumour of 
 the left breast, which sloughed, the whole of the gland coming away, 
 and the i-esulting ulcer then healed ; but this was after the whole of the 
 system was more or less aflfected, the left lung being solid from cancerous 
 deposits. 
 
 We are satisfied, therefore, that if left alone — should she not die early 
 from some other cause — the disease must eventually kill her. Hence, in the 
 present state of our knowledge, it will be our duty to ascertain whether 
 she be in a fit state to submit to an operation of a curative nature, to 
 entirely rid her of the complaint ; of a palliative nature, to modify the 
 effects of the disease ; or one for the purpose of simply prolonging life 
 for a short time, by preventing hfemorrhage, resti-aining discharges, or 
 relieving acute pain. We should carefully weigh the benefits likely to 
 follow an operation, and the risks. There are some surgeons much in 
 favor of the operation, others prejudiced against it. 
 
 In 61 cases quoted by Paget, which were not operated on, but 
 underwent palliative treatment, 29 lived from 3 to 20 years, while 
 the remaining 32 died at between 6 and 30 months. He gives an 
 average of two years' life to encephaloid growths, of four years to 
 scirrhus. 
 
 According to Gross, 146 cases had come under his observation who.se 
 history he could trace subsequent to the operation. The duration of 
 life in these cases was an average of 5 years and 9 months — a 
 considerable advantage in favor of an operation. He does not, how- 
 ever, say whether the operation was intended to be curative or 
 palliative. 
 
 Gross himself is a believer in the curative 2~>ov<er>< of a thorough 
 operation undertaken in the early stages of the disease, during which 
 the whole of the breast, skin covering it, and axillary glands, together 
 with the pectoral fascia, should, he thinks, be removed. Erichsen, in 
 his 1888 edition, and others, support him in similar terms. The 
 extirpation of the tumour can only be done by knife, caustics, or 
 cautery, and, if thoroughly performed, may rid the patient entirely of the 
 complaint. The knife is, of course, the most efficient of these 
 measures. 
 
 u
 
 290 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Gross claims by his operation to cure 30 per cent, of his cases, 
 if taken at an early stage, before the disease has spread far into 
 the neighbouring tissues. 
 
 I see no reason why this mammary form of the disease should not be 
 eradicated from the body, when the labial so frequently is. We all 
 know how many useful lives have been saved by the simple Y incision 
 in the lower lip affected with epithelioma. 
 
 As a curative or palliative measure, or for the purpose of preserving 
 life by preventing haemorrhage or relieving intense agony, it is the 
 duty of the surgeon in some cases to operate, first explaining to the 
 patient or her friends the motives that influence him. It remains 
 with her to choose whether she submit or not. 
 
 In mentioning the operation to his patient, it would not be correct 
 for the surgeon to ignore the immediate dangers of it, which according 
 to Gross, as stated in his paper on " Carcinoma of the Breast " — 
 published in the April number of 1888 of the International Journal of 
 Medical Sciences — constitute a mortality of 1 to 7 from the immediate 
 effects of the operation. 
 
 In my paper of 1877, I record that out of fourteen cases operated on, 
 only one died from the immediate ettects, or rather, from an attack of 
 pleurisy coming on on the third day after it ; the other thirteen survived, 
 these cases undergoing secondary operations at the return of the 
 disease in or about the neighbourhood of the cicatrix of the first 
 operation. This is an improvement on Gross' statistics, but I have 
 here a table of forty-seven cases, all of which have had the mammary 
 glands excised, and many the axillary glands as well. 
 
 In recording these cases, I have endeavoured to get as much information 
 with regard to them as was possible, but I am sorry to say that in many 
 instances I have not been able to procure a history subsequent to the 
 operation, and in some cases a most imperfect and unreliable one previous 
 to it. I give as nearly as I can the name of the patient, whether married, 
 single, or widow; the age when disease was first perceived by the 
 patient, the date when it was first perceived, date of first operation, by 
 whom performed, date of return of disease, date of second and subsequent 
 operations, by whom performed, date of death, age at death ; if alive, age 
 at present, and state of health, with the duration of the complaint. I 
 am indebted for twenty-three cases to the courtesy of the authorities at 
 St. Vincent's Hospital; to Dr. MacCormick, of the Prince Alfred 
 Hospital, for fourteen of his own cases ; and to Dr. Goode for seven of 
 his. 
 
 In these forty-seven cases two deaths only occurred from the immediate 
 effects of the operation, one in a woman (No. 33 of the series) aged 42, who 
 had a large f ungating encephaloid mass projecting from the mamma, which 
 bled freely, the operation being undertaken to prevent further haemorr- 
 hage. She died exhausted on the fifth day. The other patient died 
 during the administration of chloroform before she was touched by the 
 scalpel. Leaving this case out, one patient only died out of forty-six ; 
 taking it as belonging to the series, one out of 23*5 is the proportion, a 
 marked improvement on Gross's one in seven. 
 
 The duration of life of a patient, who has suffered from the disease 
 and borne the operation, can be exemplified in the table; but only in those
 
 OBSERVATIONS ON SOMK CASKS OP CANCER OF THE I3REAST. 291 
 
 in wliich there has been a subsequent lii.story after operation, and tlie 
 patient has left the liospital. I find thirty-five cases have tliis histoi-y, 
 ten of which are known to be alive. In these, the disease has lasted 
 in one case, two months ; in one, one year ; in one, one year and a 
 half; in five, two years; in one, two and a half years; in one, three 
 years. Of which cases those numbered 24, 25, and 29 are now enjoying 
 excellent health, the remaining seven are suffering more or less under 
 the return of the complaint. 
 
 Of the other fifteen cases, whose deaths are recorded with a history, 
 in two, disease lasted one year ; in three, two years ; in one, twelve 
 years ; in one, thirteen years ; in one, fourteen years ; or an average of 
 three years and nine months for the fifteen cases. 
 
 The furty-seven patients consist of twenty-three married women, 
 fifteen single, and nine widows. 
 
 After the operation, disease returned in nine cases of which there are 
 histories. In these it showed itself in the space of time mentioned 
 as follows :-— In No. 2 case, in three months ; in No. 10, in four months ; 
 in No. 15, in four months ; in No. 22, in five months ; in No. 26, in six 
 months ; in No. 27, in four months ; in No. 28, in one month ; in No. 
 71, in eighteen months; in No. 76, in one year ; or an average in the 
 nine cases of four months. 
 
 The youngest operated on was at 23 years of age, the eldest at 6S. 
 More than half (twenty -six) were operated on for the first time at between 
 40 and 50 years of age. The age of the forty-seven cases averaged 
 between 42 and 43 years at operation. 
 
 The tenth case (Mrs. Jolly's) is a remarkable one. This patient had 
 the left breast removed in Nov. 1875, the disease first having been 
 noticed in 1872. She had eight subsequent operations for the removal 
 of recurrences, and died in 1885, with the liver and other internal 
 organs affected. 
 
 (!ase 35 of the series shows an excellent result. Although there was 
 an enormous mass of diseased glands and other tissue. Dr. MacCormick, 
 the operator, determined to remove it, and finding it impossible to excise 
 the mass without injuring the axillary vein, he ligatured it in two places, 
 and cut out the piece between. There was no oedema of the arm, or 
 other bad results from this procedure. 
 
 I have no instances in this series of cases unoperated on — they have 
 all undergone the operation — so that in comparing the duration of their 
 life with those who have not been interfered with, I must fall back on 
 my 1877 series. 
 
 I find after reference to it, that there were five cases mentioned who 
 died without operative interference. In these, cancer commenced while 
 suckling ; out of these, one lasted one year, another six months ; while 
 the other three lived respectively two, three, and nineteen years, giving 
 an average of five years and two months to each. 
 
 The average duration of life in those operated on in the present series, 
 of whom we have a histoi-y, gives only three years and nine months, 
 wliich is in favour of non-interference ; chose who were not operated on 
 living eighteen months longer than those who were. 
 
 There is no histoi-y recorded in these forty-seven cases of any person 
 being cured by the operation. 
 
 u 2
 
 292 IXTERCOLOXIAL MEDICAL COXGRESS OF AUSTRALASIA. 
 
 I think the majority of the profession will however agree with lue, as 
 to the advantage to be gained in thoroughly following out Gross's plan, 
 when excision is practised as a curative measure. The question will 
 occur also, will you be justified in performing a palliative operation if 
 you consider it impossible to remove the whole of the disease, and no 
 ulceration is present 1 or if the patient be suckling, or the mamma 
 inflamed? The answer, in my opinion, should be in the negative. 
 
 After all, this operation is a very barbarous ])rocedure, similar to that 
 practised 2000 years ago. May we not entertain the hope that one of our 
 numerous distinguished pathologists may in the near future find a way 
 to prevent the excessive formation of cancer cells, rather than to cut 
 them away from the living body with a knife, as a woodman would a 
 rotten limb of a tree with an axe ; or burn them with a red hot iron, as 
 a labourer would a heap of rubbish in the corner of a back yard. Our 
 hope must be in the future, not only by use of prophylactics to prevent 
 its advent, but by properly constituted therapeutic measures expel the 
 disease when present. Whether the excessive growth of the epithelial 
 cells depends upon a microbe, bacillus, or other microscopic creature ; on 
 the excess of white blood corpuscles in the system, or on some other 
 morbid idiosyncrasy of the constitution, it is quite evident therapeutic 
 measures are required to restrain the rapidity of their increase. 
 
 "A cure for cancer " has been the usual cry of the quack during the 
 generations ; but it should now be the hope, the wish, and the summit of 
 ambition of practitioners of this age and hemisphere, to realise it by 
 other methods than excision. 
 
 In the meanwhile let us congratulate ourselves that at least one 
 operator has had such successful results — I refer to Gross, of 
 Philadelphia, who claims 30 per cent, of cures. He considers if the 
 disease has not returned in three years, the patient is cured. My 
 present series of forty-seven cases have twenty-five histories, and only 
 one has lived three years without return ; of the other twenty-two cases, 
 let us hope that many have been cured. According to Gross, who 
 claims a cure when no return occurs after three years, there is only 
 one in twenty -five cases. In my 1877 series of nineteen cases, the 
 second case was operated on when the patient was 30, and there was no 
 return at her death, at 65 — a perfect cure, the only one in fifteen 
 operations.
 
 OBSERVATIONS ON SOME CASES OF CANCER OF THE BREAST. 
 
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 298 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 ON THE USE OF SPECIAL EXERCISES, AND OF 
 ACTIVE AND PASSIVE MOVEMENTS, AS AN AID 
 TO SURGICAL TREATMENT. 
 
 By R. E. Roth, M.R.C.S. Eng. 
 
 M}' chief object in bringing the above subject before your notice is 
 the hoi)e that it may help to supply a want felt among several of my 
 colleagues who, when referiing to some of the various methods of treat- 
 ment recommended in orthoptedic text-books, find certain systematic 
 exercises (rubbing, &c.) recommended, but learn nothing as to the methods 
 and manner in which such treatment is to be employed. Information 
 also is very scanty as to the cases where such treatment by special 
 exercises and movements is applicable and advantageous. 
 
 Without doubt, the best and simplest scientifically-devised exercises, 
 founded on sound physiological and anatomical principles, are those 
 drawn up by Ling, and known as the Ling's or Swedish System of 
 Gymnastics, where each individual exercise has been studied and con- 
 structed with regard to its effect. The whole system is divided into 
 four parts, to meet the requirements of educational, aesthetic, military, 
 and medical |)ur))0ses. 
 
 In the first, " exercises, with and without gymnastic apparatus," are 
 made use of, and they are perfectly sufficient, when rationally applied, 
 for the harmonious development of the body. 
 
 The " cjesthetic " part is intended to teach the expression of ideas and 
 sentiments by means of positions and movements, and is of great use for 
 actors, orators, painters, sculptors, kc. 
 
 The " military " is based on the pedagogic branch, to which are added 
 sword, foil, and bayonet exercises, &c., necessaiy to the thorough training 
 of the soldier. 
 
 The "medical" or "movement cure" comprises special exercises 
 devised for the treatment and cure of many chronic diseases and 
 deformities ; it consists of active movements with or without assistance 
 or resistance, of movements with special apparatus, and of passive 
 movements usually grouped together as " manipulations." 
 
 Active movements are all those which are executed by the special 
 activity and determination of the moving person. They are always 
 produced by the muscles subject to our will, and are the result of the 
 organic contractility, influenced by our will. The special effects of a 
 local active movement are — (1) To put into activity every single muscle, 
 or oidy a i)art of it, or a group of muscles. (2) To increase locally the 
 afllux of arterial blood ; and (3) to increase the innervation. 
 
 Passive movements may be described as being executed either by living 
 or inanimate agents, which are alone the moving power ; they are in no 
 way connected with any special activity or determination of the person 
 operated on. Among the special effects of local passive movements may 
 be mentioned the following: — (1) the relief of pain; (2) moderate 
 increase of the local nutrition ; (3) variations in the venous and 
 lymphatic flow ; (4) restoration of the form, position, and direction of 
 the parts, as well as the mobility of the articulations; (5) stimulation 
 
 J
 
 INSTRUMENT FOU REOOHDINfJ LATERAL CURVATURE OF SPINE. 299 
 
 of the innervation in tl)e sensory fibi-es ; and (6) to increase or diminish 
 the teni[)erature of the body, or a part of it. 
 
 ^Movements are natural curative agents in many diseases. Voluntary 
 or involuntary, active or passive, tliey act in a most extensive manner, 
 by preventing, allaying, curing, and suppressing disease. They eflect 
 their purpose either as derivative from the sensitive nervous parts, or as 
 neutralising the bad effects of external injuries. In the healthy state, 
 the brain expresses its sensations and ideas by muscular action ; in 
 disease, it does the same. During pain, or any other disagreeable 
 sensation, it is the commonest tiling in the world to see the sufferer 
 either making a grimace, twisting his trunk, moving his limbs, or 
 rubbing the part. Patients in delirium or mania often find relief by 
 screaming, shouting, and other violent movements. On the other hand, 
 we often see the sufferers relieved by voluntarily suspending muscular 
 action, by resting the body, or part of it, in this or that ])osition ; for 
 instance, we might contrast the elevation of an inflamed limb with the 
 prone position of a fevei' patient, or with the stoojiing position of an 
 asthmatic martyr. 
 
 Active movements are used therapeutically, in order — To strengthen 
 and fortify a muscle — that is, to form new and stronger muscular fibres ; 
 to effect a better innervation of the motor nerves ; to increase the 
 temperature ; to promote the formation of arterial Ijlood in general ; to 
 derive blood, principally the arterial, from neighbouring organs ; to 
 effect an increased circuhition of venous blood and Ijniijjh fluid, not only 
 in the muscles, but also in more distant regions of the body ; to relieve 
 the contraction of certain muscles by strengthening their antagonists. 
 
 Passive movements are used therapeutically — In hypertroj)liy, due to 
 congestion ; for the removal of the products of inflammation ; in 
 dilatation of the veins ; in disorders of the valves of the heart ; for the 
 relief of pain. 
 
 [A number of cases were here related by the writer.] 
 
 AX INSTRUMENT FOR ACCURATELY RECORDING 
 LATERAL CURVATURE OF THE 8PINE. 
 
 By R. E. Roth, M.R.C.S. Eng. 
 
 This little instrument, which I have the pleasure of bringing before 
 your notice, I invented some time ago, in order that I might accurately 
 record from time to time, in my case-book, the improvement that took 
 place in scoliotic patients, who were undergoing a rational gymnastic 
 treatment. The usual method of i)hotographing, or making a sketch of 
 a scoliotic before and after tieatment, is always unsatisfactory, because 
 it is so easy to minimise or enlarge the cuives according to will. I take 
 advantage of the fact, that rotation invariably accompanies lateral 
 curvature, so that if we make a tracing, showing the differences of the 
 back on both sides of the spinal column, we have an accurate record of 
 the extent of the deformity. But this tiacing must l)e made under 
 certain conditions, otherwise we are liable to error. The patient having 
 had her clothing removed, and fastened around the hips, just below the
 
 300 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 trochanter, the surgeon stands ])ehind, and corrects any irregiilarity of 
 the hips by placing a suitable block, or a small book, under the foot; he 
 then requests the patient to stoop forward, and to allow the hands to 
 hang as much as possible. By this method, all weight is taken off the 
 spinal column, and any curvature and rotation that is now noticed will 
 be of a permanent character, and cannot be either increased or 
 diminished, so long as the patient is in this ])osition. In order to make 
 a tracing, 1 place the stand of the instrument at some chosen sj)Ot on the 
 spinal column, the chosen sjjot being the length of the long arm of the 
 lever from the ijart which we wish to trace. Now, on holding the stand 
 firmly down with the index and middle fingers of the left hand, and on 
 slowly moving the ivory point at the end of the lever with the right, the 
 short arm, which carries a pencil, makes a correct tracing on the slip of 
 pa])er, held firm by a curved piece of tin. The resulting tracing, which 
 is reversed in size, will depend on the ratio of the short to the long arm 
 of the lever ; in this instrument, the tracing made is one-fourth of the 
 natural size. 
 
 CASE OF COMPOUND DISLOCATION OF ANKLE JOINT, 
 
 WITH FRACTURE OF ASTRAGALUS PER ;SE, AND 
 
 RESECTION OF SAME. 
 
 By H. C. Garde, F.R.C.S. 
 
 Surgeon to the Maryborough Hospital, Queensland. 
 
 The notes of the case which I now bring before you were taken some 
 years back, but as the injury to the astragalus is of a rather exce[)tional 
 nature, they may not be deemed unworthy of reproducing. On the 11th 
 March, 1882, Robert P., aged 33 years, fell down the hold of a steamer 
 (some twelve feet) landing on his feet, and which he said immediately 
 turned under him. I .saw him on the wharf, half an hour after the 
 accident, and found him suffering from a Pott's fracture of the right 
 foot, which was readily brought into position. On cutting off the left
 
 OPERATION FOR DILATATION OF PYLORIC OIUFICK OF STOMACH. 301 
 
 boot a more serious state of affairs presented itself, viz., a laceration 
 of about an inch in lengtli on the inner side of the foot, through which 
 a fractured surface of bone protruded. My colleague, the late Dr. J . J. 
 Power, just then arriving on the scene, we decided to i-eniove the patient 
 to his own house before doing anything further. On arriving there 
 chloroform was administered, with the double view of relieving pain and 
 facilitating the reduction of the dislocated and fractured bone. On 
 careful examination, we found we had to deal with a portion of the 
 astragalus, which was dislocated inwards, forwards, and u})wards. 
 Every means, including enlargement of the wound, and division of the 
 tendo Achillis, was tried to re]ilaee the bone, but without success ; so 
 that nothing remained to be done, but either to amputate, or resect. 
 We decided on the latter, which I accordingly did, removing the body 
 and portion of the neck, the greater part of the head of the bone 
 remaining in situ. The anterior and external portion of the posterior 
 facet on the inferior surface was also fractured, and as it could not be 
 got at readily, was allowed to lemain. The foot was then brought into 
 position, and kept on a back splint. Listerism was not carried out, but 
 the strictest cleanliness was observed, with the result that the wound 
 healed in six weeks. It took a few months before he was able to get 
 about, but since then lie has continued at his work (wharf storeman), 
 and can walk without a stick, but has a hardly perceptible lini]). The 
 chief point of interest about the case is the fact that neithei- of the other 
 bones forming the joint were injured, and it is difficult to account for, 
 how such a strong bone as the astragalus should Ije smashed right across, 
 and the greater portion of the bone shot out of its place without more or 
 less injury to the other bones whicli articulate with it. 
 
 [Dr. Garde exhibited the specimen, which is a most interesting one.] 
 
 A CASE OF LORETA'8 OPERATION FOR DILATATION 
 OF THE PYLORIC ORIFICE OF THE STOMACH. 
 
 By Wm. Gardner, M.D., CM. Glas. 
 
 Lecturer on Surgery, Adelaide University. Senior Surgeon to Adelaide Hospital. 
 
 The following case is recorded, not because I deem it to be of any 
 value as an isolated instance of success, but because it is the first pub- 
 lished example in the Australian colonies of a procedure highly 
 recommended in similar conditions by Professor Loreta, of Bologna, 
 who performed his first operation in September 1882. A full account 
 of this was published in the British Medical Journal, Feb. 21st, 1885, 
 by Mr. Holmes. On April 2Gth, 1884, a short account of Professor 
 Loreta's ninth ojjeration, which was for contraction of the cardiac orifice, 
 is given. The operation has also been practised by a few other Italian 
 surgeons, and in two cases by INIcBurney, of New York, notes of whicli 
 are to be found in the Nev York Medical Journal, of Jan. 16, 1886. 
 So far as I know, the remote results of these operations have not 
 yet been publislied, and the value of the operation is still sidj judice. 
 The immediate results of the published cases have been excellent The 
 operation is suitable for cases of simple cicatricial or fibrous narrowing 
 of the pylorus, or the cardia or lower end of the ccsophagus. The
 
 302 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 narrowing iu simple cases is due to Ijypertrophy of the involuntary 
 muscular fibre, and over-distension of this is the object to be aimed at, 
 and the result is said to be as good as in cases of over-distension for 
 tibrous stricture of the rectum. 
 
 Reasoning from analogy, every surgeon would be disposed to say that 
 the good result will only be a temporaiy one, as is certainly the case iu 
 all true strictures of the urethra. This is the great point which has yet 
 to be settled, and I offer ray tirst case as an encouragement to others to 
 perform the operation, and note carefully the immediate and also the 
 remote result. In this way, and in this way only, can the permanent 
 value of the procedure be estimated. 
 
 The patient upon whom 1 operated was sent to me by my friend 
 Dr. Baly, of Yorketown, with a note, stating that she had long suffered 
 from pyloric obstruction, and that he considered the case a suitable one 
 for trying Loreta's operation. Every form of treatment had been tried 
 by him for months, and after consultation with my colleagues, I 
 determined to make the attempt, and as the evident thickening of the 
 pylorus might turn out to be malignant, I made every preparation for 
 performing })ylorectoniy, should it be deemed necessary. For the same 
 reason, I made use of a transverse incision, such as Billroth recommends 
 for pylorectomy, and I found this quite convenient for the other 
 operation. The following is tlie case : — 
 
 J. H., aged 43, admitted to Adelaide Hospital July 15, 18S8. 
 
 History. — Patient complains of sickness, and pains in the region of 
 her stomach. When she takes anything, it usually lies on her stomach, 
 and makes her feel very sick. She has been troubled with indigestion, 
 off and on, for several years, but during the last tln-ee months it has got 
 very much worse, and ])atient finds her strength failing. As a rule, she 
 vomits e\'ery other day, and generally in the evening. Sometimes, 
 however, she goes for four or live days without being sick, and then 
 vomits up over a chamberful. The pains across the upper part of her 
 abdomen are of a shooting character, and made their appearance about 
 three months ago. They are very much worse just before vomiting, on 
 account of the distension of the stomach with gas, which has then 
 occurred. The pains increase in proportion to the amount of flatulence 
 present. Previous health has been good, as is also the family history. 
 Has been married twenty-four yeai's, and has had nine children, the 
 youngest of which is Ave years old. Climactery three years ago. 
 
 r resent Condition. — The stomach is of variable size, but distinctly 
 enlai'ged, and on some days its outline can be traced on the abdominal 
 walls. To the right of the median line, and just above the umbilicus, 
 may be felt a lump aboitt the size of a walnut, which moves up and down 
 with the movements of re.spiration. The vomited matter is of a yeasty 
 cliai'acter, very acid, and contains sarcinsTe in abundance. Urine is acid, 
 and contains neither sugar or albumen. Professor Rennie kindly examined 
 the vomited matters, and reports just a trace of free hydrochloric acid. 
 
 July 19th. — Comi)lains of a boring pain in her stomach. 
 
 July 26th. — Patient anaisthetised, and stomach washed out with two 
 pints of weak boracic lotion. 
 
 July 30th. — Patient anaesthetised, and stomach washed out with five 
 pints of the lotion. The tumour could be felt readily on eacli of these 
 occasions.
 
 OPERATION FOR DILATATION OK PYLORIC ORIFICE OF STOMACH. 303 
 
 Aug. -ith.— Patient hcis been on milk diet, and lias not been sick since 
 first washed out. To liave milk, baked a|)])les, etc. 
 
 Aug. 6tli. — Patient sick this evening and last niglit. 
 
 Aug. 7th. — Patient vomited again this evening. 
 
 Aug. 11th. — Patient partially ansesthetised, and stomach washed out. 
 
 The Operation. — On the V2t\\ August, 1888, the patient having been 
 placed under the influence of ether, Dr. Gardner pei'formed the following 
 operation : — (The stomach was thoi-onghly washed out with a boric acid 
 solution). A transverse incision, about four inches long, was made in 
 the e})igastric region, and the skin, muscles, and fascia, down to the 
 peritoneum, were rajjidly divided. All bleeding points were ligatured 
 with wallal)y tendons, and the api)lication of hot sponges for a few 
 minutes effectually stoi)ped the oozing, before the peritoneum was 
 opened. Although no tumour could be recognised in the neighbourhood 
 of the pylorus, the walls of that part of the stomach were very hard, 
 and greatly thickened. A portion of the viscus was then drawn out 
 through the opening in the abdominal parietes without ditticulty, as no 
 adhesions were pi-esent. After the extruded part had been carefully 
 surrounded with hot sponges, an opening one inch long, running in the 
 long axis of the organ, was made with scissors, through which the 
 operator inserted the forefinger of his right hand. On examining the 
 pyloric orifice, he found it almost completely closed, and it was with 
 some difficulty that a No. 6 gum elastic male catheter was made to pass 
 through it. After patiently boring with the right forefinger, the passage 
 was gradually opened up, the forefinger eventually being passed with 
 ease from the stomach into the duodenum. The hasmorrhage was 
 very slight indeed, and the interior of the stomach having been cleansed 
 immediately before the operation, no difficulty was experienced with 
 the stomach contents. The wound in the gastric wall was brought 
 togetlier with great accuracy, and in a most satisfactory manner, by 
 means of Gussenbauer's sutures, which were introduced with sjjecially 
 curved needles, and an interval of about two millimetres allowed 
 between each. Fine silk was employed. All the stitches were [)laced 
 in position before any were tied. The wound in abdominal wall closed 
 in the usual manner. 
 
 Aug. 12th, evening. — Patient complaining of ])ain since the operation. 
 No vomiting. Enemata of milk, ?ijss, and brandy, ^ ss, every eight 
 hours. Enemata of port wine every eight hours, J iij. R. Strychninaj, 
 gr. 4; glycerine, 3 ij ; aquam ad., Jij. Fifteen drops (J^ gr.) hypo- 
 dermically every four hours. 
 
 Aug. 13th. — Patient slept very little during the night. Wind 
 troublesome. Passed urine at 2 a.m., lOi ozs. Temperature, 100° ; 
 pulse, 125. Enema of soap and water. No vomiting. 
 
 Aug. 14th. — Patient slept well during the night. Passed flatus i)er 
 rectum, and found great relief. No vomiting. 
 
 Aug. 15th. — Bowels not open ; has passed flatus. Thei-e is no abdom- 
 inal distension, but complains still of flatulence. There is some pain 
 in her stomach. 
 
 Aug. 16th. — Very restless during the night; still complains of 
 flatulence. No vomiting. Gruel, a teaspoonful every two hours. 
 
 Aug. 17th. — Slept very little during night; still passing flatus per 
 rectum, causing pain. No vomiting after giving gruel. One stitcli
 
 304 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 removed. 6.15 p.m. — Patient comfortable. Supp. morph. gr. \; mitte 
 iij, one every six hours. Eiiemata of brandy and milk. 
 
 Aug. 18 til. — Complains of very little pain ; still much flatus passing 
 per rectum. Bowels moved at 3.30 p.m. No vomiting. One teaspoon- 
 ful of scraped rump steak every four hours. Give ten drops of ac. hydro- 
 chlor. dil. quarter of an hour before, and then gr. iij of pepsin immediately 
 after. A teaspoonful of milk, and two teaspoonfuls of lime water, 
 every four hours, alternately with the beef. Enemata of milk every 
 four hours. Injection of strychnina, twice daily, gr. -gL. 
 
 Aug. 19th. — Wounds dressed. A little discharge. .Stitches removed. 
 
 Aug. 20th. — Wound dressed. Looking well. There is a little 
 inflanniiatory hardening about the wound. Enema of soap and water, 
 and bowels moved well. 
 
 Aug. 21st. — Omit raw meat. Give chops and fish instead, and also 
 bread and biitter. Enemata every six hours only. 
 
 Aug. 22nd. — -No vomiting. Comphiins of pain in her right side. 
 
 Aug. 21th. — There is a little discharge from the centre of the wound. 
 R. Liq. strych. m. iij, aq. ad. 3j, thrice daily before food. 
 
 Aug. 28th. — The edges of wound are uniting fairly well. The skin 
 is a little inverted at the edge. Still inflammatory hardening about the 
 wound. 
 
 Aug. 29th. — Patient complains of pain in her stomach. No vomiting. 
 Food does not cause her trouble. 
 
 Aug. 30th. — Still has crtirapy pains in her stomach at night ; relieved 
 last night by some warm water and brandy. Scarcely any discharge 
 from the wounds. 
 
 Sept. 7th. — Patient says that she feels fine ; never feels sick, but 
 nearly every night she has pains of a burning character about her 
 stomach. She eats bread and butter, eggs, toast, cake, mutton, beef, 
 custard, and drinks milk and cocoa. She does not take pudding, 
 vegetables, or tea. 
 
 The temperature I'ose above 100" on only one occasion. 
 
 For the short notes of the case, I am indebted to my dresser, Mr. Verco ; 
 and the account of the opei'ation was written for me b}'- Dr. Giles, who 
 assi.sted. 
 
 On Dec. 24:th, 1888, Dr. Baly, at my I'equest, kindly sent me the 
 following note, after examining the patient : — 
 
 " Patient looks and feels perfectly well, and has evidently gained flesh 
 in a marked degree; weight 7st 101b (weight l)efore operation not 
 known, but Mrs. Hewton thinks she must have gained a stone). Has 
 never vomited since the operation, and has had no ])ain since leaving 
 the hospital. Is able to eat ordinaiy diet without inconvenience, but 
 has felt somewhat uneasy aftei' eating beef, cabbage, or rich cake. Can 
 eat mutton, poultry, fish, and farinaceous puddings, and drinks tea three 
 or four times a week. No flatulence, heartburn, or eructations now 
 after food ; bowels regular. Ate green peas several times during the 
 season without any bad effects. Examination : — Abdomen well covered 
 (instead of appearing a mere envelope of skin, as it did before operation) ; 
 skin over site of operation freely movable ; some induration still to be 
 felt in the region of the ])ylorus. Gastric resonance not increased 
 upwards, or to the left." He adds, "you will recollect, of course, that 
 before the operation, even a little milk used to cause Mrs. H. great agony."
 
 THE SURGERY OF THE KIDXEY. 305 
 
 I have quoted Dr. Baly's words, although not intended l)y him for 
 publication, as I am anxious not to interpolate in this account any bias 
 of my own in favour of tlie operation. In conclusion, I must say that 
 in my opinion this case warrants me in recommending those of you, who 
 have the chance, to give the operation a fair trial, and publish your 
 resiilts both immediate and remote, for only in this way can we arrive 
 at a satisfactory conclusion. 
 
 THE SURGERY OF THE KIDNEY. 
 
 By William Gardner, M.D., CM. Glas. 
 Lecturer on Surgery, Adelaide University. Senior Surgeon to Adelaide Hospital. 
 
 The surgery of the kidney is one of the greatest developments of 
 modern surgery, and dates from 1869, when Simon, of Heidelberg, 
 l)erformed extirpation of the kidney with the object of curing a urinary 
 fistula. The case was a complete success, and six months after, the 
 patient was in perfect health. In 1690, Blancard suggested that 
 extirpation of the kidney might be attended with a successful result in 
 cases of renal calculus. In the earlier part of this century, the kidney 
 was several times i-emoved successfully in animals, and accidentally in 
 man, by Wolcott (1861), Spiegelberg (1867), Peaslee (1868), and 
 Spencer Wells. In 1870, Thomas Smith, Surgeon to St. Bartholomew's 
 Hospital, wrote an article in the '• Medico-Chirurgical Transactions," 
 recommending nephrotomy as a means of treating renal calculus ; and 
 this operation was performed, for other conditions, successfully in 1870 
 by Durham, Moses, Gunn, and Bryant. Nephro- lithotomy was first 
 performed by Mr. Henry Morris in 1880. Nephrorraphy was first 
 performed by Professor Hahn, of Berlin, in 1881, and since then he has 
 repeated the operation several times, and always with success. 
 
 My own operations on the kidney began with a case of nephrotomy 
 for scrofulous abscess, performed on May 16th, 1883, in the Adelaide 
 Hospital ; and although the patient only lived a month afterwards, he 
 experienced great relief, but eventually died of ui'temic convulsions. At 
 the post-mortem, it was found that botli kidneys were diseased, the 
 right (the one operated on) being in a more advanced stage of disease 
 than the left. Nephrectomy was first performed by me in October 
 1885, upon a patient who, in February 1884, had an abscess of the 
 right kidney oi)ened and drained by nephrotomy. The operation was 
 necessitated by the persistence of a urinary fistula in the right loin. 
 Langenbuch's abdominal incision was used to ascertain the state of the 
 other kidney, and as it was found not greatly enlarged, the right kidney 
 was removed by a lumbar incision, and the abdominal wound closed in 
 the ordinary way. Suppression of urine caused death in forty-eight 
 hours ; and at the post-mortem there were no signs of peritonitis, but 
 the left kidney was found to be in a state of fatty degeneration. On 
 Dec. i, 1884, I operated on a case of movable kidney, which had given 
 rise to troublesome symptoms, fixing the kidney to the sides of the 
 lumbar incision by two kangaroo tendons passed through the substance 
 of the kidney. The result was completely successful, and she has 
 remained in splendid health, and free from all her previous troubles to 
 date. Nephro-lithotomy was first perfoi-med by me on Feb. 10th, 1887, 
 
 X
 
 306 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 for calculus, and in a fortniglit the patient returned to his home, and in 
 a short time was able to resume his work as a lumper on the wharf ; 
 and a few days ago, I learnt from his father that he had never had a 
 day's illness since. 
 
 Appended to this paper is a tahle of all the operations on the kidney 
 which I have performed, and also detailed accounts of several of the 
 }nore interesting cases. They include three cases of nephro-lithotomy 
 for renal calculi; No. 7, in which a stone weighing twenty-five grains 
 was removed from a healthy kidney. The patient had been suffering 
 severely for three years, and within a month was able to return to his 
 work as a lumper on the wharf. No. 13 was operated upon by Terrier's 
 transperitoneal method, because the kidney was enlarged and contained 
 fluid. The cause was not diagnosed until the kidney was incised, and 
 then a small fragment of calculous matter was accidentally felt and 
 removed from the inner wall. A further search led to the opening up 
 of a calyx, and the removal of an irregularly-shaped calculus, weighing 
 ninety-six grains, from which the former had become detached, the line 
 of fracture being distinct, and the fragment afterwards fitted on accu- 
 rately. In this case, the sacculated kidney was not removed, but 
 drained by a glass drainage-tube, and the result was perfect, the wound 
 healing up without leaving any fistula. No. 14 was diagnosed as a 
 case of stone in the right kidney, and at the operation the organ was 
 found so irretrievably damaged, that it was removed by nephrectomy ; 
 and this course of action was taken because pyo-nephi'osis was found. 
 
 We have thus examples of three different conditions : — • 
 
 (1) A calculus removed from a sound kidney, with preservation of 
 
 the organ, and without the formation of a urinary fistula. 
 
 (2) Removal of a calculus from a hydro-nephrotic kidney, with 
 
 retention of the damaged organ, and cure Avithout the 
 formation of a urinary fistula. 
 
 (3) Removal of a calculus from the kidney, which was irretrievably 
 
 damaged and contained pus, and was, therefore, removed at 
 
 the same time. 
 The first case is undoxibtedly the best, as the healthy organ was 
 retained, and when contrasted with the others, shows the immense 
 advantage of an early operation. On the other hand, there is an 
 advantage in diminished risk in operating on cases complicated by 
 hydro- or pyo-nephrosis, because the other kidney, during the process of 
 destruction of the one, has been gradually educated up to do extra duty ; 
 and so the risk of suppression of urine is lessened, much in the same 
 way that gangrene is less frequent after ligature of the femoral for 
 aneurism, when pressure has previously been tried, than when it has 
 been performed without such previous treatment. The cases also show 
 that the remains of the kidney may be left behind when the coiitents 
 are serous, but that it is probably the best practice to remove the 
 damaged organ when pyo-nephrosis is present. 
 
 Nos. 4 and 9 in the table exhibit the great advantages to be derived 
 from nephrorraphy in suitable cases. Both cases were absolutely 
 restored to liealth. In conclusion, let me say that I have not ventured 
 on the debatable ground of diagnosis, but have endeavoured to lay before 
 you, as shortly as ])Ossible, my own work ; and I trust that it will be 
 found not to be without some interest to the members of this Congress.
 
 TUB SUUGEKY OF TIIK KIDNEY. 
 
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 X 2
 
 308 intercolonial medical coxfjkkss of at^stralasia. 
 
 Treatment of Kidney Disease. 
 Case I. 
 
 John Smith, a^t. 28, seaman ; tuberculosis of kidneys, nephrotomy, 
 death. 
 
 April 13, 1883. — Aspirated in right renal region by Dr. A^erco, and 
 two ounces of fuetid pus drawn oft'. 
 
 May 5. — Transferred to surgical wards under Dr. Gardner's care. 
 
 May 16. — Has a high evening temperature ; passes three pints urine 
 in twenty-four hours, M'hich contains pus. At 4 p.m., under ether, and 
 using the carbolic spray, Dr. Gardner made an incision down and into 
 the right kidney, evacuating from six to eight ounces fnetid pus. The 
 kidney was freely explored by the finger; no stone found. A large 
 tube inserted, and gauze dressing applied. 
 
 May 17. — Temperature normal ; feels better, and .sits up in l^ed with 
 ease ; moves more freely than before operation ; on dressing, ^ery little 
 dischai'ge found. 
 
 May 18. — Dressed; urine dai-k olive colour, and contains albumen. 
 
 May 20. — Dressed ; discharge oozing tlirough l:)andages ; some pus in 
 urine ; bowels confined. 
 
 May 21. — Temperature rising every night ; urine over three pints, ' 
 no pus ; feels well. 
 
 May 25. — Dressed ; gut sutures dissoh ing ; tube removed ; urine 
 clear, four pints per diem. 
 
 June 11. — Discharge increasing the last week; patient much weaker, 
 and at times delirious ; urine clear ; bowels rather loose ; takes nourish- 
 ment well ; an epileptiform attack to-day. 
 
 June 16. — Urine ruby red colour; contains blood. 
 
 June 17. — Worse; passes evacuations involuntarily. 
 
 June 18. — Two " fits" last night, one this morning. 
 
 June 19. — Died, having had sevei'al more "fits." 
 
 On post-mortem examination, both kidneys were found to be scrofulous, 
 and have been exhibited to tlie Society. 
 
 Cases II. and III. 
 
 Alexander M'Leod, pet. 42, gaoler ; abscess of kidney, nephrotomy, 
 recovery. 
 
 January 21, 1884. — Five years ago, experienced a scalding sensation 
 on passing urine, and this continued for about six months, when it was 
 so bad as to necessitate micturition every hour ; medical treatment for 
 six months, without much benefit. For two years svibsequently had 
 scalding, but not such frequent micturition. Two and a half years ago 
 jiassed Ijlood with the urine, and had, at intervals of about a month, 
 colic attended l)y \oniiting, and pain in the hypogastric region. This 
 lasted about two montlis. Has since been pretty well, until witliin two 
 months ago, when pain set in in the right lumljar region. No scalding 
 for about twelve montlis ; apparent fulness of right lumbar region, with 
 dulness on percussion in front; no kidney mai'gin to be made out; 
 complains of pain on manipulation in both lumbar regions, but especially 
 the right. 
 
 January 22. — Uiine slighty acid and copious ; contains phosphates, 
 and nuicli pus.
 
 THE SURr.ERY OF THE KIDNEY. 309 
 
 January 24. — Gets up once every night to micturate, and passes 
 water three times during the day ; has occasional lumbar pain passing 
 down the right thigh. 
 
 January 26. — Urine deposits less ; no albumen ; slight trace of 
 phosphates. 
 
 January 28. — Dulness of riglit back, with absence of vocal resonance 
 and vocal fremitus ; pleurisy with effusion. Transferred to Dr. Yerco's 
 care. 
 
 February 24. — Sent back from medical wards, fluid having become 
 absorbed under ti-eatment. 
 
 February 29. — Under ether, and using a carbolic spi*ay, an incision 
 was made into the kidney, and one and a half pints of tliin pus 
 evacuated. 
 
 Marcli 1. — Dressed ; very little discharge. 
 
 March 5. — Dressed ; less discharge. 
 
 Two weeks after leaving the hospital, the patient returned to his 
 duties as gaolei', and was able to continue his work to the end of April 
 1885, when he began to lose flesh, and on the 18th May was re-admitted 
 into the Adelaide Hospital. He has lost five pounds in weight during 
 the last month. There is still a sinus in the loin, from which pus 
 escapes, and a probe can be passed along it to the depth of three inches. 
 The urine is acid, slightly turbid, and contains no albumen. The 
 average daily amount for a week was 50 ozs. 
 
 June -t. — Professor Rennie kindly estimated foi- me the quantity of 
 urea daily excreted, and found it to be 400 grains. 
 
 June 5. — After a consultation with my colleagues, I determined to 
 attempt removal of the kidney, a procedure which was rendered neces- 
 sary by the downwai"d tendency of the case. The patient having been 
 put under the influence of etlier, I made an incision obliquely from the 
 twelfth rib to the crest of the ilium in the right lumbar region, keeping as 
 nearly as possible in the line of the old cicatrix. Tlie edges of the wound 
 being held aside by retractors, I continued to cut down to a depth of 
 three inches, and on thrusting in my finger, I felt three openings lead- 
 ing out laterally, which appeared to be tlie calyces of a dilated pelvis. 
 I then came to the conclusion that the kidney was so incorporated with 
 the surrounding structures, that it could not possibly be removed. A large 
 drainage tube was inserted, and the wound closed with metallic sutui^es. 
 The subsequent progi-ess of the case was uniformly favourable, thei'e 
 being no rise of temperature at any time, and the patient was dis- 
 charged on the 28th July in niucli tlie same condition as when admitted 
 to tlie wards. 
 
 October 3. — Patient came to my consulting rooms, and besought 
 me to do something for him to relieve his present condition, as he felt 
 himself sinking gradually. He elected to enter a private hospital, and 
 I determined to make another attempt to remove the kidney. 
 
 October 6. — Assisted by Dr. Giles, Dr. Moore giving ether, I made 
 an incision to the outer side of the right rectus (Langenbuch's) four 
 inches long, and divided the tissues down to the peritoneum, which I 
 carefully opened, and divided to the full extent of the external incision. 
 I then gently passed my hand into tlie abdominal cavity, and felt the 
 right kidney considerably enlarged, but still movable, and therefore not, 
 as I had imagined, incorporated with the surrounding tissues. Passing
 
 310 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 my hand cautiously across to the other side, I examined tlie left kidney, 
 and it felt to me about the usual size. I then determined to remove 
 the right kidney through the lumbar incisions, if possible. Napkins 
 dipped in warm carbolic lotion were laid over the abdominal wound, 
 which was kept thoroughly closed by Dr. Giles. I then cut down in 
 the lumbar region through my previous incision, until I felt the kidney, 
 which was very much enlarged, but freely movable. As there was not 
 room to pass in my whole hand, I made an incision along the whole 
 length of the twelfth rib on the right side, separated the peritoneum, 
 divided the rib with the bone forceps at its spinal end, and removed it. 
 I then easily introduced my hand, and grasped the kidney, which was 
 extremely brittle, and dilated to a shell. A great deal of the kidney 
 structure broke down under the finger, but by gently pulling, I was 
 enabled to get the pedicle so far out as to transfix with a double ligature, 
 and tie in two portions. The cavity was then washed out with tepid 
 water, and the peritoneum found to be intact, as the water soon began 
 to overflow. A large drainage tube was inserted, and the wound 
 brouffht toijether with metallic sutures. The abdominal wound was 
 now closed with silk sutures. Lister's antiseptic dressing was 
 employed. The whole operation lasted one hour and a half. On the 
 morning of the operation, the temperatui'e stood at 100"4° F., and 
 immediately after the operation, it fell to normal, and continued so 
 during the further progress of the case. 
 
 October 7. — Slight vomiting thi-ough the night ; profuse perspirations ; 
 passed seven ounces of high-coloui'ed urine. At 10 a.m. the wound was 
 dressed. Beef tea and brandy enemata were ordered every two hours. 
 No sickness during the afternoon. Slept at intervals. At 6.30 p.m. 
 patient became very restless, and vomited. The catheter was passed 
 twice during the day, but no urine was found in the bladder. 
 
 October 8th. — No urine passed, and vomiting continued at intervals 
 until death, which took place at 2.30 p.m. 
 
 Post-mortem Examination. — Body much emaciated, skin jaundiced, 
 abdomen distended. In the anterior abdominal wall, three inches to the 
 right of the linea alba, is a longitudinal wound brought together with 
 silk sutures. The skin in the neighbourhood of the wound is somewhat 
 dark and discoloured. Over the right kidney, in the lumbar region, 
 is a wound extending from a point just above the twelfth rib, 
 downwards for nearly six inches. Running from this, in the direction 
 of tlie I'ib, is another incision, about four inches long. Through this, 
 tlu'ee inches of the twelfth rib liave been removed. On opening the 
 abdomen, some flakes of lymph were observed on the intestines. One 
 recent adhesion exists between the wound and the ascending colon ; 
 and between the lower lobe of the li^•er and tlie intestines adjoining, 
 are several bands, also quite recent. Very extensive old fibrous 
 adhesions are found between the ascending colon and the posterior 
 al^dominal wall. The abdominal cavity contains about six ounces of 
 thin watery fluid. The inner surface of the wound in the anterior wall 
 looks healtljy, but all the sutures have torn tlirough the peritoneum, 
 and a gap of nearly one inch is seen between the divided portions, 
 showing some tension has existed. The intestines are enormously 
 distended, but not matted togetlier, and appear quite healthy. No 
 trace of tubercle in any of the mesenteric glands. Right kidney
 
 THE SUUOERY OF THE KIDNEY. 311 
 
 absent. A large cavity capable of admitting a man's two fists, enclosed 
 by thick fibrous walls, and completely shut oft' from the peritoneal sac, 
 communicates witli the wound in the right lumbar region. It contains 
 a few pieces of broken down kidney substance, and small blood clots. 
 The pedicle of the kidney is also found here, firmly tied with a double 
 silk ligature. Left kidney is enlarged, pale, soft and flabby ; the 
 capsule readily strips oft"; the cortex is somewhat wasted and yellow. 
 Distinct signs of fatty degeneration are present in this organ. The 
 right ureter is embedded throughout its entire length in dense hard 
 fibrous tissues, forming a thick band which is firmly adherent to the 
 underlying muscles. A probe passes down it with ease. There is no 
 trace of dilatation. The left ureter is normal. The bladder is small 
 and contracted. About a teaspoonful of thick pus escapes on opening. 
 The walls are a quarter of an inch in thickness. The mucous 
 membi-ane is corrugated and hypertrophied. The prostate appears 
 healthy, normal in size, and shows no sign of any tubercle. 
 
 A Case of Nepltroto^ny. 
 
 January 22, 1884. — Mrs. N. consulted me; manned twelve years; 
 two children living ; nine have died ; the children living are the fifth 
 and the first ; took ill three years ago after confinement ; micturition 
 became painful, and white sand came away in large quantities ; the 
 urine became turbid and smelt badly ; pain began in the right lumbar 
 region, and passing across the abdomen ran into the right labium. 
 When the pain in the back was worst, vomiting was present, often 
 lasting twenty-four hours ; the attacks have occurred as often as three 
 times in a week. Examination per vaginam showed endo-cervicitis and 
 abrasion of the os, with rents in the cervix ; on sounding the bladder, it 
 was found to be covered all over with phosphatic concretions. I sponged 
 out the uterus with glycer. acid, carbol., inserted a watch-spring pessary 
 to secure rest, and washed out the bladder twice a week. This treat- 
 ment was .so far successful, that after a time I lost sight of her. 
 
 In July 1884, she appeared again, and I then found that, although 
 tlie bladder was entirely free from phosphatic plates, the right kidney 
 liad become very much enlarged, and could easily be felt. I then 
 determined to explore the kidney. 
 
 On August 4 and 6, with the assistance of Dr. C. Gosse, Dr. Corbin 
 iciving ether, I performed nephrotomy. After opening the capsule of 
 the kidney, which I stitched on both sides to the edges of the wound, I 
 made an incision into the kidney, examined carefully with the finger, but 
 could find no stone. A large drainage tube was then inserted, and the 
 wound dressed with carbolised gauze. The spray was allowed to play 
 freely over the part, but was not directed on to the wound. 
 
 August 7. — Dressed the wound, which was apparently healed 
 throughout its whole length ; urine passed the last twenty-four hours 
 feebly acid, quite clear; sp. gr. 1022; patient vomiting a greenish 
 fluid. 
 
 August 8. — Urine greenisli ; sickness stopped ; dressing stained with 
 a considerable sanguineous discharge. Urine, when tested with nitric 
 acid, turns black ; sp. gr. 1022. 
 
 August 9. — One-fiftli curdy pus in the urine; sp. gr. 1022. 
 
 August 11. — Urine clearer, one-sixteenth pus only.
 
 312 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 August 13. — Sits up; takes food well; urine contains one-thirtieth 
 pus only ; tube discharging well. 
 
 August 17. — Tube washed out twice daily with weak Condy and 
 water ; urine slightly cloudy with pus. 
 
 August 19. — Introduced sound into bladder; no stone; rather more 
 pus in urine. 
 
 August 23. — Urine contains very little pus ; patient putting on flesh, 
 and walks about. 
 
 September 2. — Patient left private hospital quite strong; urine clear; 
 wound discharging very little. After returning home, patient had in 
 some way caught cold, and had severe rigors and profuse sweats for 
 many days. 
 
 A Case of Nephrotomy. 
 
 August 23, 1884.— Mrs. K. consulted me, with a history of gravel 
 for years, and pus in the urine. She complains of intense pain for 
 months in the region of the left kidney, but as she was very fat, no 
 enlargement of the organ could be made out. Her intelligence was 
 not of the higliest order, and I desired her to bring me a sample of the 
 matter she passed. In a few days she brought me an eight-ounce 
 bottle full of muco-pus. I then determined to explore the kidney, and 
 with the assistance of Dr. Jay, who gave ether, I performed the usual 
 operation for nephrotomy. The kidney was plainly seen at the bottom 
 of a deep pit, caused by excessive deposit of fat, and after fixing its 
 capsule, I cut into the substance, and explored the interior, but found 
 nothing abnormal. The wound was dressed in the usual way, and a 
 drainage tube inserted. Healing went on rapidly, and in a few days 
 the drainage tube was removed. She left the private hospital on 
 September 17th, well. In conversation with her on the day after the 
 operation, I discovered that she had made up the bottle of pus, by 
 pouring off the clear urine every day, and storing up the nmco-pus. 
 
 Case IV. — Nephrorraphy. 
 
 Mrs. G., a?t. 45, consulted me on the 6th September, 1884, for 
 excruciating pain under the ribs on the right side, and below the right 
 shoulder blade. Has eleven children, youngest three years of age. 
 She showed me a lump on the right side of the abdomen, which could 
 be freely moved about, either downwards to level of iliac crest, laterally 
 beyond the median line, and backwards it could be disj^laced so as to 
 be lost under the edge of the liver. It was perfectly smooth on the 
 surface, and about the size of an ordinary kidney. I diagnosed 
 " movable kidney," and told the patient's husband, that if at any time 
 they could assure me that the pain was unbeai^able, I would cut into 
 the loin and stitch the kidney to the edges of the incision. 
 
 In the beginning of December she returned to say that she could 
 bear the pain no longer. 
 
 Accordingly, on 4th December, with the assistance of Drs. Way and 
 Gosse (Dr. (Jraham, of Melbourne, being pi-esent), I cut down by the 
 usual incisif)n in the loin, I then opened the capsule, and put in two 
 steadying stitclies, which I passed through the sides of the incision. 
 Finally, I passed two chromicised kangaroo tendons through tlie 
 substance of the kidney, and about two iiiches apart ; then passing an
 
 THE SUKGERY OP THE KIDNEY. 313 
 
 unthreaded needle down through tlie incision on each side, T drew out 
 the kangaroo ligatures and tied them tightly, after inserting a drainage 
 tube in the lower angle of the wound. The operation was done under 
 thymol spray (1 in 1000), and dressed with thymol gauze. The 
 progress of the case was very slow, owing to the foi'mation of a 
 burrowing abscess under the fascia, necessitating incision and the 
 insertion of a drainage tube. The collection of matter could be 
 distinctly felt just inside of the anterior superior spinous process of the 
 ilium. Tliis abscess was probably caused by the decomposition of 
 blood whicli had forced its way down under the fascia. 
 
 The tinal I'esult of this case was excellent, tlie patient being now 
 entirely free from her old pains, and able to walk about with comfort. 
 The kidney can be felt obscurely in its normal position, and does not 
 undergo the slightest change of position during the movements of the 
 patient. 
 
 Case VIT. — Nephro-Lithotomi/. 
 
 Daniel D., set. 23, consulted me lirst on January 29, 1887, complain- 
 ing of pain in the left lumbar region, from which he has sufiered for the 
 last three years. Whenever he walks or runs, the urine becomes like 
 blood ; and on passing it, he has pain across the lower part of the 
 abdomen. When the pain is very severe, he has to make water 
 frequently, and sometimes there is a difficulty in starting the stream. 
 Three years ago last November, was working at a dam with an 
 excavator, and while running across it he fell down on his left side, and 
 twenty minutes after, on attempting to make water, he passed jjure 
 blood. This continued for a month. Has never been able to do a 
 hard day's work since, without feeling the pain. In every severe 
 attack, has had pain in the left testicle. Family history good ; previous 
 healtli good. Has not suffered from any A^enei'eal disease. Heart and 
 lungs noi-mal ; sounded, no stone or stricture. There is undoubted 
 tenderness over the left kidney, detected by bi-manual palpation. 
 Microscopical examination of the urine showed pus and blood-corpuscles, 
 and abundant ciystals of oxalate of lime. After a careful consideration 
 of the case, the diagnosis made was probable oxalate of lime calculus in 
 the left kidney. 
 
 On the 10th February, the patient was placed under the influence of 
 ether by Dr. Lloyd, and a transverse incision was made in the left 
 lumbar region, about four inches long, and three-quarters of an inch 
 below the twelfth rib. The dissection was continued downwards, 
 through the muscles and the lumbar aponeurosis, and the quadratus 
 lumborum was divided for one inch. Tlie bleeding was controlled by 
 the application of pressure forceps, and the separation of the supra-renal 
 fat and capsule of the kidney was made by tearing with the two fore- 
 fingers. The kidney could then be plainly felt and seen, and a fine 
 trocar was thrust into it, and gave the peculiar grating feeling caused 
 by striking calculous matter. The kidney was then incised till the 
 point of the trocar was reached, and then a small stone was felt, resting 
 in one of the calyces below the incision. By means of the left fore-finger 
 in the wound, and a small pair of lithotomy forceps passed into the 
 kidney by the right hand, the stone was delivered. The wound was then 
 douched out with warm thymol solution, and two large drainage tubes
 
 314 IXTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 inserted into the post-renal cavity, and the edges brought togetlier with 
 interrupted sutures of silver wire and wallaby tendon alternately. The 
 stone weighed twenty-five grains, and consisted of oxalate of lime. 
 
 February 10, 7 p.m. — Rallied well after the ether, temperature 98°, 
 vomited twice, some pain in the back, pulse very good. 9.30 p.m. — 
 Passed O ss. of urine, mixed with much blood. 12 p.m. — Temperature 
 101*2°. 12.30 p.m. — No sleep, restless, and in some pain; slight 
 discharge showing at lower part of tlie dressing ; salicylic wool applied. 
 
 February 11, 9 a.m. — Pulse 88, respiration 20, temperature 99 -0° ; 
 air-bed ordered; dressed; no blood in the tubes. 6 p.m. — Tempei'ature 
 100°. 8 p.m. — Sleeping soundly ; discharge has not come through 
 dressings. 
 
 February 12. — Slept fairly well through the night; pulse 88, tempera- 
 ture 99-6°; dressed, wound quite sweet, and urine not so highly coloured 
 with blood. 5 p.m. — Urine not passed since 4 a.m., drawn oft' (twelve 
 ounces) with catheter, previously washed in thymol. Dressed, shortened 
 tubes a quarter of an inch, two stitches removed. The tubes after this 
 wei'e gradually shortened, and the wound was regulai'ly kept clean with 
 thymol solution. 
 
 February 16. — Anterior half of wound well united; allowed solid 
 food. 
 
 February 17. — Bowels acted. 
 
 February 18. — One of the tubes removed. 
 
 February 21. — ^Second tube was removed; no urine was passing by 
 the lumbar wound ; dressed with red lotion. 
 
 This case is i-emarkable, as being the first reported case of nephro- 
 lithotomy in Australia. 
 
 Case XIII. — Neplivo-Litliotomy hij Terrier's Trans-Peritoneal Operation. 
 
 M^^s. D., a?t. about 55 years, had been several times under my care, 
 from November 10, 1886, for slight attacks of dyspepsia. Examination 
 of the abdomen and of the chest revealed nothing abnormal, and the 
 urine was also found to be normal. On March 6, 1888, another attack 
 occurred, which was not I'elieved by medical treatment ; and another 
 examination of the abdomen was made, with tlie result of finding an 
 enlargement of the left kidney. On March 29, I called Dr. Verco in 
 consultation, and we concluded that there were symptoms pointing to a 
 collection of fluid in or around the left kidney. We advised aspiration, 
 which was carried out on March 30, and four ounces of light amber- 
 coloured fluid were removed, without any odour of uiine. With nitrate 
 of silver, the fluid yielded a copious white precipitate ; microscopically, 
 there were no signs of hydatid. Professor Rennie, by chemical analysis, 
 could only find traces of urea. We were thus left in doubt whether 
 the case was one of hydatid or hydro-nephrosis. After the operation, 
 the kidney swelling disappeared ; three weeks after, it enlarged again ; 
 and with the assistance of Dr. Verco (Dr. Giles administering ether), 
 on Api-il 18, 1888, the abdomen was opened by Langenbuch's incision, 
 outside of the left rectus, and the parietal peritoneum was stitched to 
 the edges of tlie wound. The visceral peritoneum was then divided, 
 and also stitclied to the edges of the wound. The cystic swelling was 
 then incised sufficiently to admit the forefinger, and on introducing it,
 
 THE SUnORRY OP THE KIDNEY. 315 
 
 I could feel a small piece of calculous matter al)out the size of a split 
 pea. This I removed, and on examining still furtlier, I found a small 
 fragment also embedded in what T liad then discovered to be the renal 
 tissue. I tried to remove it with the nail, but found that on scratching 
 the tissue, the stone appeai'ed to become larger ; and inserting a knife 
 along the finger, I incised a calyx, and removed an irregularly-shaped 
 calculus weighing ninety-six grains. There had been a doubtful history 
 of an attack of renal colic, but it was certainly on the opposite side. 
 A glass di'ainage-tube was inserted, and the wound dressed with gauze 
 "and salicylic wool. The highest temperatures recorded were 99*2° on 
 the second day, and 99 '6° on the third day ; on every other occasion 
 the temjierature was normal. Urine was passed spontaneously on the 
 day of operation, and the patient only vomited once after the ether. 
 
 Case XIV. — Nepliredomy for Stone in the Kidney. 
 
 Miss M. has been under my care for years — first for disease of the 
 hip-joint, which I excised on May 1st, 1881. She recovered perfectly, 
 and enjoyed fjxir health for a few years, when symptoms of irritability 
 of the bladder came on (April 1885), and this viscus was examined with 
 a negative result. Later on (two years ago) she had an attack of renal 
 colic, and passed a small calculus per urethram. The patient was not 
 able to say from which side the pain started, and I was therefore unable 
 to say from which kidney the stone had descended. For the last year, 
 she has been passing considerable, although varying, quantities of pus in 
 the urine. There was no enlargement of either kidney ; but as there 
 was a possibility of the presence of "strumous" kidney, and as the 
 patient was disinclined to have any exploratory incision, I determined 
 to await the further development of the case. Lately, she sent word to 
 me that the pain had now declared itself in the right loin, and that she 
 had decided to enter the private hospital for operation. On examination 
 after admission, I discovered that tlie right kidney was enlarged, and 
 the probability of stone being present decided me to operate. 
 
 On July 28, 1888, Dr. Todd having put the patient under the 
 influence of ether, I made the usual lumbar incision, and after exposing 
 the capsule, I passed in a needle, and immediately felt the sensation of 
 a stone. The kidney was then incised, and exit given to a large 
 quantity of opalescent fluid, with curdy flakes in it. After this no 
 kidney could be felt, but a thickened condition of the outer wall of the 
 capsule. This was then dissected out, and looked like a piece of 
 gangrenous intestine. It was tlien decided to remove the kidney, and 
 the pedicle 'was ligatured by transfixion, and the kidney removed. 
 Unfortunately, after examination of the removed organ, no stone could 
 l)e found, and as the presence of the stone was certain, a further search 
 was made, and a hard piece of fatty tissue was incised, and the stone 
 removed. The explanation was, that in holding the kidney up to assist 
 its removal, the stone had droj^ped down, and had been in some manner 
 included in the part which had been ligatured. Drainage tubes were 
 inserted, and the wound bi'ouglit together. After the operation there 
 was vomiting of greenish fluid, which stopped after the administration 
 of a little Ijrandy and soda. At 3 p.m. on the same day tlie temperature 
 was 98°, pulse 120, respirations .32. Urine was j^assed spontaneously. 
 Very little pain. Barley water was given, and at 8 p.m. the tempera-
 
 316 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 ture was 98-2°, pulse 120, respirations 32. July 29.— Temperature 98', 
 pulse 116, respirations 24. Twenty-four ounces of urine passed in the 
 last twenty-four hours. Wound dressed, and injected out with boric 
 acid lotion ; tubes removed, cleansed, and replaced. Slept well during 
 night. Thirty-eight ounces of urine passed in twenty-four hours. On 
 the fourteenth day after operation, the patient was allowed out of bed, 
 and returned to her home at the end of three weeks with a small 
 granulating wound where the tube had been removed. 
 
 A NEW PROCEDURE FOR THE CURE OF CONGENITAL 
 TALIPES VARUS AND EQUINO-VARUS. 
 
 By T. N. FitzGerald, F.R.C.S.L 
 
 Senior Surgeon to the Melbourne Hospital. 
 
 That all the various operations designed since the time of Delpech, 
 for the treatment of talipes, have turned out in practice w4th only more 
 or less modilied success, is a truism that requires no re-assertion. 
 
 The very number and variety of methods that are constantly being 
 suggested, and the differences of opinion that exist as regards their 
 respective merits, are sufficient evidence that either the nature of this 
 deformity is not properly understood, or that, through some default, our 
 remedial measures have not yet fallen into a really satisfactory dii-ection. 
 
 In my own experience, the various surgical procedures of tenotomy, 
 tarsotomy, and tarsectomy, combined with manipulations, are not 
 infrequently failures ; at all events, their success is by no means com- 
 mensurate with the promises of their originators and advocates. In 
 some instances, the cases relapse ; and not infrequently, if the appear- 
 ance of the foot is improved, the results, as regards the usefulness of 
 the member, are but little better than the original condition. And if 
 in the proceeding of tarsotomy or tarsectomy, fibrous, instead of osseous, 
 union should happen to take place, then the state of affairs cannot 
 be deemed satisfactory. 
 
 In considering the causes of these failures from a practical and 
 clinical standpoint, I have formed some conclusions as to the natui-e of 
 talipes varus or equino-varus, and have in consequence been led to 
 devise a new method of treatment. 
 
 It is not necessary to enter at length into the various opinions which 
 liave been expressed as to what joints or })arts of the foot are distorted 
 and misplaced in this deformity ; suffice it to say, that I am entirely in 
 accordance with Mr. Par-ker in his opinion, as expressed at the last 
 August meeting of tlie British Medical Association, in the discussion on 
 cluij foot. Mr. Parker considers that every structure of the foot is 
 involved, but I also further hold tliat in severe cases, resistance to the 
 replacement of tlie deformity results from structural clianges in the bone,
 
 CURE OP COXOENITAL TALIPES VARUS AND RQUINO-VARUS. 317 
 
 as well as tlie alteration of the relati\e positions of tlieii' articailar surfaces. 
 This condition is very well desci-ibed by Mr. William Adams in his 
 able work on "Club-Foot." That this is so Mr. Parker admits, but he 
 differs in considering that it is not an essential part of the deformity. 
 The idea that the bony change is the difficulty, is the foundation of all 
 operations such as those devised by Messrs. Lund and Davies-CoUey. 
 However, there is this objection to all procedures, which requii'e for 
 their fulfilment the resection or the removal of some portion of the 
 tarsus. The inalposition may be remedied, but it is a great 
 disadvantage to leave the foot permanently weakened. 
 
 Now I hold veiy strongly that, whatever the etiology of club-foot 
 may be, the principal factor is impaired nutrition of the whole foot, 
 and particularly of the bones. How this occurs " in utero " is 
 unnecessary for me to discuss. But everyone concerned in medical 
 pi'actice must have observed the frequency with which talipes is 
 associated in a family (as instance the two brothers whose cases are 
 related at the end of this paper), or in the same child, with other 
 deformities such as hare-lip, cleft palate, spina-bifida, imperforate anus 
 and hernia. These abnormalities are admittedly due to arrest of 
 development ; but the cause is inexplicable. 
 
 With respect to the pathology of club-foot, the following seem to me 
 to be the anatomical peculiarities in a severe instance of equino- 
 ^ arus : — The astragalus is displaced forwards, outwards, and downwards, 
 so that the trochlear svirface projects in front of the tibia ; the outer 
 side of its neck is elongated, and the head directed inwards. 
 
 The scaphoid is displaced, and appi'oximated to the os calcis and 
 inner malleolus ; the external malleolus is apparently considerably 
 thrown backwards, but in reality it is only slightly displaced. The 
 OS calcis is nearly vertical ; its tuberosity is drawn upwards and 
 inwai'ds, and the whole bone generally presents a crescentic shape. 
 The upper surface of the cuboid, and the head of the fifth metatarsal 
 bone, are turned downwards. The tendo Achillis is nearly always 
 contracted, and also the tibialis anticus and posticus tendons. The 
 calcaneo-scaphoid ligament is contracted and shortened, the astragalo- 
 scaphoid ligament is lengthened, and the plantar fascia and other fibrous 
 structures contracted as described by orthops^jdic surgeons — this latter 
 being the real cause of the deformity of the sole of the foot. 
 
 What operative measures then can be adopted which may remedy 
 tiiese structural changes of form, these mal-positions of the bones, 
 without much risk to the patient, witliout weakening the foot, and by 
 which at the same time nutrition can be improved ? 
 
 In another paper, I have drawn attention to the marked effects of 
 subcutaneous drilling and gouging in improving the nutrition and 
 vitality of bone in cases of ostitis ; and it occurred to me that if the 
 poorly nourished and mal-formed bones in talipes were sufficiently 
 broken up subcutaneously, and at the same time all resisting fibrous 
 structures were freely divided, the displacement could be rectified by a 
 pi'ocess of forcible moulding togethei- of the bones. In this way, the 
 osseous tissues, rendered soft and malleable so to speak, would be 
 capable of being ci'ushed together or flattened out as occasion required. 
 Repair would then set in, new tissue be formed, and the improved
 
 318 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 position be rendered permanent, witli the probability that tlie whole 
 nutrition would be improved instead of impaired, the foot strengthened 
 instead of weakened. 
 
 The operation I perform is as follows :-— An Esmarch bandage is 
 applied from the toes to above the knee. The following tendons are 
 then divided : the tendo Achillis close to its insei'tion, the tibialis 
 antic us just above the ankle, the tibialis posticus about an inch and 
 a half above the inner malleolus, in the usual way. When this 
 part of the procedure has been completed, it becomes comparatively 
 easy to judge the amount of I'esistance offered by the contraction 
 of the ligaments and librous structures of the sole. The fear that the 
 divided ends of the tendo Acliillis will not unite, if severed as directed, 
 is, I am satisfied, groundless. It is simply necessary to see that 
 the gap (no matter how large), which is occasioned when the parts are 
 separated, is not oblitei^ated by the too firm pressure of the bandage. 
 To avoid this, I protect the ends and intervening space by a piece 
 of cardboard, over which the bandage is evenly and gently applied. 
 This portion of the tenotomy being concluded, the plantar fascia, the 
 calcaneo-scaphoid ligament, the deep ligaments, the abductor pollicis, 
 and all resisting structures down to the astragalo-scaphoid articulation 
 are freely divided. I often find it necessary to sever some of the 
 anterior fibres of the deltoid ligament. If the artery and nerve come 
 in the way, their incision does not seem to affect the issue in the 
 slightest. 
 
 Next comes the osteotomy, and as this is the most important part of 
 the operation, it will be well to be somewhat full in its explanation. 
 The instruments used are an ordinary tenotomy knife, rather long in 
 the shaft between the blade and the handle, and a chisel (a full sized 
 representation of which is given in the annexed diagram). The chisel 
 is made of the finest steel, its cutting extremity is bevelled like a V, 
 similar to Macewen's osteotome, and the stem is of a uniform size and 
 perfectly smooth and round, and just sufliciently long that it can be 
 grasped with the hand, and at the same time perfectly controlled l)y 
 the forefinger resting on and commanding the blade. To one accustomed 
 to handling instruments, the importance of the chisel being of a 
 manageable length can be easily understood, though at the first glance 
 it may seem an unimpoi'tant matter. 
 
 To proceed, the astragalus is first divided through its neck ; to effect 
 this, a valvular incision, just sufiiciently large to admit the chisel, is 
 made with the tenotome, obliquely down to the bone, the knife being 
 entered on the outside of the foot, slightly inclined from above down- 
 wards, a little Ijackwards and inwards, behind the calcaneo-cuboid 
 articulation, so that it passes in its course through the foot immediately 
 in front of the ankle-joint. The tenotome being withdrawn, the chisel, 
 firmly iield, is puslied along the channel the knife has just made, so 
 that it impinges on the bone at the spot where the astragalus may be 
 said to narrow to a neck. The chisel enters this constriction, and 
 with a little force by pushing and twisting, it is manipulated in such a 
 manner, tliat the head or part of the bone which enters into the 
 astragalo-scaplioid joint, becomes detached from the body. The inner 
 aspect of the foot is now attacked, and the scaphoid freely broken 
 up subcutaneously. Tlie os calcis is now subcutaneously divided
 
 INrKKCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 *318
 
 319' 
 
 IliTEECOLONIAL MEDICAL CONGKESS OF AUSTJiALASU. 

 
 CURE OF CONGENITAL TALIPES VARUS AND EQUINO-VARUS. 319 
 
 obliquely, at a point just behind the posterior articulating surface, in 
 fact separating the bone into neai-ly equal halves. A few drills are 
 put into the cuboid to help nutrition, and this finishes the actual 
 operation. 
 
 The next aim is to mould the foot into a normal position, and to do 
 this, considerable force is required, and it is well to have the help of 
 a trustworthy assistant, so as to prevent fracturing the tibia or fibula 
 close to the joint, or separating the epiphyses. 
 
 The rotation of the tarsal bones may be assisted by enrolling the foot 
 in a wet towel, or the member may be levered into position by means 
 of a flat piece of wood firmly attached to the sole of the foot, and the 
 OS calcis forced into place. By these means, and the exercise of a little 
 patience, it will he found that the foot can be nearly fashioned into 
 good position. Any little fragment of the scaphoid that sticks out, or 
 is unduly prominent, may be hammered back by a mallet, interposing 
 a roll of bandage between tlie foot and the blow. 
 
 All that now remains is to roll the foot in antiseptic wool, and apply 
 firm but even pressure from the toes to the knee. The limb is put in a 
 light trough splint, wdth a foot-piece so adjusted that it keeps the foot 
 in good position, i.e., at right angles with the leg ; the Esmarch 
 tourniquet is then removed. In three or four days, when the superficial 
 wounds are healed, I apply the little splint depicted in the diagram. 
 
 Fig. I. shows the ball-and-socket joint. Fig. II., the foot-piece (b), on 
 the outer side of which there is a small plate, so that the projection 
 from the ball can be screwed into it, thus allowing the foot-piece to 
 remain on the sole when the splint is removed. Fig. III. is a full view 
 of the whole apparatus. 
 
 The foot that has been operated upon is firndy and evenly strapped 
 to the foot-piece (b), and the limb is laid in the splint, which is care- 
 fully adjusted to the leg; the ball portion lying free in the socket is 
 then screwed into the foot-piece ; the foot is then turned to the desired 
 angle, and is held in position by tightening the screw c in Fig. I. 
 
 For a fortnight, the case requires careful watching, and should be 
 seen almost daily, in the event of any undue pressure occasioning 
 sloughing. At the end of this time, when the foot is taken down and 
 examined, it may require some little re-adjustment, and should be f)ut 
 up again for another week. The whole splint, with the exception of 
 the foot-piece, should be now removed every morning, and gentle 
 passive motion used, and the child may be permitted to walk on the 
 foot-piece. xYt night-time, the splint should be put on, and the foot 
 adjusted to the position desired. 
 
 At first sight, this operation, no doubt, appears rough and unsurgical 
 from the amount of force that is required to twist the foot, but the 
 same is the case with many other proceedings, the utility of which is 
 not in the least doubted. 
 
 A question that naturally arises is, whether there is not, in breaking 
 up the .scaphoid and chiselling ofF the head of the astragalus, a risk of 
 separating the fragonents from their attachments and nutritive supply, 
 thus setting up necrosis 1 Such has never occurred to me, and I think 
 the danger apprehended rather chimerical, provided that the cutting 
 is strictly subcutaneous, and that absolute cleanliness is rigorously 
 observed.
 
 320 INTERCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 8ome of my cases have been sent from the Melbourne Hospital for 
 inspection. The little fellow, Simon T., who walks so well and straight, 
 was one of the worst forms of double equino-varus. The operation was 
 performed witliin the last three months at the hospital, and was 
 witnessed by several gentlemen present. The little boy, John B., 
 aged 6, with the thin legs, but large fedt, was an extremely bad 
 case, in fact he never walked before his admission to the hospital, 
 three and a half months ago; he crawled on his hands and knees, 
 or was pushed along in a small conveyance. His feet are straight 
 and flat on tlie ground, but he does not "handle" them well yet, 
 although he walks strongly and straightly. A most interesting 
 feature about this case is, that the right tibia was over an inch 
 shorter than its fellow, and that by drilling the upper and lower 
 epiphyses the leg grew an inch in eight weeks, and is now only a quarter 
 of an inch shorter than the left. (Photographs are given of this boy 
 before and after operation). 
 
 Out of many cases, I select for illustration the photographs of two 
 brothers, Robert and Alfred C, aged respectively 8 and 6. They 
 were admitted to the Melbourne Hospital, and operated vipon in the 
 manner described. The photographs speak for themselves. Before the 
 operation, the feet were turned so that the boys walked entirely on the 
 outer side of them, and ambled about with the peculiar gait and roll 
 which are seen in all cases of aggravated equino-varus. They left the 
 hospital within two months of the operation, walking on the soles of 
 their feet, as shown in the photograph. 
 
 For the most part I find, that if the osteotomies and tenotomies are 
 fearlessly and carefully performed at tlie time of the opei^ation, very 
 little subsequent handling is required ; but occasionally I meet with feet 
 where resistance to re-shaping is out of the common. These cases not 
 only require patience on the part of the operator, but their treatment 
 should be undertaken with e"\'ery confidence that in time they must 
 yield to the measures adopted. 
 
 I have now operated on twenty cases at the Melbourne Hospital 
 alone during the past year, and up to the present, with almost invari- 
 able success. In one case some sloughing took place, and for a time I 
 was afraid that more of the foot would become involved than I cared 
 for, but a few days relieved my fears, as the slough was merely 
 suj^erficial. 
 
 Discussion ensued. 
 
 Dr. Gardner said that no one present in that theatre had ever seen 
 better results than those exhibited by Mr. FitzGerald. It did not 
 matter what theoretical objections they might have to the treatment 
 — they might say it was wrong, and calculated to set u}) acute 
 inflammation, but in the face of what Mr. FitzGerald had done so many 
 times, they must be silent. He had learnt from Mr. FitzGerald the 
 operation of drilling in bones, and he invariably drilled in suitable 
 cases. If drilling was done in the early stage, the disease would be 
 stayed. He was fully determined to adopt Mr. FitzGerald's method in 
 talipes. On one or two occasions he had i)erformed, with good results, 
 Davies-Colley's operation. He congratulated Mr. FitzGerald on his 
 excellent paper.
 
 NEW OPERATION FOR TALIPES 
 
 (Mr. FitzGeralds Paper) 
 
 John B.. /et. 6. BEFORE Operation.- Had Never Walked.
 
 NEW OPERATION FOR TALIPES 
 
 (Mr. FitzGeralds Paper) 
 
 John B. /et. 6, AFTER Operation— Stands and Walks well.
 
 NEW OPERATION FOR TALIPES 
 
 (Mr. FitzGeralds Paper) 
 
 R. C. AND A. 0. BEFORE Operation.
 
 NEW OPERATION FOR TALIPES 
 
 (Mr. FitzGerald's Paper) 
 
 R. C. AND A, C. BEFORE Operation.
 
 NEW OPERATION FOR TALIPES 
 
 (Mr. FitzGeralds Paper) 
 R. 0. AND A. 0. AFTER Operation.
 
 SUBCUTANEOUS DKILLINO FOR BONE INFLAMMATION. 321 
 
 Dr. O'Hara said he was so struck with what he heard about Mv. 
 FitzGerakl's operation for talipes, that he availed himself ' of the 
 opportunity he had had of going to the hospital to see him operate. 
 When he saw him at work, he was perfectly thunderstruck. It seemed 
 as if he could mould a foot to whatever shape he wished. Mr. 
 FitzGerakl's operations would sui)ersede several of the old-fashioned 
 ones. 
 
 Dr. Eexdle said they might look upon Mr. FitzGerald's paper as 
 one of the most original and valuable that had been bi'ought before the 
 Congress. He was struck with the originality and completeness 
 dis})layed in the operations. One great advantage over the operations 
 of cutting out was, that Mr. FitzGerald not only set up new action and 
 relieved irritation, but he preserved the attachment of the' ligaments 
 and tendons. That was a great point, and one which would make his 
 cases more successful than those of other operations. It was well- 
 known how unsatisfactory the old method had been. He had watched 
 the practice in Guy's Hospital in London, and he must say that the 
 cases in wdiich there w^ere satisfactory results were very few indeed. 
 He never saw there any cases at all equal to those shown them that 
 day. Even Mr. FitzGerald, with his great originality and courage, 
 would hardly have dared to perform the operation on the tarsus, if he 
 had not had previous experience of drilling in ostitis and bone disease. 
 He was quite converted to Mr. FitzGerald's operation for club-foot. 
 
 Dr. C. S. Ryan said he rose to express the admiration he felt on seeing 
 one of the operations performed. He had had the privilege of being 
 present when Mr. FitzGerald operated on the boy Hennessey. If any- 
 body had then told him that he would see that boy walk on the soles of 
 his feet he would not have believed him. However, it had happened, 
 and it was one of the greatest triumphs of the day. Since then, 
 he had seen two cases equally satisfactory. He did not think anybody 
 who had seen those cases would fail to be convinced that there was a 
 great deal in the operation. Since seeing them, he had done two 
 himself at the Children's Hospital, and the results were in every 
 degree satisfactory. No operation but that performed by Mr. FitzGerald 
 would have given such satisfactory results. 
 
 SUBCUTANEOUS DRILLING IN THE TREATMENT OF 
 BONE INFLAMMATION. 
 
 By T. N. FitzGerald, F.R.C.S.L 
 Senior Surgeon to the Melbourne Hospital. 
 
 I wish to bring before you briefly the method of treating chronic and 
 sub-acute inflammations of bone which I have practised for very many 
 years. Of its efficacy, I am convinced by constant verification ; and it 
 attacks a condition of inflammation which, owang to the aiifitomical 
 relations of the pai-t implicated, is particularly inaccessible to the 
 ordinary means at our disposal. 
 
 The method consists in subcutancously puncturing the bone in many 
 places with a drill inserted through a valvular skin opening; this 
 
 Y
 
 322 INTERCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 prevents the access of air, and renders the proceeding truly aseptic. 
 In tliis way, I frequently apply the drill to the shaft and extremities of 
 the tibia, to the trochanter femoris and the cervical portion of the 
 bone, to the bones of the tarsus and metatarsus, to the corresponding 
 bones of the upper extremity, and to the lower jaw, for chronic 
 inflammation and sub-acute exacerbations of the inflammatory j)rocess 
 of these bones. 
 
 Believing that the terms periostitis, osteomyelitis, and endostitis are 
 founded on theoretical rather than practical reasons, I have no 
 hesitation in passing the drill through and through the medullaiy 
 cavity, and in scoring the periosteum deeply with a tenotome. 
 
 From anatomical conditions, inflammations in any one of the 
 difierentiated portions of bone must implicate the other component 
 parts, either by their intensity or their long continuance. This 
 pathological consideration, this recognition of ostitis as an aflTection of 
 the whole bone, has an important bearing on the treatment ; this 
 can be tested clinically by the use of the drill and the tenotome, and 
 the treatment of chronic bone inflammations ought to include the use 
 of both instruments. 
 
 There is little use in trying to combat bone inflammation with 
 remedies which from all time have proved so efiicient in inflammations 
 of other textures. Rest, moist heat, depletion, and counter irritants 
 are here, by themselves, almost unavailing. In the soft parts, where 
 the tissues have become engorged and constricted with exudations, 
 and strangulation is imminent, relief may occur by increased activity 
 of the absorbents immediately outside the area of turmoil, and if the 
 condition must end in necrosis, nature can remove the necrosed portion. 
 But for bone there is no such succour, no such vent ; enclosed in 
 unyielding, indistensible channels, the unaflfected healthy lymphatics 
 lying just outside the inflammatory focus can neither increase in size, 
 nor perform much more than their usual tasks. 
 
 Within the area, for a while, all is stagnant, till tension-relief can be 
 effected by slow expansion and absorption of the bone channels, 
 resulting in that rarefaction of the osseous tissue which affbi'ds 
 suflacient room for the exudation, without that pressure which ends in 
 death. 
 
 The qviestion of pressure is, undoubtedly, the imjjortant one in all 
 inflammations of bone. Clearly then, in the treatment, the relief 
 of tension by assuring efiicient drainage is the prominent point. The 
 essential feature of bone inflammation is the plugging of the nutritive 
 and natural drain channels ; and therefore, for restoration, the removal 
 of all inflammatory products is imperative. In this direction, the 
 surgeon can come to Nature's aid by the use of either the trephine or 
 the drill. 
 
 When a bone cavity can be accurately diagnosed, or when it is 
 required to evacuate pus, or free sequestra, the trephine, as suggested by 
 M. Oilier, is an instr-ument that is perfect in its action, and effects 
 exactly what is desired. However, the smallest instrument inflicts a 
 considerable wound, which, whilst it remains open, is at any time 
 subject to infection. There is always more or less liability of severely 
 injuring the periosteum, or occasioning bleeding, and it is an appliance 
 a surgeon would reluctantly use in instances where the diagnosis was
 
 SUBCUTANEOUS DIULLlNr; FOR BONE INFLAMMATION. 323 
 
 floubtful. On the other IuiikI, the drill tluit ] have been in the habit of 
 using weekly for the last twenty years, is a surgical instrument that, in 
 most regions, is easy of application. The subcutaneous incision through 
 wliich the blade passes to reach tlie bone is of the smallest calibre, and 
 the pain resulting fi-om tlie drilling, as a rule, scarcely amounts to an 
 ache, which soon passes off. There never is, and never can be, the 
 slightest danger of conveying any infection if oi'dinary cleanliness be 
 observed. 
 
 Again, T am constantly in the haV)it of drilling bone tissue, of which 
 I am doubtful, and T feel sui'e I have saved many a limb in consequence. 
 If it does no good, it can do no possible harm. It is advisable to use it 
 several times, in fact in eight or ten different places around the 
 suspected area, i)enetrating to the medulla or right through the 
 cancellated structure on each occasion ; but I must repeat, that I never 
 fail to see that perfect cleaiiliness is observed. With this precaution, 
 the results obtained have been most satisfactory. To relate the history 
 of even some of the many cases in which the drill has shown its utility, 
 would be to occupy too long a time ; aiid besides, ostitis is of such 
 frequent occurrence, that any surgeon can easily test the efficacy of my 
 method himself. But I will take the liberty of enumerating a few of 
 the affections where this instrument, in my hands, has proved eminently 
 successful. 
 
 The drill I generally use is Woake's, as supplied by the instrument 
 makers, but I now prefer a moditication of the boat builder's bradawl, 
 fitted to a proper handle; the shaft is square, and easily passes through 
 ordinary bone tissue. 
 
 The patient here presented to you, Mr. P., is 25 years of age, a clerk. 
 For the last two years, he has had repeated attacks of severe localised 
 inflammation of the right tibia, just below the head, and extending 
 down the shaft for about three inches. He generally obtained relief 
 after a week's rest, and by the application of leeches and hot fomenta- 
 tions, with the internal administration of iodide of potassium, and 
 occasionally a Dover's powder at night. Mr. P. was brought to my 
 consulting room in great agony. I caused him to be placed under the 
 influence of an an?esthetic, and at once, subcutaneously, put eight drills 
 into the medullary canal, ordered the limb to be supported by a flannel 
 bandage, and that the patient should rest for two days. You see him 
 here, seven days after the operation, without a limp; he will tell you 
 that he has no pain, and that he is better than he has been for a length 
 of time. It may be said that the relief will be only transitory, but the 
 records of a large numbei- of similar cases prove otherwise. 
 
 For instance, under almost exactly the same conditions, T operated on 
 a bank inspector, seven years ago, Mr. M. (well known in this city), 
 who had been a very great sufferer for years, and periodically liad 
 exacerbations of acute tibial ostitis of a very severe character, with 
 nocturnal pains so great that he had to resort to narcotics. A long 
 incision was made by a surgeon down to the bone, dividing the perios- 
 teum to the extent of over three inches. Until the wound healed 
 (some eight weeks) he was fairly free from pain, l)ut it at once le- 
 commenced the moment the wound closed. In my consulting room, 
 and witliout an anaesthetic, I put a few drills subcutaneously rigiit 
 through tlie bone. Mr. M. was able to attend his office two days 
 
 y 2
 
 324 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 afterwards, and has not had the least pain since, and is in the 
 enjoyment of perfect health. For this form of affection I ha\e 
 drilled, successfully, most of the long bones, and continue to do so 
 weekly. 
 
 The OS calcis is not uncommonly the seat of a form of gouty ostitis, 
 which does not easily give way to ordinary treatment. I find that half 
 a dozen drills, three inserted obliquely on each side, with a little 
 additional treatment, relieve pain, and soon restore the heel to its 
 normal condition. Allow me here to gi-\"e one instance : — J. C, an 
 auctioneer, a tall, stout, heai'ty-looking man of about 60, had been a 
 great sufferer from pains in both heels, aggravated considerably by 
 M-alking or standing. He had several attacks of gout, and believing 
 these pains to be dependeiit on this affection, resorted to the usual anti- 
 gout treatment, but without much relief. He also tried all kinds of 
 circular pads, etc., endeavouring to take off the weight from the sore 
 spots. In this case, and without an amesthetic, I drilled both heels as 
 described. Mr. C limped away from my rooms, and was able to attend 
 at his office two days afterwards. It is now two years since the bones 
 were drilled, and Mr. C. remains quite free from his old pains. 
 
 In articular ostitis, when from extension of the inflammation or 
 interference with nutrition tlie joint trouble begins to show itself, it is 
 really wonderful what the timely and free application of the drill will do. 
 A case, for instance, that came under my notice, is a good illustration: — A 
 girl, a't. 16, was admitted into Ward 5, under my care, at the Melbourne 
 Hospital. Her history was that nine weeks previously, whilst running 
 after a cow, she slipped and fell somewhat heavily on her hip. She did 
 not feel very much pain at the time, and was able to go about with a 
 limp for several days after her fall. On rising in the moniing, the joint 
 was very stiff, and she was unable to mo^"e it vintil, as she expressed 
 herself, "the hip got warm." At the end of a week, she began to feel a 
 deep-seated pain in the hip, and the pain increased at night time, or 
 rather towards early morning. tShe continued to move abovit, but with 
 increasing difficulty, till the end of the third week, when she took to 
 bed, and the family doctor was called in. Under treatment, she 
 improved to a certain extent, but could not walk without pain, and she 
 was oliliged to take a sedative to i-elie^e the nightly jiains. On admission 
 to the hospital, evidence of liaving gone through pain or trouble was 
 plainly written on her countenance. The left leg was apparently elong- 
 ated and slightly abducted; the limb could be moderately adducted, but 
 this caused pain. There was a form of solid cedema around this hip joint, 
 but superficial manipulation could be borne. However, deep pressure 
 caused pain over tlie trochanter, but not down tlie shaft of tlie femur ; 
 slight fluctuation could be detected in the hip joint. Eight drills wei'e 
 inserted subcutaneously into the trochanter, and two sent along into 
 the neck of the bone. The joint was sulicutaneously opened by a 
 tenotome from beliind, and a rather free cut made into tlie capsule. A 
 4 11). weiglit was attached to the foot in the usual way, and sand bags 
 placed on eacli side of the limb ; the next day, pain had disappeai'ed. 
 In a fortniglit a leather splint was applied, and the patient allowed up. 
 The girl left the institution within a month perfectly well, and is now 
 in good liealth, and walks without the slightest lameness. The same 
 form of treatment equally applies to other joints.
 
 325* INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA.
 
 SUBCUTAXEOUS DRILLING FOR BONK INFLAMMATION. 325 
 
 A sliort account of a knee-joint case may be interesting. The patient, 
 <a stout healthy man, was brought to me by a suburban practitioner, who 
 related the case as follows : — 
 
 Sixteen months previously the man met with a severe injury to the 
 knee joint, caused by falling from a buggy; the joint was very much 
 wrenched and twisted. The parts were greatly swollen for several 
 weeks, and from the description, there must have been considerable 
 synovial effusion. Leeches, fomentations, &c., were applied, and at the 
 end of a few weeks the swelling greatly subsided, and the patient was 
 able to get vip and move about a little. This appeared to make him bad 
 again, and he subsequently had several relapses after each attempt to 
 use the limb. Some six mouths after the accident, the joint seemed to 
 remain lixedly swollen, and a dull acliing pain began to trouble him at 
 night, more particularly in the internal condyle; and as his condition did 
 not impro^•e, he came to town for advice about sixteen months after the 
 injury. On examination, the knee was found to be slightly flexed, and 
 the joint considerably swollen. Fluctuation could not be detected, but 
 the synovial membrane was greatly thickened, and apparently under- 
 going degeneration. The patella was firmly attached to the femur, 
 although it could be slightly moved by using force. Chloroform was 
 administei'ed and Esmarclrs bandage applied, the tourniquet being 
 fastened well up the thigh. The ham-string tendons were first freely 
 divided, and the synovial membrane subcutaneously sliced in several 
 places ; four drills were inserted oblicjuely into the inner condyle, the 
 joint enveloped in antiseptic wool, and a flannel bandage firmly applied 
 over all; the tournit[uet removed, and the limb placed on a posterior 
 splint. In three weeks, Scott's dressing was used, and gentle passive 
 motion tried. The man was under treatment for two months, and 
 returned to the country, and quite recently he wrote, saying that he 
 could use his injured leg just as well as the other. 
 
 The amount of drilling and breaking up that bones will stand, pro- 
 vided it be done aseptic-ally, that is, subcutaneously, is surprising, far 
 beyond what is generally conceived. 
 
 In as few words as possible, I will sum up what I consider to be the 
 great advantages of drilling. The instrument is easy of application, 
 and there is no doubt as to its efllcacy in clu'onic and subacute bone 
 inflammations; the rlieumatic or syphilitic character of the inflamma- 
 tion does not contra-indicate drilling. Its use is absolutely liarmless, 
 and does not prevent further operation, such as an open wound procedure, 
 or repeated drillings. It is based on the correct surgical principles of 
 drainage, stimulation, and asepsis. 
 
 The diagram represents an extension splint I have been in the habit 
 of using for some years, in affections of the knee joint, where steady 
 support and extension ai'e the surgical pi'inciples to be maintained. 
 The framework of the splint is made of veiy light sheet iron, similar to 
 that used in the construction of the ordinary Mclntyre fracture 
 apparatus, only there is no necessity for its being so stout and inflexible. 
 Its parts are arranged as follows : — Fig. I., B to c, are liollow tubes, 
 each containing double spiral spi-ings, as shown in Fig. III. Fig. II. 
 shows a crutch extremity, over one end of wliich is stretched a soft 
 leather band, and the end so made that it can glide easily into tlie first 
 mentioned tubular portion of the splint, viz., B to c in Fig. I, and B in
 
 326 INTEKCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA, 
 
 rig. III. The crutch can be transferred from one side to the other, 
 according to the limb atiected. Fig. III. indicates the position of the 
 springs, the screws which maintain their compression, and the index by 
 which, when the splint is adjusted, the amount of extension can be 
 registered. 
 
 One of the advantages of this simple apparatus is that the patient can 
 sit up, and thus tlie irksomeness of continement to bed becomes shorn 
 of half its monotony. The lightness of the apparatus is another 
 circumstance in its favour ; the invalid can be removed from bed to a 
 wheel-chair with very little exertion on the part of the nurse. More- 
 over, the apparatus permits of the knee joint being examined — 
 synoviotomised, tenotomised, drilled, or whatever may be required — with 
 scarcely the shifting of a single bandage. In this countxy, it is well 
 known that scrofulous articular affections are less frequent than at home ; 
 consequently, the tield for surgical practice in this direction is rather 
 limited, compared with the experience obtainable in any large town in 
 the old country. Nevertheless, a large number of joint disorders do 
 come under our notice, and I generally find that with the extension this 
 splint affords, and free section of the synovial membrane and drilling, 
 the results ai'e good. If these cases come under observation at anything 
 like a reasonably early stage, they can inevitably be brought to a 
 happy issue ; this much I can say, that I have not had to am])utate a 
 leg for disease of the knee for some years. 
 
 To apply the splint, the crutch end is first inserted into the tube 
 fitted for its reception ; the same with the portion a. Fig. I., and the 
 part B c. The spiings are then forcibly compressed, and retained by 
 their respective screws. The foot piece is next adjusted, and the splint 
 lengthened or shortened in such a manner that when the leg is laid on 
 the framework, the leather band of the crutch comes well up into the 
 foi'k, and bears just comfortably on the descending ramus of the pubes ; 
 the appliance of course requires padding. The foot should be nicely 
 strapped to the foot piece, and tlie whole splint, excepting from c to A, 
 attached to the limb with adhesive plaster and a bandage. When the 
 two separate parts of the splint have been nicely and firmly adjusted to 
 the leg, the screws are let go at c, and tlie desired tension is exerted on 
 the joint. 
 
 A CASE OF CLEFT PALATE. 
 
 By T. N. FitzGerald, F.R.C.S.L 
 
 Senior Surgeon to the Melbourne Hospital. 
 
 John G., xt. l-t, was admitted to the Melbourne Hospital al)Out ten 
 weeks ago with cleft of the soft palate. On admission, he spoke with the 
 usual guttural and nasal twang, but much pronounced. 
 
 He was operated upon a few days after admission — six sutures were 
 inserted, immediate union took jihico, the uvuha was well formed, and 
 in fact at present the line of incision is hardly [)erceptible, as you may 
 see.
 
 327* INTERCOLONIAL MEMCAL CONGRESS OF AUSTRALASIA. 
 
 A B
 
 A CASE OF CLEFT PALATE. 327 
 
 The reason for brinjjing this case under your notice is, to illustrate the 
 great advantages to be derived fi'om massage after such ojjerations. 
 
 In this instance when the parts were tirni, some tln-ee weeks after the 
 operation, the pahxte was massaged by one of the students under the 
 supervision of Dr. F. D. Bird. The improvement in the lad's speech 
 was very marked ; he now speaks Aery well, as you can hear, and liis 
 articulation is daily improving. I am sure the massaging has greatly 
 helped to improve the muscles of the palate. 
 
 An engraving is shown of the needles employed in this case, and 
 which I have been in the habit of using for some years. 
 
 It is universally acknowledged, that the introduction of the sutures is 
 the most troublesome iiart of the operation. However, by the use of 
 the.se needles, this diihculty is in a great measure overcome. They 
 are thus employed : — The thread is inserted into the slot shown 
 at A, which is cut into the upper side of the needle (by an error, the 
 engraver has made it appear as if the slot for carrying the thread was 
 on the lower side, and on the upper for withdrawing the needle, the 
 reverse is the case), and thus armed, its point is introduced in the 
 ordinary manner through the palate on the child's right, that is, with 
 the surgeon's left hand. The needle B, which is slotted on the lower 
 edge, is entered on the opposite side, and when behind the cleft, is partly 
 rotated in such a way as to catch and hold the thread from the other 
 needle, which is pulled through as the needle is withdrawn. 
 
 These needles require to be very carefully made, the notch being 
 deep and yet only just wide enough to admit fine thread. This of course 
 may be used to afterwards draw through any suture material desired. 
 By the aid of these needles, I have on several occasions been able to 
 complete the whole opei-ation, from the time the chlorqformist has 
 signified that everything was ready, to the fastening of the last stitch, in 
 fifteen minutes. In the case of this boy, I believe the operation was 
 completed in somewhat under that time.
 
 328 INTERCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 HYDATID DISEASE. 
 
 A General Meeting of the Congress was held in the Wilson Hall, on 
 Wednesday, January 9th, at 11 a.m., when papers were submitted, and 
 a discussion held concerning Hydatid Disease in Australasia. The 
 chair was occupied by Dr. E. C. Stirling, President of the Section 
 of Surgery. 
 
 In opening the proceedings, the Chairman said : — As our President 
 told us the other day, and as the President of the last Congress told us, 
 there are not many questions on which we in Australia can offer advice 
 or instruction to our teachers and masters of the old coiintry, but if 
 there is one subject in which we may ourselves take up the position of 
 teachers, it is in the matter of Hydatid Disease. 
 
 The following papers were then submitted :— 
 
 HYDATID DISEASE. 
 By John Davies Thomas, M.D. Lond., F.R.C.S. Eng. 
 
 Joint Lecturer on Medicine at the University of Adelaide. Physician to the 
 
 Adelaide Hospital. 
 
 The Geographical Distribution of Echinococcus Disease. 
 
 Probably, no known parasite has so extended a geographical 
 distribution as echinococcus enjoys ; for it is generally found to 
 exist, with greater or less frequency, wherever man and his faithful 
 friend and companion, the dog, are associated. Up to the present time, 
 trustworthy statistics, showing its prevalence in most of the civilised 
 countries of the world, are conspicuous by their absence. How scanty, 
 the published data upon this subject are, is clearly indicated by the 
 brief space allotted to this disease in Hirsch's admirable "Hand-book 
 of Geographical and Historical Pathology," a translation of which has 
 been published by the New Sydenham Society. Enough, however, is 
 known, to prove that echinococcus flourishes vnider almost all climatic 
 conditions, for it has been met with in Europe, Asia, Africa, North and 
 South America, and in all the colonies of Australasia ; whilst chilly 
 Iceland and sunny Australia vie with each other in offering this 
 unwelcome immigrant a congenial home. 
 
 Ilijdatid Disease in Europe. 
 
 There is probably no country in Europe in which at least the 
 occasional presence of echinococcus has not been noticed, but its 
 frequency i-anges within very wide limits. In Iceland, it is so frequent 
 as to constitute a national calamity ; in tlie northern parts of 
 Mecklenburg, too, it occurs witli unusual frecjuency. 
 
 When engaged a few years since in an enquiry into the geographical 
 distribution of hydatid disease, it seemed to me that the most reliable
 
 HYDATID DISEASE. 
 
 329 
 
 sources of information would be, (1) the official returns of the causes of 
 death in tlie various countries, and (2) the hospital statistics, especially 
 as regards their in-patients. It is obvious that, at best, the data 
 supplied from these sources can be but approximate, still they may serve 
 for the purposes of a general comparison. Unfortunately, however, 
 the available facts are but few at present. 
 
 Great Britain. 
 
 Cobbold ("Parasites, a Treatise on the Entozoa of Man and 
 Animals ") refers to the defective evidence supplied by the returns of 
 the Registi-ar-General in respect to deaths from this disease, and he 
 points out that the blame should be attached, not to the department 
 under the conti'ol of that officer, but to those who supply the certificates 
 of the cause of death. 
 
 In the table appended, there appear the number of deaths in. 
 England and Wales which wei'e attributed to hydatid disease during 
 the sixteen years preceding 1887. 
 
 Table I. — Table shoivlng the dumber of Deaths returned as due to 
 Hydatid Disease in Ungland and Wales from 1871 to 1886 
 inclusive : — 
 
 Year. 
 
 Males. 
 
 Females. 
 
 Total. 
 
 Total Deaths 
 
 FROM ALL causes. 
 
 1871 
 
 
 
 37 
 
 514,879 
 
 1872 
 
 — 
 
 — 
 
 41 
 
 492,265 
 
 1873 
 
 
 
 
 34 
 
 492.520 
 
 1874 
 
 — 
 
 — 
 
 29 
 
 526,632 
 
 1875 
 
 — 
 
 — 
 
 43 
 
 546,453 
 
 1876 
 
 13 
 
 18 
 
 31 
 
 510,315 
 
 1877 
 
 — 
 
 — 
 
 .51 
 
 500,496 
 
 1878 
 
 28 
 
 31 
 
 59 
 
 539,872 
 
 1879 
 
 22 
 
 29 
 
 51 
 
 526,2.55 
 
 1880 
 
 21 
 
 39 
 
 60 
 
 528,624 
 
 1881 
 
 23 
 
 28 
 
 51 
 
 491,935 
 
 1882 
 
 36 
 
 23 
 
 59 
 
 516,654 
 
 1883 
 
 25 
 
 28 
 
 53 
 
 522,997 
 
 1884 
 
 30 
 
 29 
 
 59 
 
 530,9-28 
 
 1885 
 
 21 
 
 25 
 
 46 
 
 522,750 
 
 1886 
 
 24 
 
 34 
 
 58 
 
 537,276 
 
 They amount to 762 deaths attributed to hydatid disease amongst 
 8,300,751 deaths from all causes, or 1 in every 10,893 — in round 
 numbers, say 11,000 — deaths from all causes. 
 
 The average annual deaths recoi'ded from this disease amounted only 
 to 47 "6. It is quite certain, however, that these returns greatly 
 understate the fi-ecjuency of this disease in England. This lias 
 been already remarked upon by tlie late Dr. Cobbold (" Parasites," 
 p. 285) who stated his conclusions as follows : — " As regards hydatids, 
 I believe the returns to be excessively deficient. In place of an 
 average of thirty-four deaths annually from this cause in the United 
 Kingdom (sic), I am of opinion, that at least four hundred deaths are
 
 S30 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 due to hydatids. This opinion, and the data on which it was founded 
 were communicated by me twelve years ago to the Linnean Society, 
 and I have since become acquainted with facts which lead me 
 to conclude that my original estimate was very mucli below the mark. 
 The post-mortem registrar of one of our large hosjDitals has told me 
 that of late years as many as ten deaths might be reckoned as annually 
 due to hydatids in their institution alone. In a smaller hospital, I 
 ascertained that the average was about four. Obviously, if these 
 estimates are correct, the Registrar-General's returns for the United 
 Kingdom do not record a tithe of the annual mortality due to 
 hydatids." 
 
 From enquiries which I have prosecuted independently, by means of 
 the Hospital statistics of some of the principal London institutions, I 
 can strongly confirm the statements of Cobbold. I have been able to 
 examine the statistics of several London hospitals for many years ; the 
 chief data appear in the table attached. In the London hospital, 
 during the five years, 1876-81, twenty-four cases were treated, amongst 
 a total of 13,297 medical in-patients. 
 
 Cases of Hydatid Disease treated in certain London Hospitals :- 
 
 Name of Hospital. 
 
 Period over which the 
 Returns Extend. 
 
 Number of Total Number of 
 Hydatids. In-Patients Treated. 
 
 St. Thomas' 
 
 St. Bartholumew's . . 
 
 St. George's . . 
 
 Middlesex 
 
 University College . . 
 
 11 jears 
 21 ,. 
 13 „ 
 
 12 „ 
 11 „ 
 
 44 t 34,559 
 108 1 115,402 
 22 45,599 
 29 19,570 
 26 ' 25,322 
 
 
 
 229 240,452 
 
 From the above table, based upon nearly a quarter of a million of 
 in-patients treated in these hospitals, it may be roughly estimated that 
 not more than one oi\t of each 1000 suftered from hydatid disease, at 
 any rate so as to render it their principal complaint. But it must be 
 remembered that where post-mortem examinations are performed 
 regularly, as in many hospitals, it is common to discover hydatids, the 
 presence of which had been unsuspected during life. For example, 
 Murchison ("Clinical Lectures on Diseases of the Liver," third edition, 
 1885, foot-note to p. 55), states that "Out of 2100 post-mortem 
 e.xaniinations recorded at the Middlesex Hospital between April 19, 1853, 
 and August 25, 1809, hydatids were found in only thirteen, or once in 
 161 cases ; and in only seven of the thirteen cases, or once in 300 cases, 
 "W'ere they the cause of death." A similar statement was made in 1869, by 
 Dr. W. Ogle, at a meeting of the Royal Medical and Chirurgical Society, 
 when he remarked that, " Cases of hydatids were vei-y rare ; in 3000 
 records of post-mortem examinations at St. George's Hospital, in 
 eighteen only had he found notice of hydatids, wljich were the cause 
 of death in six cases only. — [British Medical Journal, April 24, 1S69 ; 
 p. 387.) 
 
 In certain parts of England, however, the disease appears to occur 
 more often — for example, in Canihridgeshiro, for Dr. Bradbury writes
 
 HYDATID DISEASE. 
 
 331 
 
 that " Hydiitid disease is not uncoinnion in Cambridgeshire, i)robably 
 owing to the quantity of surface-water drunk, in wliich sheep-dogs have 
 deposited the ova of taenia echinococcus. During the last few years, I 
 have seen ten or twelve cases of hydatids of the liver, and I have 
 noticed that when cases have occurred elsewhere, many of the ])atients 
 have at some time resided in Cambridgeshire." — (I!7'ittsh Medical 
 Journal, October 6, 1877 ; p. 472.) 
 
 In Scothxnd, hydatids seem to be met with even less frequently than 
 in England, for L)r. Scott Orr (Glasr/ow Medical Journal, January 1876), 
 lias searched the records of the lloyal Infirmary, Glasgow, from the 
 eai'liest periods, but has only found three cases — one in the mamma, and 
 two in the liver. Dr. Clairdner also states ("Clinical Medicine," p. 431), 
 that among many thousand dissections, which he had either |)erformed, 
 or seen performed, during his connection with the Edinburgh Royal 
 Infirmary, in only one instance had a hydatid been found in any part of 
 the body, and it was in the upper part of the right lung. The patient 
 also apparently came from Newcastle. 
 
 As regards the Continent of Europe, great variations in the frequency 
 of the disease appears to prevail, but for the most part it cannot be 
 regarded as a common complaint ; an exception to this rule exists, how- 
 ever, in the case of Mecklenburg. To this, allusion will be made 
 hereafter. 
 
 Germany and Austria-HuiKjanj. 
 
 The official returns of the causes of death for these countries, and 
 indeed for the whole of Europe, have not been accessible to me. The 
 only data are those procured from the published statements relative to 
 the number of cases treated in the principal hospitals, and the revelations 
 of their autopsies. In the case of most of these institutions, I am 
 indebted to the writings of Neisser ("Die Echinococcen-Krankheit," 
 Von Dr. Albert Neisser, Berlin, 1877), and of Madelung (" Beitriige 
 Mecklenburgischer Aerzte zur Lehre von der Echinococcen-Krankheit," 
 Madelung, Stuttgart, 1885). The returns for the huge K. K. Kranken- 
 haus, of Vienna, were kindly ]irocured for me Viy Professor Schroetter. 
 The statistics for the Augusta Hospital, Berlin, were obtained from 
 Berger(" Inaug. Dissert." Berlin, 188o — see also, "Yirchow and Hirsch's 
 Jahresbericht," 1885, Vol I., page 315). 
 
 Table II. — Table shoivivg the Number of Cases Treated for Hydatid 
 Disease in Certain Places : — 
 
 Place. 
 
 Berlin (Augusta Hospital) , 
 
 Leip^ic 
 
 Breslan 
 
 Nuremburg , . 
 
 Hamburg 
 
 Wurzbiu'g . . 
 
 Jena . . 
 
 Vieuua 
 
 Cases of 
 Hydatids. 
 
 14 
 11) 
 20 
 
 none 
 
 none 
 
 rare 
 
 annually 
 
 03 
 
 Total Number 
 
 OF Patients 
 
 Treated. 
 
 85,062 
 lo.SOO 
 18,000 
 10,000 
 
 232,336 
 
 Period over 
 
 WHICH Returns 
 
 Extend. 
 
 1875-1885 
 1852-1869 
 
 187'1-1884
 
 332 
 
 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA, 
 
 It will be seen, both from the table of cases treated, and the table of 
 the results of the post-mortem examinations, that over Gei-many and 
 Austria-Hungary generally, echinococcus is not common; but in two 
 places in Northern Germany, viz., Greifswakl, and especially in Rostock, 
 the disease caused by it is more frequent ; indeed, so far as is now 
 known, hydatid disease is more common in the northern parts of 
 Mecklenburg than anywhere else in Europe, except in Iceland. This 
 fact has not escaped the attention of physicians in that country, for 
 under the auspices and supervision of Professor Madelung, of Rostock, 
 an elaborate investigation was entered into, with the view of ascertain- 
 inof the extent of this affection in Mecklenburg, and its local causes. 
 The enquiry has resulted in the publication of a very interesting and 
 valuable volume. The conclusion arrived at is that " Echinococcus 
 disease occurs in Mecklenburg very much more frequently than in the 
 rest of Northern Germany, and in the neighbouring Scandinavian 
 countries." — (Madelung, op. cit., page 24). 
 
 Table III. — Table showing the Number of Cases in ivhich Hydatid Cysts 
 loere Discovered during the Performance of Post-mortem Examinations 
 in certain Places : — 
 
 Norway and Sweden. 
 In Norway this disease is rare, for Oscar Bloch ("Virchow and Hirsch's 
 Jahresbericht," 18S2, Vol. I., page 309) reports a case recorded by 
 Rolfsen, of subcutaneous hydatid of the back ; the case had a special 
 interest, " because it is the only example of echinococcus in a native- 
 born person in Norway." 
 
 Denmarlc. 
 Krabbe reported to Madelung (in a communication, dated November 
 16, 1884, op. cit., page 23), "that in Denmark, echinococcus disease 
 only rarely occurs; and, so far as he knew, it was not more frequent in 
 any one part of that country than in the rest. In the hospitals of 
 Copenhagen, perhajis, hardly one case yearly appeared." 
 
 Iceland. 
 Tliis counti'y has long had the unenviable fame of being tliat in 
 which echinococcus causes its worst ravages, both in man and beast.
 
 HYDATID DISEASE. 333 
 
 Krnbbe, who was deputed hy the Danish Go\erunient to investigate 
 and report upon the subject, pu1)lished the results of his enquiry iu 
 1866. He states that it was only for about a century past that a body 
 of properly educated medical men had existed in Iceland ; nevertheless, 
 there was good reason for Ijelie^ing that this disease had been as 
 prevalent for centuries past in Iceland as it was known to be at the 
 time of his visit. Schleisner, who travelled in this country in 1847-48, 
 seems to have been the first writer who clearly recognised the true 
 natui'e of the disease, for he remarks that "it is a disease caused by 
 entozoa, which develop not only in the liver, but also in the whole 
 organism." The subject was afterwards more closely investigated by 
 Eschricht in 1853. 
 
 Very varied accounts have been gi\en by different writers as to the 
 prevalence of the disease. Thus Schleisner stated, " tliat among the 
 "2600 sick who appeared in the medical reports, there were 328, or about 
 one-eighth ; and among the 327 under his personal care, fifty-seven, or 
 moi-e than one-sixth, in whoni the liver was attacked by hydatids." 
 Thorstensen, who practised in Iceland for more than twenty years, 
 estimated that one-seventh of all the inliabitants had the disease. 
 Gerault, who wrote in 1857, remarks that the official returns supplied 
 to the Danish Government showed that not less than one-fifth of the 
 entire population was infested with echinococcus. Eschricht's estimate 
 was one-sixth. Other authorities regard these estimates as too high. 
 Thus Finsen, who paid especial attention to this matter from 1857 to 
 1862, recorded that in the district of Ofjord, whei'e he resided, and 
 which had a population of about 4500 inhabitants, he treated on an 
 average 596 persons per annum, of whom sixteen, or about one thirty- 
 eighth, were cases of hydatid disease ; and he was acquainted in this 
 district with seAenty-seven living persons who had then, or who had 
 had, this complaint, i.e., one fifty-eighth of the entire population. In 
 the district of Tliingo, which reckoned 5500 persons, the proportion of 
 hydatids to other cases of disease was one to twenty first ; and there 
 Finsen knew forty-two persons attacked by this parasite, or one one- 
 hundredth of the district population. 
 
 Dr. J. Hjaltelin (" Reports on the Progress of Practical and Scientific 
 Medicine in Different Parts of the World," edited by Horace Dobell, 
 M.D. ; London, 1869, p. 287), the late chief physician of Iceland, wrote 
 in 1869: — "That tlie endemic echinococci are very frequent in this 
 country, both in men and domesticated animals, especially in sheep, is 
 uncjuestionable ; but their statistical frequency cannot, at present, be 
 stated with any reliable certainty. The late chief physician of this 
 island. Dr. Thorsteinson, who had paid a good deal of attention to this 
 subject during his long career as the chief medical officer of Iceland, 
 held that about every sixth or seventh of all the Icelanders were affected 
 with echinococci. One physician still practising, living in the north 
 part of this country, Dr. Skaptason, who has practised there during a 
 period of more than thirty years, is of the same opinion. The third 
 district physician, who has served for thirty-two years, viz., Dr. 
 Thoraensen, and made himself famous by treating some cases of hydatids 
 with electricity, fully agrees with the aforesaid opinion of Dr. Thor- 
 steinson on the subject. I myself feel inclined to the same opinion, 
 although Dr. J. Finsen holds a \ery different view ; for, from his nine
 
 334 IXTKRCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 years' experience, he says that out of 7539 cases of disease treated by 
 him, 280 were echinococci, or one in 26 '9. This, I think, is ratlier too 
 low, althougli at present it is, for the want of liospitals, very difficult 
 to obtain any statistical proof on this question. According to the 
 results of many autopsies made here in Reykjavik during the last ten 
 years, hydatids have been found in every sixth body. Tliis, however, 
 is no conclusive proof of the frequency of this chronic malady, for many 
 have died from hydatids who were not examined ; although, on the 
 other hand, echinococci have been fovmd in some dead bodies where 
 they were not known to exist during life. Of all the cases treated in 
 our hospital this year, nearly every lifth has been a case of echinococci, 
 either external or internal ; and of the many cases treated by myself 
 during the last two years, even moi'e than one-tenth have been echino- 
 cocci." 
 
 Even allowing for tlie discrepancies in these various estimates, tlie 
 main fact stands out clearly, viz., that there is in this country a most 
 extensive endemic distril^ution of this dangerous parasite. 
 
 Sioitzerland. 
 
 The disease here appears to be of only occasional occurrence, for in 
 Zurich Lebert found, among two hundred autopsies, no example of 
 echinococcus. In the face of this, it is a remarkable circumstance that, 
 out of thirty-live cases of multilocular ulcerating hydatid collected by 
 Klebs, Marie Prougeansky, and Morin, no fewer than nineteen had 
 been found in Switzerland. 
 
 France. 
 
 Judging from the great number of Paris graduation theses in which 
 various aspects of this disease are discussed, liydatid disease cannot be 
 very rare in some parts of France ; Ijut I know of no statistics bearing 
 upon this point. Davaine (" Traite des Entozoaires," 1877, p. 389) 
 quotes Leudet, who gave it as his exjjerience that hydatids were more 
 connnon in Rouen than in Paris. Out of nearly two hundred autopsies 
 performed by Leudet at the Surgical Clinique at Rouen, hydatids were 
 present in six cases. During six years of service as interne at Paris, a 
 far smaller proportionate number of hydatids came under his notice. 
 
 Itali/^ Spain, and Russia. 
 
 The disease is occasionally observed in these places, but no published 
 .accounts of its prevalence exist, as far as I have been able to ascertain. 
 
 Africa. 
 
 As regards our knowledge of disease in it, Africa well deserves its 
 cognomen of " The Dark Continent," for, with rare exceptions, we know 
 notliing of the diseases which devastate its dusky multitudes. The only 
 countries of which we possess some slight information in regard to the 
 occurrence of this disease (hydatid) in the continent of Africa, are 
 Algeria, Egypt, and Cape Colony. 
 
 A Igeria. 
 
 The French military surgeons, serving in this country, have frequently 
 observed hydatids, Ijoth in the French soldiers and in the natives of the
 
 ]IYDATID DISEASE. 335 
 
 land. Dr. Vital met with a dozen instances in the hospital of Con- 
 stantine. — (" Davaine," op. cit., ]). 389). Laveran (cited in " Virchow 
 and Hirsch's Jahresbericht," 1885, Vol. II., p. 13C), cites four cases of 
 hydatid cysts of the lungs, all of which caine from Algeria, where the 
 disease is common, in consecjuence of the number of dogs which often 
 share the dwellings of their masters. 
 
 Egypt. 
 Bilharz met w'ith three cases of hydatid of the liver in this country. 
 
 Cupe Colony. 
 In the official Blue Book for 1884, four cases of hydatid of the liver, 
 and in that for 1885, six cases in the same organ, are recorded as having 
 been treated in the public liospitals of the colony. It may therefore be 
 concluded that it at any rate occasionally appears here. 
 
 America. 
 
 Davaine remarks that hydatids " are ver}' i^are in the United States," 
 and adds that Leidy, in his " Synopsis," mentions but two cases of this 
 kind — one, which occurred in the son of an English sailor, and a second 
 in a Frenchman. 
 
 In reply to an enquiry made by me, the Secretary of the National 
 Board of Health, writing under date, Washington, February 13, 1882, 
 re])orted that the only information I'especting hydatid disease in 
 America, procured up to that date, was that supplied by Dr. Morris 
 Longstreth, Physician and Pathologist to the Pennsylvania Hospital, 
 Philadelphia. Dr. Longstreth referred to three specimens in the 
 museum of the Pennsylvania Hospital, all of which came from 
 foreigners; "neither of them had been in our country long, and they 
 spoke the English language very imperfectly." 
 
 Dr. \V. Osier, formerly of Montreal (•' On Echinococcus Disease in 
 America," by William r)sler, M.D., M.Pi.C.P. London, in the American 
 Journal of the Medical Sciences, October 1882), has carefully investigated 
 the subject of hydatid disease in America. He states that " in this 
 section of the country it is rarely met with, and in the inspection of over 
 eight hundred bodies, only three instances have been found." From 
 various sources in America, including museums, journals, transactions, and 
 private sources, Dr. Osier has succeeded in collecting sixty-one cases of 
 echinococcus disease ; but he remarks, " unfortunately, we cannot say 
 positively how many of these cases were truly American, i.e., originated 
 here, and how many were imported ; but in sixteen, it is stated that 
 the patients were Eurojiean. In the majority, the nationality was not 
 given, but in all probability at least one-third of the cases were imported, 
 leaving only about forty native cases. This immunity may he due 
 either to scarcity of the adult worm, or to the absence of conditions 
 favourable to tlie infection of man. The tcenia echinococcus is certainly 
 a rare parasite. In some scores of dogs, which I have examined during 
 the past fifteen years, I have never met with a specimen, nor do I know 
 of its detection by any American observer." As Dr. Osier remarks, it 
 is probably present in the dogs to a greater extent than might be 
 supposed from the facts just mentioned, for echinococcus cysts are by no 
 means rare in the lower animals in America.
 
 336 IXTERCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Meocico. 
 It must occasionally appear in tins country, for Semeleder reports in 
 "Virchow and Hirscli's Jaliresbericht," for 1880, a case of hydatid of 
 the liver ; punctured ; died ; post-mortem examination. 
 
 Asia. 
 The only Asiatic lands relative to which we possess any information 
 bearing upon the prevalence of hydatid disease, are Ceylon and British 
 India. 
 
 Ce>/Ion. 
 
 As the result of an enquiry, made in the year 1885, I am able to 
 state on the authority of Dr. W. R. Kynsey, the principal medical 
 officer of the colony, that " there is absolutely no hydatid disease in this 
 country. I have gone carefully over the hospital post-mortem books, 
 and am unable to trace any cases of disease in connection with hydatids, 
 and our post-mortem examinations are most carefully made." During 
 the twenty-two years, 1863 to 1884 inclusive, the number of deaths 
 registered in the colony was 1,109,724, and not one was from 
 echinococcus. 
 
 British India — Province of Madras. 
 Dr. G. T. Thomas has kindly investigated the records of the Madras 
 General Hospital for many years past, and could find only five cases of 
 hydatid disease among the vast number of patients, native and Eui'opean, 
 that have been treated within its walls ; of these, four were Europeans, 
 and one a Hindu. As regards the organs invaded — two were in the 
 liver, two in the lungs, and one in the right ventricle of the heart. One 
 of the " Europeans " was an Australian jockey. Surgeon Sturmer, who 
 had been ten years in Madras, and was also Secretary to the Surgeon- 
 General, had seen only two cases — one in a European woman, the other 
 in a native woman. Dr. Thomas adds, " Hydatid disease is said, by all 
 of the profession, to be very uncommon in the Presidency, or this part 
 of it. The returns from the out-lying dispensaries show hydatids as 
 occurring seldom, if ever ; they may, of course, have occurred, and been 
 returned under headings of other diseases." It is curious, that while 
 hydatid disease is so rare in man in this part of India, it is yet common 
 in the domestic herbivoi'a. Thus, James Mills, Esq., Inspector of Cattle 
 Diseases of the Army Veterinary Department, in the Madras Presidency, 
 wrote to me that, " echinococcus veterinorum is most common in 
 Madras ; and at the slaughter-houses, the cysts found in the livers of 
 sheep can be coiuited by hundreds daily ; as far as I have seen, they are 
 not so common in cattle." 
 
 The Presidency of Bengal. 
 Here, as in Madras, echinococcus is very I'are in man. In the 
 Medical College Hospital, between May 1866 and the end of 1884, 
 there were treated as in-patients, 21,043 male Europeans, but among 
 them, no case of this disease. During the years 1876 to 1884, inclusive,, 
 11,873 male natives were treated, also with no case of hydatids. 
 Finally, out of 13,504 women (native and European) admitted between 
 April 1878 and the end of 1884, only one case of hydatids occurred. In 
 the catalogue of the museum of the Medical College Hospital, Calcutta,,
 
 HYDATID DISEASE. 337' 
 
 there are four specimens of hydatid of the liver; one only of these died 
 at the hospital — two of these certainly came from Europeans. J)r. 
 D. Cr. Crawford, to whom I am indebted for much information relative 
 to this subject, in Bengal, also e.xamined the post-mortem books of the 
 Medical College Hospital, with the following results : — Surgical cases 
 from October 8, 1873, to June 26, 1884, 498 cases, no hydatids; 
 medical cases, from Se))tember 29, 1873, to January 1, 1885, 1836 cases, 
 with one hydatid — this was in a Hindu male. In another large 
 hospital in Calcutta, viz., tlie Mayo Native Hospital, during the years 
 1876 to 1880, inclusive, one case of hydatid of the liver was treated. 
 The Presidency European General Hospital, Calcutta, founded about 
 1780, contains a little over 200 beds, but retuinis only one case of 
 hydatid disease. 
 
 The North-West Provinces and the Punjauh. 
 Surgeon-General S. C. Townseud, C.B., reported in 1882, that — "no 
 hydatid diseases have ever l)een recorded at Amritsar or Peshawur." 
 At Lahore, however, four cases of echinococcus in natives were met 
 with between the years 1863 and 1881. From the Delhi Civil Hospital, 
 Eamkiishen (Assistant-Surgeon) reported — •" No cases of hydatid cyst 
 have been observed in this hospital, either in the wards, among the out- 
 patients, or in the post-mortem room." 
 
 The Bomhay Presidency. 
 
 Dr. Hatch, Surgeon to the Jamsetjee Jeejeebhoy Hospital, has kindly 
 sufjplied me with the following facts : — In the hospital referred to, 
 during the years 187r) to 188.3, inclusive, 70,254 in-patients were 
 treated, with one case of hydatid disease-— in a man, who died after an 
 operation by puncture. In the Goculdas Jeypal Hospital, Bombay, 
 during the years 1874 to 1884, inclusive, 22,873 in-patients were under 
 treatment ; among them were two cases of echinococcus disease — one in 
 the liver, the other connected with the bladder. 
 
 From the preceding data, it will be seen that throughout the whole of 
 India, echinococcus is rare in man; this is remarkable, inasmuch as the 
 jiarasite is very connnon in the domestic herbivora, at any rate, in some 
 parts of India. 
 
 Hydatid Diseases in the Colonies of Australasia. 
 It has long been known that hydatid disease is very common in some 
 parts of Australia, and references have been made to its prevalence by 
 various writers. For instance, so far back as April 1861, Di-. R. F. 
 Hudson remarked that hy'datids were becoming common in Melbourne, 
 and he "ventured to predict that hydatids would become of frequent 
 occurrence in Australia." Subsequent experience has proved the sound- 
 ness of Dr. Hudson's judgment. The principal sources of information 
 here, as in Europe, are the hospital statistics and the bills of mortality. 
 
 Victoria. 
 I am indebted to the kindness of Mr. H. H. Hayter, the Government 
 Statist of Victoria, for a complete record of the number of deaths, 
 registered as due to hydatid disease, for the past twenty-five years. 
 They appear in Table IV. It will be observed, that 901 cases of death 
 from this cause have been registered during the period in question ; of 
 
 z
 
 338 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 these, 509 occurred in males and 392 in females. The percentage of the 
 total mortality, attributable to echinococcus disease, varied in different 
 years from 0-152 in 1871 to 0495 in 1879, the average being 0-323. 
 There has been a gradual increase in the numVjer of deaths from this 
 cause. This is well seen, if we compare the five quinquennial })eriods 
 embraced in the past quarter of a century : — 
 
 Fh-st quinquennium 18fi3-1867 79 cases 
 
 Second „ 1868-1872 116 „ 
 
 Third „ 1873-1877 191 ,, 
 
 Fourth „ 1878-1882 251 „ 
 
 Fifth „ 1883-1887 264 „ 
 
 901 „ 
 The increase in the number of deaths registered from hydatid disease, 
 is probably due to several causes, viz. :—(l) The population of the 
 colony has grown rapidly, for example : — 
 
 Estimate.! population in 1865 621,095 
 
 1875 791,399 
 
 „ „ 1885 991,869 
 
 But this, alone, cannot explain the increase in the number of deaths 
 attributed to echinococcus, for in the fifth quinquennium there were 
 more than three times as many deaths registered (from this cause) as in 
 tlie first quinquennium ; but the population, meanwhile, had increased 
 only by a little more than one-half. It is evident, therefore, that other 
 causes contribute to increase the number of deaths registered from this 
 disease. (2) Probably the disease is becoming better known, both to 
 the general j)ublic and the medical jjrofession ; and thus, deaths due to 
 it are more frequently recorded correctly. (3) There is reason to feai- 
 that the disease is actually more prevalent than formerly. 
 
 As might have been expected, a considerable proportion of the deaths 
 from this cause occurred in the hospitals of the colony. From data 
 courteously supplied by Mr. Hayter, it appears that more than one-third 
 of the deaths from hydatid disease, during the ten years 1872 to 1881 
 inclusive, took [jlace in the hospitals. 
 
 Hospital /Statistics. — As the result of an extensive enquiry made in 
 the year 1880 (for details, see "Hydatid Disease, with Sjiecial Reference 
 to its Prevalence in Australia," by J. Davies Thomas, M.D., Adelaide, 
 1884), over 1000 cases were found to have been treated in the hospitals of 
 the colony. Taking the gross results, it was ascertained that about one, out 
 of one hundred and seventy-five of all cases admitted into the Victorian 
 hospitals, was a case of tliis disease. In the following hosintals, during 
 the period over which their returns extended, there were said to have 
 been no cases of echinococcus treated, viz.: — Belfast, Mansfield, Swan 
 Hill, Maldon, Portland, and Warrnambool. The highest i)roportion of 
 cases was found in the Alexandra, Wood's Point, Horsham, and Sand- 
 liurst Hospitals; but as the three first-named hospitals had only a small 
 numljer of in-jiatients under treatment, but little weight can be attached 
 to their apparently liigh proportion of hydatids. Tlie case, however, is 
 different as regards Sandliurst ; where, during the twenty-two years over 
 which the returns extend, there were treated as in-patients 14,058 
 persons, including one hundred and fourteen cases of hydatid disease, 
 being at the rate of about one to every one hundred and twenty-three 
 in-patients treated.
 
 HYDATID DISEASE. 
 
 339 
 
 Table IV. — l\ible shoivini/ the Nimiher of Persons of each Sex that Died 
 in Victoria, from Hydatid Disease, during the Twenty-five Years, 
 1863 to 1887 inclusive: — 
 
 
 
 
 
 Percentage of Total Deaths 
 
 Year. 
 
 Males. 
 
 Females. 
 2 
 
 Total. 
 
 Caused bv Hydatid Disea.se. 
 
 1863 
 
 3 
 
 5 
 
 _ 
 
 1864 
 
 6 
 
 3 
 
 9 
 
 — 
 
 1865 
 
 9 
 
 6 
 
 15 
 
 . — 
 
 1866 
 
 18 
 
 7 
 
 25 
 
 — 
 
 1567 
 
 13 
 
 12 
 
 25 
 
 — 
 
 1868 
 
 •21 
 
 12 
 
 33 
 
 0-329 
 
 1869 
 
 12 
 
 10 
 
 22 
 
 0-208 
 
 1870 
 
 10 
 
 7 
 
 17 
 
 0-164 
 
 1871 
 
 6 
 
 9 
 
 15 
 
 0-152 
 
 1872 
 
 24 
 
 5 
 
 29 
 
 0-269 
 
 1873 
 
 17 
 
 12 
 
 29 
 
 0-253 
 
 1874 
 
 20 
 
 21 
 
 41 
 
 0-336 
 
 1875 
 
 25 
 
 22 
 
 47 
 
 0-308 
 
 1876 
 
 23 
 
 13 
 
 36 
 
 0-266 
 
 1877 
 
 24 
 
 14 
 
 38 
 
 0-298 
 
 1878 
 
 17 
 
 20 
 
 37 
 
 0-291 
 
 1879 
 
 29 
 
 31 
 
 60 
 
 U-495 
 
 1880 
 
 28 
 
 20 
 
 48 
 
 0-412 
 
 1881 
 
 30 
 
 18 
 
 48 
 
 0-390 
 
 1882 
 
 34 
 
 24 
 
 58 
 
 0-42 
 
 1883 
 
 27 
 
 29 
 
 56 
 
 0-43 
 
 1884 
 
 29 
 
 30 
 
 59 
 
 0-44 
 
 1885 
 
 29 
 
 18 
 
 47 
 
 0-33 
 
 1886 
 
 27 
 
 24 
 
 51 
 
 0-34 
 
 1887 
 
 28 
 
 23 
 
 51 
 
 0-83 
 
 
 509 
 
 392 
 
 901 
 
 6-461 
 
 The annual average for the twenty year.s, 1868-87, was 0-323 per 
 cent. of the total deatli.s. 
 
 It would be extremely niisleadiug to conclude that the number of 
 cases of hydatid disease treated in any Victorian hospital really repre- 
 sented the prevalence of the disease in the adjacent part of the country, 
 for owing to the migratory habits of the Australian country population, 
 this could not be the case ; a patient treated in Melbourne may have 
 acquired his infection in Xew South Wales, &c. 
 
 New South Wales. 
 
 The tJnder-S(?cretary, writing under date, )Sydney, April 11^ 1878, 
 reports that, " No sej)arate classification of hydatid disease was made 
 before the year 1875." Dui-ing the seven years, 1875-1881, inclusive, 
 tifty-six deaths were registered from this disease, out of a total of 75,503 
 deaths from all causes. This is at the rate of 0-741 per 1000. More 
 recent returns from this colony, although applied for, have not been 
 received. The hos])ital returns obtained from twenty-four public insti- 
 tutions prior to the year 1879, show that out of a total of 35,760 
 in-patients treated, there were ninety-four cases of hydatid disease, l^eing 
 at the rate of one out of every 3804'2 persons treated. 
 
 z 2
 
 340 
 
 IXTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 (Queensland. 
 From tlie published returns, it a|)pears that no particulars were 
 supplied as to deaths from hydatid disease prior to the year 1878, but 
 the annexed table shows tlie deaths registered from this cause from 
 1878 to 1887, inclusive. 
 
 Table Y. — Table showing the Number of Deaths Registered from 
 Hydatid Disease in Queensland, : — 
 
 Percentage ok Mortality 
 Due to Hvdatid Disease. 
 
 Year. 
 
 Males. 
 
 Females. 
 
 Total. 
 
 1878 
 
 
 2 
 
 2 
 
 1879 
 
 — 
 
 2 
 
 — 
 
 1880 
 
 1 
 
 
 
 1 
 
 1881 
 
 — 
 
 2 
 
 2 
 
 1832 
 
 2 
 
 1 
 
 3 
 
 1883 
 
 2 
 
 2 
 
 4 
 
 1884 
 
 12 
 
 13 
 
 25 
 
 1885 
 
 11 
 
 8 
 
 19 
 
 1886 
 
 7 
 
 2 
 
 9 
 
 1887 
 
 9 
 
 8 
 
 17 
 
 0-05 
 
 0-03 
 0-06 
 0-07 
 0-08 
 0-3« 
 0-30 
 0-16 
 033 
 
 It will be noticed, that a remarkable increase has taken place in the 
 deaths from this cause since 1883. That this disease was formerly rare 
 in Queensland is shown, not only by the Eegistrai'-General's returns of 
 deaths, but also by the hospital statistics as far as these were procurable 
 by me. It will be interesting to notice whether the spread of the 
 pai-asite will continue in this colony. 
 
 Soutli Australia. 
 No deaths from this disease appear to have been registered before the 
 year 1871. It is remarkable, that in different years the number of 
 deaths from this canse has varied greatly in this colony. 
 
 Table VI. — Deaths Iicgistered from Hydatid Disease in South 
 A ustralia : — 
 
 
 
 
 
 Percentage of the Total 
 
 Year. 
 
 Males. 
 
 Females. 
 
 Total. 
 
 Mortality CAUSED bv 
 Hydatids. 
 
 1871 
 
 _ 
 
 1 
 
 1 
 
 
 1872 
 
 — 
 
 — 
 
 — 
 
 
 
 1873 
 
 1 
 
 2 
 
 3 
 
 
 
 1874 
 
 — 
 
 1 
 
 1 
 
 
 
 1875 
 
 1 
 
 1 
 
 2 
 
 
 
 1876 \ 
 
 1877 r 
 
 8 
 
 3 
 
 11 
 
 1-61 per 1000 
 
 1878"^ 
 
 1 
 
 2 
 
 3 
 
 
 1879) 
 
 
 
 
 
 18801 
 1881/ 
 
 9 
 
 4 
 
 13 
 
 1-61 
 
 1882 
 
 7 
 
 5 
 
 12 
 
 2-78 
 
 1883 
 
 (; 
 
 — 
 
 6 
 
 0-14 
 
 1884 
 
 9 
 
 3 
 
 12 
 
 0-25 
 
 1885 
 
 4 
 
 1 
 
 5 
 
 0-12 
 
 1886 
 
 8 
 
 1(1 
 
 18 
 
 0-42 
 
 1887 
 
 4 
 
 3 
 
 9 
 
 0-23
 
 HYDATID DISEASE. 
 
 341 
 
 Hospital Siatidics.—Thd i)riiici])al liospitals in the colony arc. the 
 AdeUiide Hospital, anil that at Mount Ganibier. 
 
 At the Adelaide Hospital there were treated, during the thirty-six 
 years, 1S52-18S7, inclusive, 293 cases of hydatid disease among 48,716 
 in-patients, or at tlie rate of one out of 1G6 in-patients treated. During 
 the last few years, there has been a notable increase in the proportion of 
 cases of this disease treated in this hospital. For example— the average 
 ])ro])ortion of hydatids among the in-patients for the thirty-one years 
 preceding 188.'5, was one out of 222 in-])atients ; it has now risen to 
 an average of one in 166 during the last thirty-six years. During the 
 live years, 1873 to 1877, inclusive, there were seventy cases admitted; 
 from 1878 to 1882, inclusive, there were seventy-four cases: but during 
 the last live years, 1883 to 1887, inclusive, the number rose to 118. 
 This is not due to any increase in the number of in-patients treated; 
 on the contrary, there has been an actual diminution in their number. 
 
 Western A ustralia. 
 In March 1878, the Colonial Secretary wrote that he regretted his 
 inability to supply information as to deaths from hydatid disease, 
 because—" Under the Eegistration Act of this Colony, it is not com- 
 pulsory on individuals registering deaths to produce the certificate of a 
 professional man ; consequently, causes of death in most instances are 
 recorded in general terms." Tiie Colonial Surgeon also reported — " That 
 no cases of death have occurred in Western Australia .from the disease 
 in question during the period from 1878 to October 1882, the few cases 
 that have been brought under his notice having all been successfully 
 treated." 
 
 XeiD Zealand. 
 The returns of the causes of death were not compiled by the Registrar- 
 General's Department ]/rior to the year 1873. The number of deaths 
 registered from hydatids from 1878 to 1887, inclusive, appear in the 
 table appended. 
 
 Table VII. — iJt^athti from Uijdalld Disease in New Zealand: — 
 
 
 
 
 
 Percentage of Total 
 
 Yi;.\R. 
 
 Males. 
 2 
 
 Females. 
 
 Total, 
 
 Mortality due to 
 Hydatid Disease. 
 
 1878 
 
 4 
 
 6 
 
 0-129 
 
 1879 
 
 4 
 
 3 
 
 7 
 
 0125 
 
 1880 
 
 8 
 
 6 
 
 9 
 
 0-165 
 
 1881 
 
 
 
 3 
 
 3 
 
 0-055 
 
 1882 
 
 5 
 
 2 
 
 7 
 
 0-123 
 
 1888 
 
 
 
 1 
 
 1 
 
 0-0165 
 
 188-i 
 
 2 
 
 1 
 
 3 
 
 0-0522 
 
 1885 
 
 1 
 
 2 
 
 3 
 
 00493 
 
 1886 
 
 3 
 
 1 
 
 4 
 
 0-0652 
 
 1887 
 
 20 
 
 2 
 
 2 
 
 0-C325 
 
 In ten j-ears . . 
 
 25 
 
 45 
 
 
 It will be seen that the disease is not common in this Colony 
 is also borne out by the hospital statistics. 
 
 This
 
 342 
 
 IXTEHCOLOXIAL MEDICAL COXGUESS OF AUSTRALASIA. 
 
 Tasmania. 
 
 Here, as in New ZeaLmd, the disease is not frequently met with. 
 This is evident from the record of the registered deaths. 
 
 Table YIII. — Deaths from Hydatid iJlsease in Tasrnavia 
 
 
 
 
 
 PERrENTAfiE OF TOTA t. 
 
 Yk.^r. 
 
 Males. 
 
 Fkmai.es. 
 
 Total. 
 
 MoRIAI.lTV nUE TO 
 
 Hvi'AiiL) Disease. 
 
 1878 
 
 2 
 
 
 2 
 
 0-117() 
 
 1879 
 
 1 
 
 1 
 
 2 
 
 0-118O 
 
 1880 
 
 1 
 
 — 
 
 1 
 
 0-054() 
 
 1881 
 
 — 
 
 I 
 
 1 
 
 0-0577 
 
 1882 
 
 2 
 
 2 
 
 4 
 
 0-209 
 
 1883 
 
 4 
 
 — 
 
 4 
 
 0-188 
 
 188i 
 
 2 
 
 4 
 
 
 
 0-3015 
 
 1885 
 
 1 
 
 1 
 
 2 
 
 0-0982 
 
 1886 
 
 — 
 
 2 
 
 2 
 
 0-1062 
 
 1887 
 
 1 
 
 2 
 
 3 
 
 0-1388 
 
 In teu years . . 
 
 14 
 
 13 
 
 27 
 
 
 Age in Relation to Hydatid Disease. 
 
 No age is necessarily exempt from echinococcus disease, for whenever 
 the ripe eggs of the ^o roper tape-worm are swallowed, infection will 
 follow. But the chances of infection of infants and of young children 
 are small. A sucking babe is very unlikely to receive infection in any 
 way, and yet Cruveilhier mentions the case of a child, aged twelve days, 
 that appeared to have a hydatid cyst ; but in this instance, there were 
 strong reasons for doubting whether the observation was correct. I 
 have, however, recorded (AustraUaii Medical JonrnaJ, October 15, 1882, 
 page 438) the case of a boy, aged two years and one month, in whom T 
 operated upon a hydatid cyst of the liver Old age gives no exemption, 
 foi' Monod met with a case in which the patient was seventy-seven 
 years old, and Charcot saw a hydatid in the phalanx of the index-finger 
 of a man eighty-one years of age. 
 
 From the natural history of the disease, it is evident that, other 
 things being equal, the longer a person lives, the greater are his chances 
 of becoming infected with echinococcus ; but on the other hand, witli 
 advancing age, there are fewer persons left alive to take the disease. 
 It must also be remembered that the parasite requires usually a 
 coi\siderable time to make its presence known in the body of its liost. 
 Probal)Iy, on an average, five or six years pass between the moment 
 M'hen the egg is swallowed up to the time when the great size of the 
 bladder-worm, or the accidents caused by its rupture. Arc, betray its 
 presence. In consecjuence of these various conditions, we find that the 
 frecjuency of the disease increases with eacli decade of life up to al:)out 
 thirty or forty years of age ; it afterwards declines, so that after sixty 
 it is not connnon. 
 
 The age distribution of the disease is shown in the accompanying 
 table, based on 1301 cases collected by me from \arious parts of the 
 world.
 
 HYDATID DISEASE. 
 
 343 
 
 Table IX. — Table s/toivinr/ the J)lstribution, according to Age, of 1301 
 Cases of Echinococcus Disease, collected from various 2J(t'>'fs of the 
 World :— 
 
 Age. 
 
 Ni'MBEK OF Cases. 
 
 Peucentage. 
 
 1 to 10 years 
 
 old 
 
 91 
 
 7-00 
 
 11 to 20 „ 
 
 ,, 
 
 222 
 
 17-06 
 
 21 to 30 „ 
 
 ,, 
 
 376 
 
 28-90 
 
 31 to 40 
 
 1, 
 
 299 
 
 22-98 
 
 41 to 50 
 
 „ 
 
 171 
 
 13-14 
 
 51 to 60 „ 
 
 ji 
 
 108 
 
 8-30 
 
 61 to 70 „ 
 
 .. 
 
 34 
 
 2-62 
 
 
 1301 
 
 100-CO 
 
 With minor and probably, in a certain sense, accidental exceptions, 
 this age distribution prevails in the case of all the organs of the body 
 excepting the brain, in which the highest mortality from echinococcus 
 occurs in the second decade of life. 
 
 Sex IX Relation to Hydatid Disease. 
 
 There seems, a priori, to exist no valid reason why, tlu'oughout the 
 world generally, the two sexes should suffer in unequal proportion from 
 this disease, and indeed Davaine ("Traite des Entozoaires," second 
 edition, page 387), and other writers on the subject have usually failed 
 to discover any such difference. If in a given country one sex suffers 
 more frequently than the otlier, this may be due to one or both of the 
 following causes, viz.: — (1) The two sexes may form unequal propor- 
 tions of tlie community; or (2) The occupations and habits of tlie men 
 and women may expose them unequally to the chance of infection. 
 
 As regards the former of these factors, the numbers of the two sexes 
 living do not difier greatly, at any rate in the case of the principal races 
 of the civilized world. If we take the principal nations of Europe as a 
 whole, the sexes stand thus in the population : — Males, 48-5 per cent.; 
 female-s, 51*5 per cent. But with regard to the liability to echinococcus 
 disease in Europe as a whole, I find, from 11-52 published cases, that 
 tlie numbers of each sex stand thus: — Males 586, or 50-86 per cent.; 
 females 566, or 49-14 per cent. So that in Europe in general, although 
 tlie living females outnumber the males, yet rather moi'e males than 
 females acquire hydatid disease. 
 
 In England and "Wales, however, according to the Mortality Returns 
 of the Registrar-General, out of 527 deaths attributed to liydatids, tliere 
 were — Males 243, or 46-11 per cent.; females 284, or 53-87 per cent. 
 In England, then, there is a slight but distinct preponderance of females 
 attacked. 
 
 In Iceland, this attains a still more marked degree; for it is generally 
 admitted by physicians practising in this land, that women here are far 
 more often the A^ictims of the disease, than men. Finsen even states 
 the ratio to be as high as two and a half women to one man. This is 
 not to be explained by a great preponderance of females in the Icelandic 
 population, because from data derived from Burton (" Ultima Thule, or
 
 344 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 a Summer in Iceland," by Richard F. Burton), I find the proportions of 
 the sexes in Iceland to be — Males, 47*49 per cent.; females, 53-51 per cent. 
 The cause of the preponderance of females among the sufterers from this 
 disease in Iceland, is probably correctly stated by Finsen to be, that the 
 domestic avocations of the women which oc'cupy them in cooking and in 
 washing kitchen utensils, <kc., render them more liable to swallow the 
 eggs of Taenia echinococcus than men are ; this especially, in consequence 
 of the Icelandic dogs being allowed to lick the vessels employed in the 
 kitchens. 
 
 That this explanation is correct, is rendered probable by cases the 
 reverse of this, viz., in Mecklenburg, where, according to many writers, 
 e.g., Madelung ("Beitrage Mecklenburgischer Aerzte zur Lehi-evon der 
 Echinococcen-Krankheit," Madelung, Stuttgart, 1885), hydatid disease 
 presents itself with unusual frequency, the ratio in which the sexes are 
 attacked is as follows: — Males 106, or 54-36 per cent.; females 89, or 
 45-64 per cent. 
 
 In the Australasian colonies as a whole, inclusive of New Zealand 
 and Tasmania, the returns of deaths registered as due to this disease 
 show a very decided preponderance of males, viz.: — Males 55-86, 
 females 45*14 per cent, (see Table X.) In New Zealand only was there 
 a majority of females. The proportion of the two sexes in the total 
 population has varied greatly from time to time in the Australasian 
 colonies, for in the early days of their colonisation, many more men than 
 women became immigrants. In consequence of this, the average ratio 
 of the sexes in Victoria during the twenty years commencing with 1861 
 appears to have been — Males, 100; females, 74. More recent enquiries 
 based upon Mr. Hayter's valuable returns ("Victorian Year Book," 
 1885-86, pages 44 and 45), give the following as the approximate ratios 
 of the sexes in the Australasian colonies as a whole: — Males 54-18, 
 females 45-81 per cent. From these data, it may be concluded that the 
 sexes are attacked by this disease in about the same proportion as they 
 occur in the total population, viz., about five males to four females. 
 
 Table X. — Table shoioing'the Nicmher of Persons of each. Sex that Died 
 of Hydatid Disease in the Australasian Colonies during the under- 
 mentioned periods. Cominledfrom official sources :— 
 
 Name of Colony. 
 
 Period. 
 
 Males. 
 
 Females. 
 
 Total. 
 
 Victoria . . 
 
 1862-87 
 
 512 
 
 394 
 
 906 
 
 New South Wales 
 
 1875-81 
 
 29 
 
 27 
 
 56 
 
 Queensland 
 
 1878-87 
 
 44 
 
 38 
 
 82 
 
 South Australia . . 
 
 1871-87 
 
 58 
 
 38 
 
 96 
 
 New Zealand 
 
 1878-87 
 
 20 
 
 25 
 
 45 
 
 Tasmania 
 
 1878-87 
 
 14 
 
 13 
 
 27 
 
 
 677 
 
 535 
 
 1212
 
 THE SURGICAL TREATMENT OP HYDATID DISEASE. 345 
 
 THE SURGICAL TREATMENT OF HYDATID DISEASE. 
 By AY. Gardner, M.D., Ch. M. Glas. 
 
 Lecturer on Surgery, Adelaide University. Senior Surgeon to Adelaide Hospital. 
 
 The invitation to open the discussion on the Surgical Treatment 
 of Hydatid Disease was given to me, Avhen in Melbourne, by 
 our esteemed President, and so right loyally did Melbourne medical 
 men support us in our first attempt at a Congress, both by their 
 presence and by valuable contriijutions, that I felt no course was 
 open to me but to accept gratefully the honour, and do my best, 
 fully conscious, however, that I should only be able to give the 
 subject scant justice, and touch lightly only on the various aspects 
 of the question. My aim will be to place the subject before you in sucli 
 a way as to enable you during the ensuing discussion to keep strictly to 
 tlie question of treatment, and thus we shall be able to extract from 
 those of you who have had large experience in the treatment of tJie 
 disease, results of your various methods which, when summed up and 
 critically analysed, will render it possible to arrive at some conclusions 
 whicli may serve as guides to Australian pr-actitioners generally ; and 
 may also be the means of authoritatively informing practitioners at 
 Home of our opinions which, owing to our infrequent contributions to 
 tlie literature of the subject, they have so far been unable to learn, and 
 which has led up to the erroneous statement of our views by a member 
 of the Clinical Society of London, at its meeting held in December 1887. 
 The following quotation from the Report of the Clinical Society, in tlie 
 British Medical Journal of December 17th, 1887, shows clearly the 
 error to which I have referred: — "Mr. Godlee called attention to the 
 different treatment adopted for these cases in Australia and in this 
 country. There, aspiration was employed, and a cure usually effected ; 
 if not, the surgeon then pushed a trocar and canula through the 
 abdominal wall, and so drained the cyst usually to its cure. Here, 
 surgeons cut down to the cyst,, which being done, the question arose 
 whether the cyst should then lie at once opened, or should it be first 
 attached to the external skin opening, and then opened subsequently. 
 His plan was to tap the cyst, and then stitch the cyst wall to the 
 cutaneous wall." This paper will show that our practice for a number 
 of years has been identical with that laid down by Mr. Godlee as the 
 treatment pursued in Great Britain. 
 
 The plan which I shall adopt in this paper is to describe : — 
 
 I. — All the various surgical metliods employed in the treatment of 
 hydatids. 
 
 II. — To compile from various sources, and place before you statistics, 
 showing the results of the various methods of treatment. 
 
 III. — Lastly, I shall lay before you shortly my own views, and the 
 methods which I at present adopt, and the results which I have 
 oljtained during the last four years, i.e., since I made a distinct departure 
 from my former methods. 
 
 Part I.^ — The Yarious Methods of Surgical Treatment. 
 (1) Aspiration or tapping witli fine trocar and canula, with or with- 
 out the injection into the cyst of iodine, bile, Sec.
 
 346 IXTERCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 (2) Electrolysis. 
 
 (3) Introduction and retention of large ti-ocar and canula. Of this, 
 there ai'e four subdivisions : — 
 
 («) Insertion of a circle of needles to procure adhesions bet^^'een 
 visceral and parietal layers of the peritoneum. 
 
 (b) Incision down to the peritoneum with tlie knife. 
 
 (c) Use of potassa fusa to procure adhesions prior to opening tlie 
 
 cyst. 
 ((/) Immediate introduction and retention. 
 
 (4) Abdominal and thoracic section, allowing membranes to be 
 expelled spontaneously. Of this, there are two subdivisions : — 
 
 (a) The insertion of Chassaignac's rubber tube, with immediate 
 
 stitching of the cyst wall to the abdominal wall in the 
 abdominal cases. 
 
 (b) The same treatment, with a preliminary operation some days 
 
 before, to secure adhesion l^etween the visceral and parietal 
 layers of the pleura, and of the peritoneum. 
 
 (5) Abdominal and- thoracic section, associated with the immediate 
 removal of the whole or the bulk of the cysts, by douching with boric 
 acid lotion, and the use of long holding-forceps ; and finally, the inser- 
 ■tion of a rubber tube. Of this, there are two subdivisions : — 
 
 (a) With immediate stitching of the cyst wall to the abdominal 
 
 wall in the abdominal cases. 
 
 (b) With a preliminary operation some days before, to secure 
 
 adhesion between the viscei'al and parietal layers of the 
 pleura, and of the peritoneum. 
 
 Part II. — Statistics of the Various Methods of Treatment. 
 
 Reliable statistics of the first two methods, viz., aspiration and 
 electrolysis, are absolutely impossible to obtain, on account of the fact 
 that in the great majority of the cases, the surgeon loses sight of the 
 patient; and possibly also, because in a vast number of cases, the 
 sufferer, finding that his cyst has re-filled, seeks other advice. The 
 surgeon who is then consulted, finding that aspiration has been tried 
 and failed to cure, advises and carries out an abdominal or thoracic 
 section. It cannot be doubted, also, that aspii-ation, especially in 
 pulmonary hydatids, is a form of treatment not free from danger, as in 
 forty-three cases of hydatid disease occurring in the Adelaide Hospital 
 during the last four years, two are entered as deaths after aspiration 
 of lung hydatids. 
 
 I liave collected eight published cases of death following aspiration, 
 performed by Australian surgeons between 1878 and 1888, so that the 
 operation is not free from risk. Cases, however, are on record, which 
 have been watched for years, and prove conclusively that aspiration is 
 occasionally really successful. It is, however, decidedly unreliable, 
 and I liave given it up conii)letely, except as a diagnostic aid at the time 
 of performing a r'adical operation. 
 
 Thei-e is also before me a table of tliirteen cases of treatment by 
 electrolysis, of wliich one failed and one died, leaving a total of eleven 
 recoveries in tliirteen cases, or a percentage of 15-38 of deaths. This 
 number is, obviously, of no value in discussing comparative results.
 
 THE SUKGICAT. TREATMENT OF IIVDATID DISEASE. 347 
 
 Dr. D;^^■ies Tlionin.s li;is collected from ^;u•ious sources ei<>hty-four 
 cnses of treatment by caustics, with fifty-nine recoveries and twenty-tive 
 deatlis. The treatment in most of the cases was complicated Ijy the 
 iuti-oduction of several methods, in addition to Recamier's caustic 
 method. They serve to demonstrate the terriljle mortality which attend 
 such procedures, viz., 29-76 per cent, of deaths. 
 
 In 1885 I made a collection of Australian statistics of radical opera- 
 tions for abdominal and lung hydatids, by various surgeons, and I liaA e 
 now slightly adderl to it. They number forty-six, with eight deaths, 
 giving a death-rate of 17 "39 per cent. 
 
 I also submit a list of internal hydatids, treated in the Adelaide 
 Hospital, from January 1, 1885, to the end of 1888. Seven cases of 
 livei- hydatid were ti-eated with retained canula, with two deaths, or a 
 death-i-ate of 28-57 per cent. Thirty-live cases were treated by section, 
 with the following results: — 
 
 Liver 23 . . Deaths 5 . . Cures 18 
 
 Luug 4 .. ,, ■ — .. ,, 4 
 
 Omentum 4 . . ,, 1 .. ,, H 
 
 Pleura ;> .. „ — .. ,, ^ 
 
 Kidney 1 .. ,, — .. ,. 1 
 
 35 6 29 
 
 That is a death-rate for section of 17-14 per cent., or on tlie whole 
 forty-two cases, a death-rate of 19-04 per cent. 
 
 In another table at the close of this paper is a collection of thirty- 
 two cases of section occurring in my own practice, from January 1, 
 1885, to the end of 1888, showing 100 per cent, of recoveries in the 
 thoracic sections, and a mortality of 6-25 per cent, in the thirty-two 
 sections. 
 
 Dr. Davies Thomas has collated the deaths and recoveries in ninety 
 cases of hydatids treated by retained canula. The percentage of deaths 
 is 26-66 per cent., and cures 64 per cent., the balance consisting of cases 
 in which the result was doubtful. 
 
 Part III. 
 
 In the beginning of 1885, a case of hydatid of the li\er occurred in 
 my practice, which, terminating fatally from septictemia, led me to the 
 conclusion that danger was to be expected from allowing the cysts to be 
 sjiontaneously expelled, or from removing them gradually with the 
 forceps. 
 
 The case was shortly as follows: — 
 
 Mrs. B. consulted me for a pain in the right side of the chest, in front. 
 Lungs and heart were found normal on examination. There was no 
 l)ulging in the I'egion of the liver, and the lower edge was not lower 
 than usual. The upper border on percussion was found normal in 
 position, but there was an extension of dulness upwards at one point in 
 the line, semi-circular in shape, and having a radius of about two inches. 
 I determined to explore this with the aspirator, but on inserting the 
 needle, no fluid came away, and I was forced to the conclusion that I 
 had made a mistake; but on reaching home I luckily \)\ew through the 
 needle on to a glass slide, and under the microscope discovered about 
 twenty separate hooklets. I then removed subsequently part of a rib,
 
 348 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 and incised the cyst, inserting a rubber tube. Very little came out 
 at the operation, the mother cyst being absolutely packed tight with 
 daughter cysts. 
 
 I left the Colony at the time for my annual holiday, and the case 
 was attended by my friend, the late Dr. Chas. Gosse, who, following 
 the practice of that time, drew out the cysts as they appeared in the 
 drainage-tube. Had there been an opening made in the back, and the 
 whole of tlie contents Avashed out early in the case, I feel sure the 
 result would have been different. 
 
 This led me to formulate for myself the following rule, viz., to I'emove 
 all cysts contained in the external envelope at the time of operation. 
 Since that date, my practice has invariably been not to use the aspirator 
 exce23t at the time of operation, and then only to make sure of the best 
 point to attack the cyst. 
 
 The operation consists, then, in the thorax, of resecting parts of two 
 or more ribs, then incising the pleura, cutting through the visceral 
 pleura into the lung, and then removing the membranes thoroughly. 
 
 In the abdomen, I cut down on the most prominent part of the cyst, 
 and if the cyst wall will hold stitches, I place a circle of stitches uniting 
 the cyst wall to the parietal peritoneum. Then my assistant presses 
 with a circle of sponges the abdominal wall against the cyst, and, with 
 a sharp-pointed knife, the cyst is boldly opened for about one inch. As 
 soon as the knife is removed, the finger enters, and large curved needles 
 are then passed through the cyst and the abdominal wall, at fii'st at 
 four points, and then a few secondary sutures in between. As soon as 
 this is finished, the cyst is distended with boric lotion, and as the current 
 returns, the membranes are gradually extruded, the exit of the mother- 
 cyst being aided with ovum- or other suitable holding-forceps. A soft 
 rubber tube is then inserted, and over all a dressing of carbolised 
 gauze, followed by salicylic wool, and finally, by a large pad of oakum 
 enclosed in carbolised gauze. The cyst is then washed out daily, in 
 abdominal cases. In thoracic cases, douching frequently sets up violent 
 coughing, and if so, has to be very little used, or given up altogether. 
 In two of my lung cases, I have had an empyema form, compelling me 
 to resect a rib and drain from the lowest point of the pleura. To 
 obviate this in future, I intend to resect pieces of several ribs to give 
 plenty of room, and then endeavour to unite the visceral to the parietal 
 pleura, immediately before cutting into the cyst. 
 
 The table which is here introduced, contains all my sections for 
 hydatid during the last four years into the abdomen and thorax, and in 
 each case, except that of Mrs. B., all the cyst, or at least the greater 
 bulk of it, was removed at the time of operation, only small fragments 
 appearing afterwards. Tlie i-esults are as follow : — 
 
 Thoracic Sections 9 . . Cures 9 . . Deaths — 
 
 Abdominal Sections — 
 
 Liver .. 20 .. .,19 .. „ 1 
 
 Broad Ligament 1 .. ,,1 •• m — 
 
 Kidney .. 1 .. ,,1 •• n — 
 
 Omentum .. 1 .. ,, — .. >, - 
 
 Totals .. .32 .. ,.30 .. „ 2 
 
 Or a mortality of 6-25 per cent, in tliirty-two operations.
 
 THE SURGICAL TREATMENT OF HYDATID DISEASE. 
 
 349 
 
 
 
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 352 INTERCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 THE OPERATIVE TREATMENT OF ECHINOCOCCUS 
 
 CYSTS. 
 
 By John Davies Thomas, M.D. Lend., F.R.C.S. Eng. 
 
 Joint Lecturer on Medicine in the University of Adelaide. Physician to the 
 
 Adelaide Hospital. 
 
 Part I. 
 
 (a) Operations by ])uncture. 
 
 (b) The treatment of eehinococcus cysts by means of medicated 
 injections. 
 
 (c) The treatment of hydatid cysts by electricity. 
 
 Part II. — Radical Oj)erations. 
 (a) Treatment by caustics (Recamier's method). 
 [0) Treatment by canule-;i-demeure. 
 (c) Various forms of incision operations. 
 
 Perhaps among the diseases which afflict mankind, there is none for 
 the relief of which a greater diversity of treatment has been practised, 
 than " hydatid " disease. But varied as are the surgical procedures 
 which have been followed for this object, they yet ma}' be chissified, for 
 the pur[)Oses of criticism, under three headings, viz. : — 
 
 I. — Those by which it is intended that the parasite shall be 
 destroyed, without, however, aiming at its entire removal from the body 
 of its " host." To this group belong — 
 
 (a) Operations of puncture or " tapping "— aspiratory or simple — 
 by which the fluid contents of the bladder-worm are removed 
 to a greater or less extent. 
 (A) The injection through a canula, previously inserted, of various 
 
 bodies supposed to act as ])arasiticides. 
 ((■) The destruction of the parasite by electricity. 
 
 II. — -Those operations, which have as their object the extraction of 
 the entire bladder-worm, with any daughter-cysts that may be present ; 
 such oi)erations may be regarded as radical operations. To this class 
 belong cases in which the i)arasite is removed by an artificial opening 
 into its sac, procured by — 
 
 [a) Caustics. 
 
 (/>) Canule-H-demeure. 
 
 (c) The varied forms of incision operations. 
 
 III. — A third grouj) of operations is constituted by a comparatively 
 few recorded cases, where not only has the parasite been removed, but 
 also, more or less completely, its fibrous sac as well. These operations 
 may be regarded as " ultra-radical," in consequence both of their greater 
 gravity, and of the limited number of cases in which they can be 
 regarded as permissible. 
 
 Before proceeding to the discussion of the claims of the different 
 modes of treatment, it is desirable to consider briefly the nature of the 
 conditions p)esent. In its normal state, the eehinococcus cyst lies 
 imbedded in some organ, tissue, or " closed cavity " of its host ; almost 
 invariably it is completely enveloped in an adventitious sac, or capsule,
 
 THE OPERATIVE TIJEATMEXT OF ECIIIKOCOCCUS CYSTS. 353 
 
 wliicli is not an integral jiait of tlie parasite, Imt is a niorhid product of 
 the organ or tissue in Avhich tlie bladder-worm has taken up its abode ; 
 it is, nevertheless, a structure of great importance to the parasite, for 
 through it, by a process of diosmosis, the latter obtains its supply of 
 ]>abu]um from the blood of its liost ; its functional integrity therefore 
 determines whether the parasite shall dwell in plenty, or die of inanition. 
 When the parasite, and consequently also its fibrous sac, is young, the 
 latter is very richly supplied with blood-vessels, which are derived from 
 the neighbouring normal vessels ; consequently, the removal of the fibrous 
 sac of necessity entails a very abundant employment of ligatures. But 
 from the very natui-e of the fibrous capsule, whicli consists of stratified 
 layers of connective tissue, it tends to contract, and in doing so, to 
 ira])air its own vascular supply; hence follow extreme induration and 
 rigidity of the cajisule, and calcareous degeneration. This process may 
 issue in complete calcitication of the entire sac, if it be of small size, but 
 in the case of large cysts, the process is more or less localised ; some 
 portions of its surface being thick, tough, and often infiltrated with 
 calcareous salts, whilst others are much less indurated and rigid. 
 Calcai'eous degeneration, here as elsewhere, is a necrotic change, and is 
 in this case an indication of impaired blood supply. The effect of this 
 alteration upon the enclosed parasite is, when it has reached an extreme 
 degree, fatal, by cutting off its sujiply of pabulum. When the parasite 
 dies from this cause, as is fi^quently the case, its fluid contents become 
 more or less opaque, the scolices die and disintegrate, a putty-like matter 
 is found between the parasite and its capsule, and ultimately nothing 
 remains except a tough sac much contracted in size, within which are 
 found a })utty-like mass, with the remains, if any, of the mother-cyst, 
 variously folded and plaited in a manner resembling the aestivation of 
 certain plants. It is important, clinically speaking, to recognise that 
 the mere death of the parasite does not of necessity mean the cure of the 
 host ; for it is quite common to meet with hydatids requiring operation, 
 but in whicli the parasite is dead and far advanced in spontaneous decay. 
 
 In estimating the results of different plans of treatment, several 
 conditions have to be regaixled, viz : — 
 
 (1) Tlte locality of the parasite. — It is evident that an echinococcus 
 cyst in the female breast may be safely removed, without remo\'al of the 
 mamma itself; whilst a colony of hydatids in the interior of the thigh 
 bone may entail amputation of the hip joint, and so may kill the host 
 indirectly. — (Case recorded by Kanzow and Virchow, and cited in 
 '•Vii'chow and Hirsch's Jahresbericht," V^ol. XV., Part 1, page 341.) 
 Then the cyst may be so })laced as to render diagnosis, and consequently 
 treatment, impossible — for example, in the walls of the heart, in the 
 interior of the brain, Arc. Speaking generally, the most important 
 cases of hydatid disease, on account of their relative frequency, 
 are those of the interior of the thorax and abdomen, and more par- 
 ticularly those of the liver and lungs. About 72 per cent, of all 
 cases of echinococcus disease in man occur in connection with the 
 abdominal cavity ; but as regards individual organs, the liver is most 
 frequently invaded (in 67 per cent.), and the lungs next (in nearly 
 12 per cent.) Even in the case of the different organs situated 
 in the same cavity, the special local conditions exert a great influence 
 both upon the prognosis and treatment. For example, echinococci of 
 
 lA
 
 354 INTEUCOLONIAL MEDICAL COXGKESS OF AUSTRALASIA. 
 
 the pericardium and heart must, for the ])rescnt at least, be regarded as 
 alike beyond the reach of diagnosis and of treatment. Echinococci of 
 the lung are greatly affected in their career by the frequency of their 
 rupture into the bronchial tracts. Many cases of this disease in the 
 lungs are spontaneously cured by the elimination of the parasite through 
 the air-passages : and, moreover, a considerable proportion of the cases 
 of pulmonary hydatids, reputedly " cured " by tapping operations, 
 really have recovered in consequence of the expulsion of tlie remains of 
 the parasite by coughing, although the bladder-worm was killed by the 
 puncture. Moreover, in the case of jjulmonary hydatids which have 
 ruptured either spontaneously or in consequence of surgical interference, 
 it frequently happens that bacteria are conveyed by the air entering the 
 cavity, through the bronchial tubes which open into it, and thus 
 putrefactive changes are induced in the contents of the sac. From this 
 cause, pyi'exia, cough, night sweats and emaciation may arise, and the 
 patient often prese)its the precise general aspect of a jihthisical suffei'er. 
 In hydatids of the liver and kidney also, the existence of the natural 
 ducts of these organs often occasions special accidents to befall them. 
 In the case of liver cysts, bile may enter into the sac after the mothei-- 
 cyst has ruptured, and the remains of the i)arasite or any daughter-cysts 
 present may pass into or through the l)ile ducts, or may be arrested in 
 them and cause jaundice. Hydatids of the kidney are particularly 
 liable to rupture spontaneously into the pelvis of the organ, or into 
 some other part of the urinary ducts, for more than two-thirds of the 
 cases collected by Beraud (Beraud's " Des Hydatides des Reins," 
 Paris Thesis, ISGl, page 47) terminated in this way. On the other 
 hand, the spleen, omentum, mesentery, and the abdominal cavity, which 
 often are tlie seats of echinococcus cysts, have no natural channels which 
 can serve as outlets for the ])arasite. 
 
 (2.) 77i(' age of the parasite. — With advancing age the fibrous capsule 
 l)ecomes thicker, more rigid, and tends to undergo calcareous degeneration : 
 it also ac(|uires more extensive and closei- connection with the adjacent 
 structures, and in consequence, it collapses less readily when its contents 
 are removed. I have seen a case of hydatid cyst which |)rojected from 
 the under surface of the liver, and which extended deep into the recto- 
 vesical pouch, where the fibrous capsule was so closely adherent to both 
 the anterior and posterior walls of the abdomen, that it was a puzzle 
 to discover where the intestines were placed. It is evident that, under 
 such circumstances, much delay must occur in the process of obliteration 
 of the cavity formerly filled with the bladder-worm, for usually the sac 
 yields to the pressure of the stomach, intestines, Ac, and thus its 
 opposed walls come in contact, and arc soon united by membranous 
 adhesions. Again, when the fibrous capsule is extensively degenerated, 
 it may become detached in larger or smaller portions during the process 
 of cure ; this is especially apt to occur where the sac has undergone 
 calcareous degeneration. 
 
 (3.) The occurrence of suj)puration in the sac, or of putrefactive 
 changes in its contents, with or without the accumulation of gas, exert 
 a weighty infiuence upon the prognosis and projjcr treatment. Usually, 
 such conditions render a radical operation imperatively necessary. 
 
 In this essay, J ])roi)ose to briefly review the modes of treatment more 
 commonly aiJoptcd for the relief of hydatid disease, especially as concerns
 
 THE OPERATIVK TRKATMKXT OF KCIIINOCOCCUS CYSTS. 3.j5 
 
 tlieir efiieacy ami their danger to life ; but, as I have elsowliere recently 
 discussed {A>(stra/l(ni MnViral Jonrnal, 1888) at lengtli many of tlie 
 plans of treatment, I shall here only refer to the conclusions arrived at 
 with regard to the following methods, viz., punctures, injections, electri- 
 city, caustics, and canule-a-demeure. It is intended, however, that the 
 more modern methods of incision, according to the modifications of 
 Simon, Volkmann, and Lindemann, shall receive fuller consideration. 
 
 (a) Operations nv Puncture, either Aspiratory, or by Means 
 OF A Simple Trochar and Canula. 
 
 Tapjiing, at first with a common trochar of small calibre, and, after its 
 introduction by Dieulafoy, by the aspirator and fine canulii, has been a 
 favourite mode of treatment in most ])arts of the world where hydatid 
 disease is met with. In has been strongly advocated by Murchison in 
 England, by Boinet and Dieulafoy in France, by Iljaltaliu in Iceland, 
 and by Hudson, MacGillivray, Bird, and others in Australia. 
 
 Until quite recently in Australia, inincture has been the recognised 
 regular mode of treatment for all cases of internal hydatids. This fact 
 alone should be jjroof that sometimes cure i-esults from tapping opera- 
 tions ; but on the other hand, it is certain that in a large proportion of 
 eases, it fails to rescue the ])atient from death. It must also be conceded 
 that the treatment by puncture is attractive from its sim])licity, and its 
 apparent freedom from risk : moreover, if we accept without criticism 
 the statements of many of its advocates, it might be concluded that 
 failure to cure by it is oxce])tional. But a closer scrutiny brings with 
 it much scepticism, for the statistical <lata based upon the number of 
 reputed " cures " by tapi)ing operations are in the last degree unsatis- 
 factory, inasmuch as it is certain that in many of them the cyst re-fills, 
 and becomes a source of peril to the patient. Such an occurrence has 
 been known to take place even as long as ten years after the patient 
 was believed to have been cured ; indeed, it is almost impossible to fix 
 a time at which an hydatid cyst, treated by puncture, may safely be 
 said to be cured. It follows, therefore, that in statistics bearing upon 
 this question, the numV)er of reputed cures must be accepted with very 
 large reservation. 
 
 Simple and harmless as ])uncture with a small ti'ochar generally is, 
 yet it not mifrequently hai)pens that alarming symptoms follow it, and 
 in a few cases death has even taken i)lace. I have elsewhere (Ansfralian 
 Medical Journal, April 1888) referred to three cases in which death 
 occurred immediately after puncture of hydatid cysts in the liver, 
 aj)parently from shock. I have also seen a ])atient in imminent danger 
 for hours from shock, after a puncture of a hydatid cyst of the spleen, 
 although a very fine needle was used [Australasian Medical (Jaxette, June 
 1887). The pathogeny of such cases is obscure at present. 
 
 In the case of j>ulmonary hydatids also, death has been known to 
 supervene rapidly aftei- jjuncture. [n two cases kindly communicated 
 to me by L>r. Lonsdale Holden, of Hobart, the patients died, one in. 
 about five minutes, the other in about half an hour after puncture with 
 a fine trochar. Dr. Holden was inclined to regard these as deaths frou) 
 syncoi)e. It seems to me however that, at any rate, in some cases of 
 sudden death after the j)uncture of large pulmonary cysts, the patient 
 has really died of suffocation, in consequence of the flooding of the 
 
 1a 2
 
 356 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 loronchial tracts of both lungs l)y the outflow of hydatid fluid from the 
 punctured cyst. That this accident is not more frequent under tliese 
 circumstances is probably attributable to the fact that the collapsed 
 mother-cyst often occludes the openings of the bronchial tubes on the 
 ■walls of the cavity. (For a discussion of this point, see " Hydatid Disease 
 of the Lungs," Proceedings of the South Australian I>ranch of the 
 British Medical Association, September 1884.) 
 
 In a case recorded by Schede (cited in Madelung, " Beitriige Mecklen- 
 burgischer ^rzte zur Lehre von der Echinococcen-Krankheit," Stuttgart, 
 1885, p. 86), a woman, aged twenty-three, died from sufi'ocation in the 
 course of a few minutes after an exploratorj puncture of a huge hydatid 
 of the right lung. 
 
 I have witnessed most urgent dyspncea from the same cause. When, 
 an echinococcus cyst of the kidney is punctured, its contents may escape 
 by the ureter into the bladder, and so become eliminated, as in a case 
 related by Bradbury {British Medical Journal, October 6, 1887, p. 471). 
 In the case of liver cysts, escape of the parasite by the bile ducts after 
 puncture is not very common, probably in consequence of the compara- 
 tively small size of the intra-hepatic ducts ; jaundice from their blockage 
 is probably more often met with. There is good reason for believing 
 that a large proportion of the cases of lung hydatids cured after punctxire 
 recover simply in consequence of the expectoration of the membranes, 
 although it is true that the puncture killed the bladder-worm, and so 
 rendered possible its expulsion by coughing. 
 
 The recorded deaths after the puncture of pulmonary hydatids appear 
 to me to be of sufficient interest and importance to merit notice in this 
 paper ; they are fully recorded in a table published in the Australian 
 Medical Journal, of July 1889. In four cases, death seems to have 
 resulted from rupture into the pleural cavity. In one, death was apparently 
 due chiefly to a cyst of the liver that was also present. In four instances, 
 death took place very soon after puncture ; one them admittedly died 
 from suffocation, the others possibly from the same cause, or from shock. 
 The i-emaining cases sank from dyspncea, pyrexia, and exhaustion. 
 
 Table I. — Table showlnr/ the Besidts of Tapping Operations upon 
 Echinococcus Cysts in various I^arts of the Body : — 
 
 
 
 
 Failurf. of I 
 
 
 
 
 
 SiTl'ATIOS OF 
 
 Deaths. 
 
 Not 
 
 PrNCTUKE tj 
 
 
 Reputed 
 
 Result 
 
 Total. 
 
 Cyst. 
 
 
 Relieved. 
 
 (other openi- 
 tioiis). j 
 
 
 Cukes. 
 
 Unknown. 
 
 
 Liver . . 
 
 73 
 
 5 
 
 92 
 
 68 
 
 168 
 
 10 
 
 411 
 
 Lunj,' . . 
 
 14 
 
 — 
 
 20 ' 
 
 1 
 
 14 
 
 4 
 
 53 
 
 Spleen 
 
 2 
 
 — 
 
 7 
 
 4 
 
 6 
 
 1 
 
 20 
 
 Kidney 
 
 — 
 
 — 
 
 4 1 
 
 
 2 
 
 — 
 
 6 
 
 Omentum ,mes- 
 
 
 
 1 
 
 
 
 
 
 enteiy, etc. . . 
 
 1 
 
 — 
 
 ^ i 
 
 — 
 
 3 
 
 — 
 
 7 
 
 ' Abdomen ". . 
 
 1 
 
 — 
 
 1 
 
 
 
 1 
 
 2 
 
 10 
 
 Male Pelvis . . 
 
 4* 
 
 
 4 ' 
 
 — 
 
 5t 
 
 — 
 
 13 
 
 Total 
 
 95 
 
 5 
 
 131 
 
 73 
 
 199 
 
 17 
 
 520 
 
 • Once the bladder as well as the cyst was inmctuied ; twice the cyst was punctured per rectum, 
 t Three doubtful cures.
 
 THE OPERATIVE TIUCATMENT OF ECniNOCOCCUS CYSTS. 357 
 
 The general conclusions to be drawn from the statistics of tapping 
 operations, as shown in Tal>le I., are that the death-rate has been about 
 19 percent.; that in 46 percent, it evidently failed to cure the patients; 
 and that, although 54 per cent, were regarded as relieved or cured, still 
 in the majority of them the patients had not been under the observation 
 of the operators for a sufficiently long time after the operation to justify 
 the conclusion that a })ermanent cure had been effected. 
 
 Sumjaari/ of the Results of Tapyinc/ Operations : — 
 Deaths . . . . . . . • • • 18-88 per cent. 
 
 Not relieved .. .. .. .. •• 0-99 
 
 ■Unsuccessful punctures followed by other operations 26-04 ,, 
 
 Total failure of punctures . . .. .. 45-91 ,, 
 
 Believed .. .. .. .. .. li"51 
 
 Eeputed cures •. .. .. ..39-56 
 
 Total successes of punctures .. .. 54-07 ,, 
 
 The results of aspiratory puncture show only about half the ratio of 
 deaths as compared with puncture with an ordinary trochar. The 
 mortality rises with the number of tappings required. The be.st results 
 are met with in living juvenile echinoccocci of moderate size, the worst 
 in old degenerated or suppurated cysts. 
 
 [b) The Treatment of Echinococcus Cysts by Means of 
 Medicated Ixjections. 
 
 Injections have been e.\tensively eni])loyed as adjuncts to various 
 forms of radical operations, e.tj., in the course of treatment by caustics 
 and by canule-a-demeure, lirc. ; their object being, partly to evacuate the 
 solid contents of the sac, and |)artly to correct decomposition ; however, 
 they have also had a limited use as direct parasiticides, and also, 
 apparently, with a vague idea that they caused adhesive inflammation 
 in the sac, and thus led to the cure of the disease; in this case puncture 
 forms, of necessity, a part of the treatment. 
 
 Out of eighteen cases in Avhich injections were employed in this 
 manner, five died and thirteen recovered. Numerous substances have 
 been used as injections, e.g., iodine, alcohol, carbolic acid, ox-bile, extract 
 of male fern, A:c. ; the latest modification being that suggested by 
 Professor Bacelli, of Rome; he advises that about ten centigrammes of 
 the contents of the parasite should be removed, and replaced by an equal 
 bulk of a two per 1000 solution of mercuric chloride. At present, 
 no satisfactory conclusion can be drawn as to the effect of this treat- 
 ment, but there seems to be no reason to expect better results from 
 it than from the use of iodine or carbolic acid. (For a fuller discussion 
 of this mode of treatment see the Australian MedicalJonrnal, June 1888.) 
 
 (c) The Treatment of Hydatid Cysts by Electricity. 
 Electromotive force has been tried in various forms for the ])urpose of 
 destroying this parasite, as faradism, galvanism, and by way of electro- 
 lysis. The last-named is the only form of application of electricity 
 worthy of .serious consideration. It has been tried ))rincipally in cases 
 of liver echinococci. Out of twelve cases, collected from various sources, 
 one died; in one case it distinctly failed to cure, but in the remaining 
 ten cases it was claimed that cure resulted.
 
 358 
 
 INTKUCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 In one case of Splenic hydatid recorded by Magdelaine (Paris Thesis, 
 1868), electro-puncture was tried for one minute, but indications of 
 peritonitis followed in a few days, and the patient was then successfully 
 treated by Recamier's method. For the present it seems to me that the 
 successes claimed for electrolysis in the treatment of this disease are 
 probably referable sim])ly to the puncture which is its necessary accom- 
 paniment. (For a further discussion of tliis subject, see the Australian 
 Jlledical Journal, June 1888.) 
 
 Radical Operations. 
 We now arrive at the consideration of " Radical Operations." These 
 include — (a) Caustic treatment; (6) Canule-a-demeure operations; and 
 (c) Various modifications of incision procedures. 
 
 (a) Caustics. Recamier's Method. 
 
 The uncertainty of cure after tapping with a fine trochar, and the 
 danger occasioned by the escape of the cyst contents into the peritoneal 
 cavity when a large instrument is used, led to attempts being made 
 to procure adhesions between the sac and the parietes by various 
 methods. One of the earliest and most important of these, was the use 
 of caustics, applied repeatedly at short intervals of time, until the 
 surface of the sac was reached, or even until an opening in the sac 
 itself was procured; the contents were tlien removed, and the effects of 
 their decomposition were, as far as possible, corrected by the i;se of 
 antiseptic injections. The principal chemical agents employed for this 
 purpose were caustic potash and zinc chloride. 
 
 As the process of opening the cyst by caustics was a very tedious one, 
 many operators hastened it by making incisions to a certain depth, and 
 then applying caustic to the floor of tlie wound, and in the majority of 
 cases the sac itself was opened either by an incision or by puncture with 
 a large trochar. The general results of the caustic method appear in 
 Table II. 
 
 Table II. — Shoiving the Results of Treatment hy Caustics in Ninety-Jive 
 Coses of Echinococcus Cysts Situated in Various Organs : — 
 
 OncAN Affkcted. 
 
 Deaths. 
 
 Failures 
 
 TO CURK. 
 
 ClIRFS RKSt'LT 
 
 TOIAL. 
 
 Liver 
 Kidney . . 
 Spleen . . 
 
 Abtloraiiial hydatids of 
 uncertain seat 
 
 25 
 3 
 
 4 
 
 2 
 
 55 2 
 
 1 1 — 
 
 2 — 
 
 1 i — 
 
 84 
 4 
 6 
 
 1 
 
 Total . . 
 
 32 
 
 2 
 
 59 2 
 
 1 
 
 95 
 
 Summarii of Tahle II. 
 
 Deaths . . . . . . H;-i-(;8 per cent. 
 
 Cures G2-l() 
 
 Faihu-es to Cure .. .. 210 ,, 
 
 llesult Uncertain .. .. 2-10 
 
 99-98 
 It will 1)0 seen that about one-thii'd of the cases so treated died.
 
 THE OPERATIVE TREATMENT OF ECIIINOCOCCUS CYSTS. 359 
 
 Tliis method of treatment is to be condemned for the following 
 reasons : — • 
 
 (1) Its high mortality, nearly thirty-four per cent. 
 
 (2) Its extreme painful ness ; for in children it has even been found 
 necessary to discontinue the treatment for this cause. 
 
 (3) Its prolonged duration ; probably three or four months on an 
 average are required for convalescence, which can hardly be said to begin 
 until the motlier-oyst has escajied. 
 
 (4) Its total inapplicability in some localities, e.g., fur lung hydatids, 
 or pelvic cysts. 
 
 (5) Even when applicable in a given case, it cannot be depended 
 upon to procure etiicient adhesions. 
 
 For these reasons, Recamier's treatment should forthwith pass into 
 disuse. 
 
 [h) Canule-a-demeure. 
 
 The aims of this i)lan of treatment are identical with those of 
 Iiecamier's method, viz., to establish a free o])ening into the sac of the 
 parasite, in order to extract its contents, and at the same time to 
 establish adhesions, in order that none of the cyst contents should escape 
 into the peritoneal cavity ; there can be no doubt that this metliod 
 represented a great advance upon the treatment by caustics, as is 
 sufficiently proven by its lower death rate, and also by the fact that it 
 can be adopted when the parasite is situated within the limits of the 
 thoracic parietes. In ninety cases in which this treatment was 
 employed for liver hydatids, there were tw,enty-four deaths, or at the 
 rate of nearly twenty-seven per cent.; but this is better than the death- 
 rate of the caustic treatment, which amounts to over thirty-three per 
 cent. In three cases of sjjlenic hydatid, however, so treated, all proved 
 fatal. In a large proportion of the fatal cases, death took place from 
 septicaemia, caused principally by imperfect evacuation of the cyst 
 contents, which generally soon become decomposed; two of the deaths 
 from peritonitis appear to have resulted from escape of the cyst contents 
 into the peritoneum, and in one of them the canula had slipped out of 
 the sac. 
 
 The objections to the canule-u-demeure treatment are: — 
 
 (1) The uncertainty of the course of the canula. In most cases it is 
 not difficult to avoid transfixing the intestine or stomach, but it is 
 common to traverse the omentum ; but in the case, for example, of a 
 pelvic hydatid projecting in the hypogastric region, it may easily happen 
 that the iirinary Itladder may be carried up by the cyst, and that it may 
 be transfixed by the trochar. It is needless to comment upon the probable 
 result. 
 
 (2) In the case of a deeply-seated cyst, it is quite connnon for the 
 canula to slip out of the sac, in consequence of the collapse of the 
 ]iarasite, caused by the evacuation of its fluid contents. I have seen fatal 
 ])neumo-thorax caused in this way, by an attem])t to treat a pulmonary 
 cyst by canule-a-demeure; even when a long trochar is used this may 
 happen, and on the other hand, if the instrument be too long, it may 
 wound the distal wall of the capsule. 
 
 (3) It is practically impossible to prevent the cyst contents from 
 becoming septic ; the amount of discharge is so great that the usual
 
 360 IMTEKCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 antiseptic precautions fail ; indeed it is probable that if perfect asepticisia 
 could be maintained, adhesions would not form ; this, at any rate, has 
 been the experience of Trendelenberg with regard to Simon's operation 
 of double puncture, in which two canulas are retained in the sac for the 
 sole ])urpose of causing adhesions. 
 
 (4) The process is a slow one, for on an average convalescence 
 occu])ies from two to four months, and it has been known to extend to 
 ten or twelve months; the reason of this is, that a considerable time is 
 occupied in the process of making an opening into the sac of sufficient 
 size to allow the mother-cyst to be extracted, and usually it comes away 
 in fragments, and until all the solid constituents of the parasite have 
 been removed, the sac rarely closes ; moreover, the presence of any 
 shreds of membrane induces suppuration and decomposition in the sac, 
 and thus tends to cause septicaemia, and to delay convalescence. 
 
 (c) Various Forms op Incisiox Operatioxs. 
 
 Operations by incisions upon hydatid cysts are influenced in an 
 important manner by the precise locality of the parasite, so that it is 
 necessary to consider separately — (a) abdominal, and (b) thoracic 
 hydatids. 
 
 Some hydatid cysts, which have their origin within the abdomen, 
 necessitate opei'ations which invade the thoracic cavity, e.g., echinococci 
 of the convex surface of the liver, aiTd those connected with the upper 
 part of the spleen. 
 
 In consequence of their relative frequency, the most important 
 abdominal hydatids are those of the liver, and consequently they merit 
 our first and most attentive consideration. 
 
 The Treatiaeat of Ecliinococcus Cysts of the Liver hy various Muds of 
 Incision Operations. 
 
 The recorded cases of liver echinococci, treated by various modes of 
 incision, comprise a motley group. The earlier cases so dealt with 
 were usually operated on under the impression that they were abscesses 
 pointing on the surface ; but, in later instances, the incision Avas made 
 after unsuccessful attempts to cure the disease by other plans of treat- 
 ment, such as tapping and canule-a-demeure. Arc. Very frequently, 
 during the employment of the caustic treatment, the sac was opened by 
 an incision when it was believed that adhesions had been procured ; and 
 in other in.stances, preliminary incisions were made into, but not 
 through, the abdominal walls, caustics being then applied to the bottom 
 of tlie wound. In a few cases, non-suppurating hydatids were rashly 
 cut into, without any precautions being taken to previously procure 
 adliesions, the result generally being that the patient died quickly of 
 peritonitis irom escape of the cyst-contents into the peritoneal cavity. 
 Tlie danger of such a procedure soon forced itself upon the notice of 
 operatoi-s, and thenceforth it became a recognised principle, that 
 hydatids of tlie liver should not l)e incised, unless adhesions were 
 believed to be present. 
 
 To attain this end, caustics were used by many operators, but others 
 regarded them as unsatisfactory, and various means of procuring 
 adhesions were suggested and practised. For example. Trousseau had 
 recourse to multiple acupuncture for this purpose. Begin's method
 
 THE OPEKATIVE TREATMENT OF ECHINOCOCCUS CYSTS. 3G1 
 
 consisted in reaching tlie tiuiiour by repeated incisions, the wound 
 being meanwhile plugged with lint ; sometimes the first incision was 
 carried down to the peritoneum, and occasionally even tlu'ough tliat 
 structure. A modification of this procedure, resulting from the intro- 
 duction of the antiseptic method, has been advocated and successfully 
 practised by A'olkmann. Another plan, having a similar aim, is 
 Simon's method of double-puncture, followed by incision. Finally, as a 
 result of the recent advances in abdominal surgery, comes the method 
 of treatment generally associated in Germany with the name of 
 Lindemann, of Hanover, by which the sac is immediately incised, its 
 contents evacuated, the lips of the wound in the fibrous capsule being 
 securely attached by sutures to the edges of the parietal incision. 
 
 Before entering into a detailed discussion of these various operations, 
 it is necessary to distinguish between those cases in which tlie parasite 
 is accessible through the abdominal parietes, and those in which it can 
 be reached only by traversing the pleura, as when the cyst occupies 
 the convexity of the liver; for it is obvious that the invasion of the 
 pleura inti'oduces a new element of difficulty and danger into the 
 treatment. 
 
 In order to arrive at trustworthy conclusions, it is necessary also to 
 separate those cases in which no precautions against escape of the cyst- 
 contents into the peritoneal and pleural cavities have been taken, from 
 those where such precautions have been taken. Also, it is needful to 
 consider the influence of antiseptic treatment ; of complete evacuation 
 of the solid and fluid contents of the sac ; of effective drainage, Szc. 
 
 It follows that a just criticism of the results of the various incision 
 operations is not by any means a simple matter. Operations by 
 incision will be considered under two principal groups, viz., (n) 
 abdominal incisions, (6) thoracic incisions. 
 
 1. — Simple Ahdominal Incisions, loithout jrrecaiUions. 
 
 In.tliis class will come simple abdominal incisions in which no special 
 precautions were taken to prevent the escape of the cyst contents into 
 the peritoneal cavity. Many of these were operated upon under the 
 mistaken idea that they were cases of abscess. 
 
 General Results. 
 
 No. of Ca^es. I'er Cent. 
 
 Deaths 23 .. 38-5 
 
 Cures .. .. .. .. 34 .. o6'-> 
 
 Recoveries .. .. .. 3 .. 50 
 
 GO 100-0 
 
 It will be seen by the above table that simple incision, without 
 precautions, is a very mortal operation. 
 
 Causes of Death. 
 
 Cas 
 
 Peritonitis certainly in . . . . . . . . 7 
 
 Peritonitis probably iu . . . . . . . . 4 
 
 Septicffimia ,. .. .. .. .. 7 
 
 Exhaustion ,, .. .. .. .. 1 
 
 Pleurisy ,, . . . . . . . . 1 
 
 Uncertain ,, .. .. .. .. 3 
 
 23
 
 362 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Peritonitis seems to ha-\e been the cause of death in about half the 
 fatal cases, and to have been itself occasioned by the escape of the 
 cyst-contents into the abdominal cavity ; in one instance, however, 
 the fatal peritonitis was produced by tlie accidental puncture of the 
 bladder in an attempt to procure drainage. The majority of the 
 remaining deaths were apparently due to imperfect evacuation of the 
 decomposed cyst-coiatents causing blood-poisoning. Multiple cysts were 
 present in five fatal cases. 
 
 Cures. — In 23 of these cases it is clearly set forth that suppuration had 
 taken place in the sac, and consequently, there is little doubt but that 
 adhesions had formed ; indeed, in some instances, it is expressly stated 
 that the tumour was regarded as an abscess. It would profit little to 
 devote much space to the discussion of this form of treatment; it 
 suffices, however, by its appalling mortality, to teach the lesson that the 
 cyst-contents should be jealously excluded from the peritoneal cavity. 
 This vitally important object may be attained, before the opening of 
 the sac, as by the methods of Simon and A'olkmann, or at the time of 
 incising the sac, as by the method of Lindemann. 
 
 Simon's Operation of Double-Puncture followed by Incision. 
 
 References. 
 
 Simon. — Mittheilungen aus der chirurgischen Station des Kranken- 
 hauses zu Piostock. — Deutsche KUnik, No. 43, October 27, 1866. 
 
 Uterliart. — Ueber die Incision nach Doppelpunktion zur Heilung der 
 Echinococcencysten des Unterleibes, nebst Beschi'eibung zweier 
 Operations-fadle, welche in der chirurgischen Klinik des Rostocker 
 Krankenhauses vorkamen. — Berliner Kiiiiische Wochenschri/f, No. 17, 
 April 27, 1868. 
 
 Wall/'. — Operative Behandlung zweier Unterleibs Echinococcen,.nel)st 
 einigen Bemerkungen ueber f unf fruher in der hiesigen Klinik operirte 
 Faille. — Berliner Klinische Woclienschrift, No. 5, January 31, 1870. 
 
 Treiulelenhury, in Madelung. — Beitra^ge Mecklenburgischer ^rzte 
 zur Lehre von der Echinococcen-Krankheit. — Stuttgart 1885, page 155, 
 et seq. 
 
 Recognising the dangers of permitting the escape of the cyst-contents 
 into tlie abdominal cavity, and impressed with the disadvantages of the 
 method of Recamier in the treatment of liver hydatids, Simon 
 devised and practised the method of procedure associated with his name. 
 It nnist be premised, that botli by Simon and by his followers it was 
 considered tliat suppuration of the cyst-contents formed an essential 
 feature of the intended process of cure ; this is clearly set forth in the 
 contributions both of Uterhart and Simon himself {loco cit.) 
 
 The plan of operation as described by Uterhart is as follows : — At 
 the most prominent part of the tumour, or where fluctuation is most 
 pronounced, a fine exploratory ti'ochar and canula are introduced to a 
 depth of some inches ; the trochar is removed, and the character of the 
 fluid that escapes is observed, in order to establish the diagnosis ; if 
 this be satisfactorily determined, a second fine or a somewhat larger 
 instrument is inserted at a point two and a half or three centimetres 
 (say an inch) distant. After a part of tlie contained fluid has been 
 permitted to flow away through the canuhv, the latter are plugged with 
 
 I
 
 THK OPKRATIVK TREATMENT OF ECIIIXOCOCCUS CYSTS. 301^ 
 
 cafbolisecl \\';ix, ancl a pi'otective dressing' is applied ; for the next few- 
 days the patient must remain very quiet in ])efl. In two or three days' 
 time a portion of tlie accumulated fluid is a<i;ain allowed to escape in 
 (irder to see whether it contains any admixture of pus, and tliis 
 inspection is repeated at intervals until tlie opacity of the fluid, and the 
 penetrating; odour, render probable the detachment and commencing 
 decomposition of the mother-cyst. 8imon generally allowed the canuhv 
 to remain in the sac until the fluid of the cyst began to escape at the 
 sides of the instruments. Then adhesions are likely to have been 
 established between the sac and the parietes, and now incision into the 
 cyst is performed between the two points of puncture. Unless some 
 urgent symptoms, such as liigh fever witli signs of op2:)ression, appear, 
 the opei'ator may delay incision until the fourteenth day, or later. The 
 solid constituents of the parasite should be remo^-ed as completely as 
 ])ossible by means of forceps, ikc. 
 
 Uterhart compares this method with the caustic treatment, and 
 insists upon the following points in its favour : — 
 
 1. That the diagnosis is safely established, before the connnencemeiit 
 of the opei'ation, by the introduction of the flrst canula. 
 
 2. The great certainty of the pi'oduction of adhesions between the 
 sac and the parietes. He states that on one occasion, after the double 
 puncture of a case of hydro-nephrosis, in a pei'son who died soon after 
 the operation from double pneumonia, the post-mortem examination 
 showed that very extensive adhesions had formed within 48 hours. It 
 can also be seen that, in two or three days' time after puncture, the 
 tumour- no longer slides under the abdominal walls synchronously with 
 the movements of respiration. It can hardly be doubted that, as 
 compared with tlie caustic treatment for the production of adhesions, 
 Simon's method is preferable. 
 
 3. The lesser degree of reaction upon the genei-al health, and the 
 smaller amount of painfulness, as compared with Recamier's plan. 
 
 4. The shorter duration of the treatment prior to the opening of the 
 .sac — ten to fourteen days after double puncture the sac may be incised, 
 whilst in some cases under caustic many weeks or even months may 
 elapse before a free exit is procured. 
 
 A modification of Simon's pi'ocedure was practised in one recorded 
 case by Boinet. A large cyst of the li\ er was treated by canule-a- 
 demeure, the patient soon showing dangerous symptoms of septiciemic 
 poisoning, apparently due to decomposition of the contents of the sac 
 and imperfect drainage. To relieve the patient Boinet removed the 
 canula, and passed along its track a strongly curved ti'ochar, so as to 
 make a counter-opening into the sac ; through this canula he trans- 
 mitted an india-rubber drainage tube, the two projecting ends of whicli 
 were secured together outside the abdominal wall ; in the course of a 
 few days, feeling assured that adhesions had formed, he di^•ided the 
 tissues between the outlets of the drainage tube. 
 
 It cannot l)e denied that Simon's opei'ation represented a decided 
 advance upon Recamier's method, but still it left much to be desired. 
 Simon thought that radical operation was not permissible in recent 
 cases of hydatid disease, and that it should be performed only when the 
 tumour had attained a considerable size, or when suppuration had taken 
 place ; he regarded old cysts, witli rigid Avails, as those particularly
 
 364 INTEHCOLONIAL .MEDICAL CONGKESS OF AUSTRALASIA, 
 
 suited for liis method of treatment. Uterhart, however, considered 
 that all cases of echinococcus cysts, that could be satisfactorily diagnosed, 
 were tit cases for this operation. 
 
 Objections to Simon's Operation. 
 
 1. Suppuration of the cyst-contents, with resulting pyrexia, Ac, 
 seems to be an invai'iable accompaniment of Simon's operation ; the 
 temperature usually ranges from 100-4° to 102-4°, and continues until 
 the sac is incised ; it has been attributed by Woltf {loco cit.) partly to 
 the peritonitis excited by the irritation of the canul*, but as it 
 generally subsides soon after incision of the cyst, it is more probably 
 due to the retention of suppurated cyst-contents. It is acknowledged 
 by most writers who have advocated this method, that sujjpuration, 
 if not an essential element of it, at least is its constant accompaniment ; 
 occasionally attempts have been made to treat the cases by antiseptic 
 precautions, but usually, if not invariably, this has failed, for the sac 
 has generally suppurated, or adhesions have not formed. 
 
 As an example of the extreme difficulty met with in the attempt to 
 carry out Simon's method with Listerian precautions, I may cite briefly 
 a case treated in Yolkmann's clinique at Halle, and recorded by 
 Ranke (Berl. Kiln., Wochensch., Nov. 9, 1874, page 565). In this 
 instance, a hydatid cyst of the liver was iirst punctured by an 
 exploratory trochar under strict antiseptic precautions, and normal 
 clear non-albuminous hydatid fluid escaped ; an attack of urticaria 
 followed ; live days later two canulaj were introduced, also with 
 antiseptic measui'es, and after the escape of 1500 grammes of light- 
 yellowish clear fluid containing traces of albumen, the canulte were 
 plugged with carbolised wax ; Lister's dressing was applied and 
 continued for six days ; the canulee were then i-emoved and rej^laced by 
 a silver sound for three days. During the whole of this time the 
 temperature remained nox-mal ; then continuous pyrexia, with increase 
 in size of the tumour, came on. Seventeen days after puncture, 
 incision was performed, and it was found that the omentum, which was 
 adherent to the parietal peritoneum, had to be divided in order to reach 
 the cyst, and yet in this case suppuration took place ; and notwitli- 
 standing this, when the sac was incised, it was found necessary to stitch 
 it to the abdominal wound. As an indication of the pains taken in the 
 treatment it may be stated than no fewer than four dressings daily 
 "were employed for some time ; Ranke naturally points out that this 
 would be impracticable in private pi-actice. 
 
 2. Trendelenburg {loco cit.), who had enjoyed special opportunities of 
 witnessing and practising Simon's method at Rostock, remarks that it 
 was not found to be satisfactory, because it could not be depended upon 
 to procure adhesions, at any rate to a sufficient extent to make the 
 subsequent incision safe eight days after the insertion of the canuhe. 
 Indeed, lie attributes Simon's success in oljtaining adhesions to his use 
 of non-disinfected canuhe, in conse(]uence of which a rapid decomposition 
 of tlie cyst-contents took j)lace, and tliis evoked adhesive inflammation 
 between tlie sac and tlie pai-ietes, and Ti-endelenburg found that by 
 the strictly antiseptic use of this metliod, the adliesions were so 
 imperfect at the time of incision that it was found necessary to stitch 
 the sac to the parietes.
 
 TIIK OPKUATIVE Tlir.ATMKNT OF KCIIIXOCOCCrS CYSTS. 365 
 
 The J\'esu/fs of Siiiiou'f! OjH'ration. — I have been able to collect only 
 24 cases in which this method of treatment was adopted ; in 21 of 
 them the parasite was situated in the liver, in 3 in the spleen. 
 
 Lirer Uchinococci Treated hij Shnoiis Method. — Out of the 21 cases, 
 there were — cures 10, deaths 10, result not stated 1 case. As regards 
 the fatal cases, one died, not from the operation or the parasite, but 
 from dysentery which was, at the time, pi'evalent in the Hos23ital where 
 the patient was treated. Peritonitis was the immediate cause of death 
 in more than half, i.e., in five instances ; in some of them it is expressly 
 stated that when the incision was being performed it was noticed that 
 the adhesions were xevy imperfect, and it is probable that, in most of 
 the cases in question, the peritonitis was caused In' imperfect closure of 
 the peritoneum, and consequent escape of the ftvtid contents of the cyst 
 into the abdominal cavity. Septic;vmia was tlie cause of death in two 
 cases ; in one it was associated with erysipelas, in the other it was 
 largely due to the slow and inq:)erfeet evacuation of the putrid cyst 
 contents. In one case, recorded by Fiedler (Devfsch. Archiv far Kiln. 
 Medic. 1869), the patient died of collapse immediately after injection 
 of the sac (see Austndian Medical Journal, March 1889.) 
 
 Hi/datids of the Spleen Treated hy Simmies Method. — In one case, 
 reported by Uterhart, two tine trochars were insei"ted into the tumour 
 in the usual manner, but when the bridge of tissues between tlie 
 punctures was incised, it was discovered that some intervening coils of 
 the intestine had been cut, and that the canuhv had penetrated 
 only one centimetre deep into the sac ; the cut intestine was sutured, 
 and the patient recovered both from his hydatid and the operation. 
 Perhaps no case could more clearly demonstrate the drawbacks of 
 Simon's method than this one does. A second case by Wilde (Archiv. 
 filr Klin. Medic, von Ziemssen, VIII.) recovered, but the fistula did not 
 entirely close for 16 months. A third case, recorded by Wolff (Berl. 
 Klin. Wochenschr. 1870, No. 5, page 56), died 25 days after the 
 operation, of pyaemia. 
 
 The general results of Simon's treatment, in the published cases that 
 I have met with, are therefore by no means good, as the following 
 summary shows: — deaths, 11; cures 13 cases. One of the deaths 
 was not due to the parasite or the operation. 
 
 Incision Operations Performed in Tavo or More Stages ; 
 Methods of Begin, Yolkmaxn and others. 
 
 The attempt to procure adhesions between the parietes and the sac or 
 the liver OA'erlying the hydatid, has been made by carrying an incision 
 cautiously down to the peritoneum, or even through that structure ; the 
 resulting wound being then plugged for a few days, until the irritation 
 of the injuiy and the dressing has caused local peritonitis and adhesions. 
 Begin followed this plan, and plugged the wound with common lint ; 
 but after the introduction of the antiseptic method, the dressing 
 consisted of carbolised gauze, &c. — this modification is known in 
 Germany as Volkmann's method. In anotlier modification the surface 
 of the sac is exposed, and is then stitched to the lips of tlie wound, 
 which is packed with an antiseptic dressing. 
 
 I have collected seventeen cases treated by one or other of these 
 procedures, with fourteen recoveries and three deaths.
 
 SdQ INTEUCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 This opei'ation is decidedly inferior to that of Lindemann, which is 
 next described, and presents no advantages as to safety. 
 
 Lindemann's Operation. 
 
 liej'erences. 
 
 Stenyer. — Ziir Operativen Behandlung der Abscesse iind Hydatiden 
 der Leber. — Berliner Klin. WochenschriJ't, 1877. 
 
 Kirchner. — Ein Beitrag zur Operation der Echinococcen der Organe 
 der Bauchliohle. — Inavij. Dissert. Berlin 1879. 
 
 ScJdegteudal. — Die Lindeniannsche Einzeitige Operation der Echino- 
 coccen der Bauchorgane. — Arc/iiu j'nr Klinische Cldruryie, 1886. 
 
 Landau. — Zur Operativen Behandlung der Echinococcen in der 
 Bauchhohle. — Berl. Klin. WocJienscli., 1880. 
 
 Lawsoii Tail. — Four cases of Hepatotomy. — Birinin(jJtani Medical 
 lievleio, October 1881. 
 
 8chlegtendal (^loco clt.) has conclusively estaljlished the claims of 
 Lindemann to be considered the practical originator of the mode of 
 treatment of hydatid cysts associated with his name in Germany. The 
 first operation of this kind, at any rate of which we have clear details, 
 was performed by Lindemann in 1871 ; but the earliest account of the 
 method was not published until 1879 by Kirchner {op. cit.) 
 
 The history of Lindemann's first case, as related by 8chlegtendal, is 
 interesting. The patient in question had a tumoui' of the liver, relative 
 to the nature of which a difference of opinion existed between Lindemann 
 and Stromeyer. The tumour was so tense, and the abdominal wall 
 overlying it so thin, that spontaneous rupture was imminent, and 
 an incision was performed. The opening in the sac was attached to the 
 parietal incision by deep stitches, and the patient recovered rapidly. 
 Although this operation was apparently not premeditated in the form 
 in which it was performed, yet the lesson taught by it was not lost, and 
 in futui'e Lindemann incised the parietes, exposed the sac, opened it, 
 and stitched it to the abdominal wound, all under antiseptic precautions; 
 and thus he initiated what is without doul:)t the most effective and 
 safe form of i-adical treatment. 
 
 JNIeanwhile, and two years prior to the publication of Kii'chner's work, 
 Si^-nger [loco cit.) published a method of opei'ation, which differed but 
 little fi"om Lindemann's plan. The abdominal wall was incised down to 
 the cyst, which was at once secured by stitches to the lips of the 
 external wound, and then was incised. Landau's operation was 
 practically similar. Lawson Tait, in 1881, published an account of four 
 cases, in which virtually the method of Lindemann had been followed. 
 Furtlier allusion to the history of the operation is needless, for any 
 credit of priority must in fairness be conceded to Lindemann, of 
 Hanover. 
 
 The Mode of Operation. 
 
 Th(^ usual proccdun^ of antiseptic laparotomy is employed, with or 
 without tlu! trouljlesomc! adjunct of the steam spray. Before the 
 peritoneum is reached all l)le(;diiig is arrested, either by foi'ci-pi'essui'e, 
 or, if need 1)6, by aseptic ligature (carbolised kangaroo tendon, catgut, 
 or silk) ; tlie peritoneum is then cai-efully incised to the same extent as
 
 THE OPERATIVE THEATMENT OF ECIIINOCOCCUS CYSTS. :K)7 
 
 the rest of the parietal hiyers, and now usually, if the site of the 
 operation has been well chosen, the surface of the parasite enclosed 
 in its sac appears. Occasionally a piece of omentum, oi* even a loop of 
 intestine may intervene, and in some cases (especially if the parasite 
 be A-ery old, or suppui'ation have taken place) the sac may be adherent 
 to the parietes. When this is not the case, a loop of stout aseptic 
 silk is passed through the sac wall on each side, parallel to the lips of 
 the wound. In order to pass these loops through the tough sac, I 
 have found it most convenient to employ a strong well-curved needle, 
 set in a tinu handle ; the needle may be tlu'eaded either before or after 
 having been passed through the sac. 
 
 Aftei' the passage of the needles and loops, there is usually some 
 escape of the Huid contents of the cyst at the sites of tlie puncture. 
 This is especially apt to occur in the case of living echinococci in which 
 the tluid is at a high pressure. Great care should be taken to prevent 
 the escape of the Huid — especially if it be purulent or foetid — into the 
 peritoneal ca\ ity ; this can be done by drawing the sac firmly up to the 
 parietal wound by means of the loops, and by the use of a sponge. A 
 part of the fluid contents of the cyst may now be removed by means of 
 a trochar, or the sac may be immediately incised. AVhen most of the 
 fluid has been evacixated, the lips of the cut in the sac must be carefully 
 stitched to the corresponding ones in the parietal wound. For tJiis 
 purpose carbolised kangaroo tendon, or silk, or silver wire may be used ; 
 the stitches should be applied at intervals of about a quarter of an inch 
 apart, so as to closely unite the sac to the external wound ; some 
 operators include the skin, others, such as Trendelenljui'g, include only 
 the peritoneum, the mviscular layers, and tendinous fascisv. It is 
 claimed that by excluding the skin, there is less risk of dragging on the 
 lips of the wound during the contraction of the sac that occurs during 
 the process of cure. It is an open question, however, whether the 
 greater security of hold obtained by including the skin does not 
 compensate for the local ii'ritation often produced by the tension upon 
 the skin. I have seen much redness of the skin around the wound, and 
 e\en the detachment of a piece of the flbrous capsule, result from this 
 cause, but apparently witl)out any untoward influence upon the process 
 of cui'e; the irritation of the skin soon subsides after the removal of tlie 
 deep stitches. 
 
 When the sac has been safely stitched, the solid and remaining fluid 
 contents of it sliould he carefully, and if possible completely, removed ; 
 for it must be remembered that these are foreign bodies, and until they 
 are completely expelled, the sac cannot close. I place great stress upon 
 this, for the presence in a remote cul-de-sac of even a small shred of cyst 
 is a cause of continued discharge. To attain this object, various forms 
 of forceps are useful, Ijut it is desirable that instruments for this 
 purpose should be provided with broad fenestrated jaws, which bite in 
 parallel planes, and so obtain a wide but gentle grasp. Much care is 
 needed to preAent the tearing of the mother-cyst in the process of its 
 removal. In order to remove the daughter-cysts, if any be present, and 
 to get rid of any fragment of the mother-cyst that may remain, it is 
 advisable to wasli out the sac with sterilised water, thymol or carbolic 
 lotion, or some other antiseptic fluid ; a syringe, provided with a long 
 tube, beinfj inserted to the bottom of the sac.
 
 368 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Finally, a long and wide india-rubljer drainage tube, with lateral 
 perforations, is inserted into the wound, and the patient is turned on 
 the side, in order to drain the ca^■ity of the injection still left in it. It 
 is also an excellent plan to withdraw, by means of a syringe, to the 
 nozzle of which a long piece of india-rubber tubing is attached, the last 
 traces of fluid from the bottom of the sac ; or the interior of the cavity 
 may be sponged dry. 
 
 Antiseptic dressings of some kind should certainly be used. I 
 am in the habit of employing a large pad, the basis of which is a layer 
 of picked oakum about an inch-and-a-half thick, over this is .spread a 
 layer of Hartmann's wood-wool to the depth of half an inch or so ; the 
 whole is then enclosed in a layer of alembroth or other antiseptic gauze. 
 The pad is so placed as to provide for the natural gravitation flow of 
 the discharge. 
 
 If the sac be thoroughly cleared out at the time of the operation, the 
 amount of the discharge is usually small, but a daily dressing is 
 commonly needed for the flrst few days. If the case proceed satis- 
 factorily, there is no suppuration from the sac, but there is usually a 
 little pus discharged from the lips of the wound. The stitches may be 
 remo^•ed in Ave or six days. 
 
 By Lindemann's operation, unlike Simon's, suppuration of the sac is 
 not a necessary element, but, on the contrary, an accidental and 
 undesirable one. The normal process of cure was well seen in the case 
 of a child, aged 8, treated in 1886 by my colleague, Dr. Yerco. 
 Lindemann's operation was perfoi-med, and for four days the progress 
 of the case was satisfactory ; on the fifth day, however, convulsions 
 came on, with increased rapidity of pulse and respiration, and deepening 
 loss of consciousness, and the patient died, from no evident cause 
 discoverable during life or after death. The condition of the sac was 
 as follows : — " The walls of the cavity had folded together over a 
 considerable area, especially at the outer and back part, so that the 
 opposed surfaces had come together, and here lymph had been poured 
 out, which had united the surfaces by plastic adhesion, and had to this 
 extent obliterated the sac." 
 
 Early union of this kind can only take place when the fibrous capsule 
 is not rigid from degeneration ; but when the opposite condition exists, 
 tlie process of cure must, of necessity, be less prompt, for the walls of 
 the cavity do not readily fall together. 
 
 When the walls of the cavity collapse, after the removal of the 
 mother-cyst, etc., it is, in my opinion, better not to use injections 
 during the after treatment, but when drainage by collapse of the sac 
 and gravitation is inadequate, and pus accumulates, as when the 
 parasite invades or starts in the pelvis, injections may be necessary, 
 I have seen pyrexia result in such a case from no discoverable cause, 
 except that, in spite of the use of large drainage tubes, ttc, the 
 secretions of the cavity could not freely escape. 
 
 In cases where there is a tendency to the accumulation of tlie secre- 
 tions of the capsule in the pelvis, prol)ably the employment of aseptic 
 i:ai)illary drains, enclosed in india-rubber (h-ainage tubes, Avould be 
 preferable to injections. I have not yet had the o]iportunity of trying 
 this mode of drainage in hydatid cysts.
 
 THE OPERATIVE TREATMENT OF ECHINOCOCCUS CYSTS. 369 
 
 The Results of Abdominal Sections lierformed on Ilj/datid Cysts of 
 the Liver, accordiny to Lindemann's Method. 
 I have collected 68 c;ises of Li^•er Hydatids, treated by abdominal 
 section, immediate removal of the mother-cyst, and stitching of the 
 sac to the parietal wound. 
 
 General Eesults. 
 
 Deaths .. 7 or 10- 29 per cent. 
 
 Recoveries .. 61 or 89-70 per cent. 
 
 Deaths. — In one case the patient died during the operation from the 
 sudden arrest of the circulation thi-ough the heart, Ijy a hydatid cyst in 
 it. In two cases there were mviltiple hydatids in the body. 
 
 Cures. — These amounted to the extraordinarily high proportion of 
 nearly 90 per cent., and this fact alone establishes the claim of this 
 operation to be regarded as by far the best method of treatment of 
 liver hydatids now practised, at any rate when the cyst is accessible by 
 an abdominal incision. 
 
 Not only are the tinal results good, but the duration of convalescence 
 is brief, for in 19 cases in which this point is alluded to, the period of 
 convalescence was as follows : — - 
 
 In 3 weeks . . . . . . 1 case. 
 
 In 4 weeks . . . . . . 2 cases. 
 
 In 5 weeks . . . . . . 2 cases. 
 
 In 6 weeks . . . . . . 1 case. 
 
 In 2 months . . . . . . 6 cases. 
 
 In 2^ mouths . . . . . . 4 eases. 
 
 In 3^ months . . . . . . 3 cases. 
 
 19 
 Thoracic Incisions. 
 
 Cases of Hydatid Disease treated by Incisions through the Chest 
 Walls, with or without excision of a portion of one or more ribs, belong- 
 to five distinct groups, viz : — 
 
 1. Unruptured Hydatids situated on or near the convex surface of 
 the Liver, and therefore not accessible by abdominal incision. 
 
 2. Hydatid Cysts, usually of the right lobe of the Liver, which have 
 ruptured into the Pleura, treated by incision and drainage of the 
 pleural cavity. 
 
 3. Pulmonary Hydatid Cysts which may or may not have ruptured 
 into the broncliial tract. 
 
 4. Pulmonary Hydatids which have ruptured into the Pleura. 
 
 5. Hydatids of the Pleura operated on by Incision. These are but 
 few in numljer, and will not be described in this communication. 
 
 1. — Unrioptured Hydatids situated at or near the Convex Surface 
 
 of the Liver. 
 Echinococcus cysts which have originated near the upper surface of 
 tlie liver, but still within that organ, usually grow in the direction of 
 least resistance, which then happens to be upwards. They consequently 
 invade the right chest, and often are with difficulty to be distinguished 
 from hydatids of the base of the right lung. Cases have been recorded 
 in which the parasite appeared to have originated between the diaphragm 
 and the upper surface of the liver ; and what is perhaps even more 
 
 1b
 
 370 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 curious, hydatid cysts have been met witli in the substance of the 
 diaphragm itself. For example, Vital* mentions the case of an Algerian 
 native, aged 35, who died of chronic dysentery, at whose post-mortem 
 examination numerous hydatids were found, including one of the size of 
 a child's head, which had developed in the substance of the diaphragm, 
 and was covered in part by the pei'itoneum, and in part by the 
 pleura. 
 
 In the Pathological Museum of the University of Oxford, there is 
 also a specimen of this kind. 
 
 Until quite recently, hydatid cysts in this locality have always been 
 treated by puncture with a tine trochar or aspirator needle ; a few, 
 howevex', have been dealt with by the canule-iVdemeure method. 
 
 The results of the treatment of liver cysts by canule-a-demeure 
 traversing the thorax, have not been very satisfactory, for in five such 
 cases collected by me, there were three deaths and two recoveries. 
 
 The main difficulties in this mode of treatment, as applied to cysts in 
 this locality, have been to prevent the canula from slipping out of 
 the collapsed cyst, and to ensure complete evacuation of the cyst 
 contents. 
 
 1. — Echinococcus Cysts of the Upper Surface of the Liver, operated 
 on through the Chest Walls. 
 
 The treatment by direct incision through the thoracic walls, of cysts 
 on the convex surface of the liAer, is certainly one of the boldest 
 innoA'ations of modern surgery. As far as I have been able to discover, 
 the first deliberate operation of this kind was performed by Isi^ael. . It 
 was briefly alluded to in Yircliow and Hirsch's Jahresbericht for 1879, 
 Vol. II., page 412. 
 
 In this case, an incision was made in the axillary line, an inch of the 
 sixth rib being removed, and the pleura was opened to a corresponding 
 extent ; the wound was then plugged with antiseptic gauze. Seven 
 days later the diaphi-agm was incised, and the wound was again plugged 
 with gauze. Finally, nine days afterwards, the sac itself was freely 
 incised, evacuated, and drained. 
 
 An undoubted improvement upon this method is to cut immediately 
 down to the sac, to pass a couple of loops of stout carbolised silk 
 through it, in order that when the sac collapses hj the evacuation of its 
 fluid contents, it may not retract beyond reach. The sac being securely 
 held by the loops, a trochar is passed into it midway between the loops, 
 and a part of the fluid is permitted, to escape in order to reduce the 
 pressure in the sac, and so prevent any escape into the peritoneum ; the 
 sac is then freely incised, and the mother-cyst, tfec, completely 
 removed. If it is found that the opening made into the sac is not 
 likely to freely drain the cavity, a counter-opening should be made at 
 the time of the operation. 
 
 The entire treatment should be carried out under strict antiseptic 
 precautions, and here, if anywliere, the steam spray is useful, for unless 
 adhesions happen to exist, pneumo-thorax is inevitable ; however, with 
 careful antiseptic treatment and drainage of tlie pleura, the I'esults are 
 likely to be satisfactory. 
 
 * Cited by Lenoel. Kystes Hydatifiues de la Bate, Paris Thesis, 1879. Obs. 
 XXIX., page 68.
 
 THE OPKRATIVK TUK.\TME\T OF ECIIINOCOCCUS CYSTS. 371 
 
 I have oolleeted .seventeen eases in which hydatid cysts of tlie 
 convexity of the livei' ha\ e been treated by thoracic incision {AnstraUan 
 Medical Jotiriud, August and September 1889) with various precautions 
 .against the infection of the pleura ; there were 12 recoveries and 5 deaths. 
 In one of tlie fatal cases, death was not due to operation or to the primary 
 disease, but to htvmori'hage from an ulcer of the stomach. In a second 
 one, the patient was apj)arently morilnmdfrom pneumonia at the time of 
 operation. In another, the cause of death was obscure, the patient was 
 apparently progressing satisfactorily xnitil the fifth day, when she was 
 seized with abdominal pain, sujjposed to be due to intestinal colic, and 
 died in about twelve hours. At the post-mortem examination, iiothing 
 Avrong as far as the operation was concerned could ha discovered ; 
 there was, however, a patch of recent peritonitis on the left lobe of the 
 liver, and old ribbon-like l)ands of adhesion connected the cyst with 
 the peh'is. It was thought that the stretching of these bands had 
 possibly com])ressed the intestine, and had thus caused the colic and the 
 fatal result. 
 
 2. — Liver Ilijdatids which had previoushj Ruptured into the Pleura, 
 
 operated on by Thoracentesis. 
 
 This class of cases presents many points of resemblance with lung 
 
 hydatids which have ruptured into the pleura. In lioth cases the 
 
 etiects will depend upon various conditions, the principal of which ai'e : — 
 
 1. The characters and quantity of the Iiydatid fluid entering the 
 pleura. 
 
 2. Whether tlie mother-cyst or any daughter-cysts pass into the 
 pleura. 
 
 3. Whether, in tiie case of a liver cyst, bile reaches the pleural 
 cavity, or in the case of a ruptured pulmonary hydatid, air passes in, 
 and if so, whether bacteria are also introduced by the air dii-ectly or by 
 putrescent fluid from the pulmonary cavity. 
 
 If only a small quantity of clear normal hydatid fluid enter the 
 pleura, there is reason to think that temporary pyrexia and an eruption 
 of urticaria may be the only ill etfects, and that the fluid will be 
 ra])idly absorbed. If the quantity be lai'ge, absorption will not take 
 place, but the mixture of hydatid fluid and resulting j^leuritic effusion 
 may remain serous for a consideral)le time. If the fluid of the parasite 
 be thick and opaque in consequence of degeneration, or still more so, 
 if it be purulent or foetid, it is nearly certain that a severe form of 
 pyothorax will Ije induced, which, unless promptly treated, will rapidly 
 destroy the patient. 
 
 When pulmonary hydatids rupture into the pleura, the probability 
 of pneumo-thorax is very great, but this is not likely to occur from the 
 bursting of an hydatid of the liver. A case, however, has been 
 recorded by Bristowe (Path. Soc. Trans. 1851-52), in which it was 
 believed that ofFensi^"e gas had been generated in the pleural cavity by 
 a liver cyst wdiich had burst into it. It is worthy of remark, however, 
 that in this case it is stated that there was a very free connnunication 
 of the dilated right hepatic duct with the cavity of the rujjtured 
 hydatid, and so it is possible that the septic condition arose by way of 
 the duodenum and dilated duct, and did not originate de iiooo in the 
 pleural cavity. 
 
 1b 2
 
 372 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 The rupture of an echinococcus cyst of the liver into the pleura is an 
 accident of very great gravity to the patient, and even when operative 
 measures are taken, the risk of death is very great, for among eight 
 cases treated by thoracentesis, no fewer than six ended fatally ; it is 
 probable, however, that an operation performed earlier might have been 
 successful in some of the fatal cases. 
 
 4. — Pulmonary Echinococcus Cysts treated by the Establishment of a 
 Free Opeomig into the Sac, obtained by Incisions or otherwise. 
 
 Hydatid disease of the lungs is without doubt a very grave malady, 
 especially when no surgical treatment is attempted for its relief. 
 
 Up to the year 1884, 1 had collected from various sources 208 cases 
 which had not been operated on, or if operated on, no statement to that 
 effect is made in the reports of the cases. The results were as follows : — 
 
 Died 113 cases. 
 
 Cured or relieved . . 71 ,, 
 
 Eesult uncertain .. .. 24 ,, 
 
 If we omit the 24 cases in which the tinal result was not definitely 
 ascertained, the result stands thus : — 
 
 Deaths . . . . 61-4 per cent. 
 
 Recoveries .. .. 38-6 ,, 
 
 It is evident, therefore, that the disease is a formidable one, and 
 even if we exclude all the deaths which caniiot fairly be attributed to 
 the direct influence of the parasite in the lungs, there yet is sound 
 reason for believing that more than half the cases of pulmonary hydatid, 
 wliich are not surgically treated, die.* 
 
 The most favourable accident of the disease is rupture into the 
 bronchial tract, for about thi'ee-fourths of these cases appear to recover ; 
 at any rate, the following were the results in 133 such cases : — 
 
 Residts of Spontaneous Rivpture of Pidmonary Hydatids into the 
 
 Broncldal Tract. 
 
 Deaths 31 cases. 
 
 Eeputed recoveries . . 80 , , 
 
 Result unknown . . . . 2'2 ,, 
 
 133 
 I have already alluded to the results of puncture in hydatid cysts of 
 the lungs, but it would lead to a digression of undue length to discuss 
 the (question fully on this occasion. I shall therefore content myself 
 with the following .statements : — 
 
 1. That the puncture, especially of large lung cysts, is by no means 
 devoid of inniiediate danger. 
 
 2. Tliat puncture often fails to cure the disease, and that in many cases 
 in wliich it seems to do so, cure is really etl'ected by the expectoration 
 of the mother-cyst, a process often accompanied by much danger to the 
 patient from suflbcation, hsemoptysis, and hectic. 
 
 3. That even when the sac has l)een completely evacuated by the 
 parasite, the vessels on its walls have become so degenerated from the 
 long continued suppuration as to readily rupture and cause hccmorrhage. 
 
 * For a fuller discussion on this point, see " Hj-datid ^Disease of the Lungs." 
 Adelaide, 1884, page 45.
 
 THE OPEHATIVK THEATMKNT OP ECHINOCOCCUS CYSTS. 373 
 
 This has proved fatal, as in cases recorded by Habershon (Guy's 
 Hospital lleports for 1872-3), and Kidd (Path. Soc. Trans. Vol. 30). 
 It is evident therefore, that it is desirable to reduce to its minimum 
 tlie period of suppuration. 
 
 Less frequently tlian into tlie bronchial tracts, pulmonaiy hydatids 
 rupture into the pleural cavity ; generally speaking, sucli cases prove 
 fatjil unless promptly operated on. 
 
 In very rare cases rupture has been known to take place externally, 
 or into the pericardium. 
 
 Occasionally the cyst continues to enlarge, until the long-continued 
 impediment to respiration and the pressure effects of the parasite 
 destroy the patient. 
 
 The probability that ajiy case of hydatid disease, the presence of 
 Avhich has been ascertained during life, will undergo spontaneous cure 
 by degeneration is virtually nil. 
 
 Upon the whole, I am convinced that patients suffering from 
 moderate-sized or large pulmonary hydatids are most safely treated by 
 free openings into the sac, and immediate removal of the parasite. 
 
 I have collected 38 cases in which this method was adopted ; of 
 these, 6 died and 32 recovered. 
 
 One of these was opei'ated on as far back as 1812, but this and all 
 the eai'lier cases were treated in this manner, in consequence of an 
 error of diagnosis ; they were generally regarded as cases of empyema, 
 pointing on the surface. 
 
 There can be no doubt, that to Dr. Bird of Melbourne, Australian 
 physicians are largely indebted for the conviction, that an abscess or 
 suppurating hydatid in the lung should no more be sacred from the 
 knife of the sui'geon, than an abscess in the breast. 
 
 I am disposed to go a step further in this direction, and to operate 
 upon any case of pulmonary hydatid in Avhich there is proof positive of 
 the nature of the disease and its precise locality, with one proviso, viz., 
 that there shall be a distinct, even though limited area of dulness on 
 some pai't of the chest-wall ; when, on the other hand, the alteration of 
 the percussion note is to the production of a tympanitic note, which 
 .seems to me to indicate compression of lung which still contaiiis ai)-, I 
 should feel disposed to punctui'e witli the a.spiratory needle. 
 
 In the earlier deliberate radical operations upon pulmonary hydatids, 
 the mother-cyst had ruptured, and the operations really were upon 
 abscesses of the lung containing more or less disintegrated hydatid 
 membrane ; in such cases, adhesions generally existed between tlie 
 surface of the lung over tlie cyst and the costal pleura ; consequently, 
 no precautions were thought necessary in order to prevent the escape 
 of the cyst-contents into the pleural cavity. However, it was always 
 uncertain whether adhesions were present or not, until the sac was 
 actually opened, when if there were no adhesions, the mischief was 
 done. 
 
 I therefore think that in all cases of this operation, the following 
 procedure should be ado])ted : — An incision about three inches long 
 should be made over tlie central portion of the cyst ; when all the 
 superficial tissues liave been divided, and the ribs are exposed, about an 
 inch and a half or two inches of one rib, or if i^etjuired of two ribs, 
 are excised, the periosteum l^eing previously stripped off by means of a
 
 374 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 suitable elevator. The pleura should not be torn, if possible, until the 
 piece of rib has been removed, and until all bleeding has been arrested 
 by the usual measures (it is rarely necessary to use a ligature). A 
 small trochar should noAv be passed into the cyst through the pleura, and 
 the depth at which fluid is fli\st met with be noticed, and if at this 
 stage the cyst cannot be found, the wound may be closed without 
 serious injury to the patient ; this, of coui'se, should rarely occur. 
 The exjiloration being satisfactory, a strong well-cur^'ed needle, set in 
 a sti'ong handle, is passed through the pleura and sac-wall into the interior 
 of the parasite, its point is then brought out so as to include a couple 
 of inches of the wall of the sac, and unless this has previously been 
 done, the needle is now threaded with a loop of stout aseptic silk, 
 which is drawn througli by the withdrawal of the needle ; a second 
 similar loop is passed through the sac, parallel to the first one ; in 
 this way the fibrous capsule is securely held dviring the next stages of 
 the operation. It is well now to introduce a small trochar midway 
 between the loops, in order to remove a pai^t of the fluid contents of 
 the sac ; this lessens the risk of escape of any of the fluid into the 
 pleural cavity, in case adhesions ai'e absent. The sac is now to be 
 freely incised, to at least a sufiicient extent to permit two fingers of 
 the operator to pass. The remaining fluid and solid contents of the 
 sac are then removed as completely as possible, by the use of fingers 
 and suitable forceps. Finally, the interior of the empty cavity should 
 be thoroughly sponged out. The wound in the sac is stitched securely 
 to the lips of the external wound ; the sutures should be of aseptic 
 material, and stout enough not to easily cut through ; for this purpose, 
 cai'bolised silk, kangaroo tendon, and silver wire, are equally well 
 adapted ; a large drainage tube is inserted, and the usual antiseptic 
 dressings are applied. As the contents of the previously ruptured 
 lung hydatids are often already ftetid, strict Listerism is neither 
 necessary nor practicable. The employment of injections in the 
 treatment of these cases is undesirable, in consequence of the severe 
 cough caused by the passage of the fluid into the bronchial tubes. The 
 results are usually excellent and immediate, for cough and exjiectoration 
 cease, pyrexia disappears, and the patient rapidly gains flesh and 
 strengtli. 
 
 Among the 38 cases collected, there were 32 recoveries and 6 deaths ; 
 and of 8 cases operated on by me, 7 recovered completely. In one 
 fatal instance, the right lung was so extensively destroyed by the 
 parasite, that recovery was hardly to be expected. It was estimated 
 that in this case the bladder-worm had a superficies of 256 square 
 inches, and the mother-cyst (drained as completely as possible of fluid) 
 weighed ten ounces avoirdupois. 
 
 In two cases, the oper;ition seems to ]\ii\e failed, principally because 
 the sac; was not completely emptied of membranes, and because the 
 drainage was inade(iuate. 
 
 4. — Pulnioudry lltjdntlds which had previouslii ruptured into the 
 P/eural Cavity, treated by Thoracentesis. 
 The rupture of a pulmonary hydatid into the pleura is a source of very 
 grave peril to the patient ; but the gravity varies according to circum- 
 stances, especially according to the condition of the contents of the sac at
 
 THE OPERATIVE TKEATMEXT OF ECHINOCOCCUS CYSTS. 375 
 
 the moment of rupture. If clear normal hydatid fluid is eflu.sed in 
 moderate amount, the resultin<^ symptoms are far less alarming than when 
 the fluid has undergone decomposition. It is probably also of great 
 importance whether or not the mother-cyst or any daugliter-cysts 
 present liave passed into the pleura. The size of the oritice of rupture 
 also must not only affect tlie extent to which the cyst contents escape 
 into the pleura, but also must influence largely the risk of free passage 
 of air into the pleural cavity by way of the bronchial tubes which open 
 into the sac. It is obvious, that a large opening renders moi'e probable 
 the entry of bacteria into the pleura through the sac, and thus septic 
 changes in the former are more readily induced. 
 
 It would appear, that I'upture may occur first into the pleura and 
 then into a Ijronchial tube, or vice versd, or that both events may 
 take place simultaneously. Usually, these accidents appear to occur 
 spontaneously, but now and then, the excitement of a tit of anger, 
 as in a case recorded by Fouquier ; ■'' or an injury to the chest from a 
 blow with the fist, as in a case under my care ; or a fall from a cab ; f 
 or the impact of the chest against the water in diving from a height, 
 as in a case recorded by Wischer, j may cause the rupture. 
 
 Jn neai'ly all the recorded cases, death has resulted from rupture into 
 the pleura, unless surgical measures have been taken to drain that 
 cavity, and permit the remains of the parasite to escape. 
 
 I have recorded three cases (Australian Medical Journal, September 
 1 889), in which cure followed free incision into the pleura for the relief 
 of this condition. In two of the cases there was fwtid pyo-pneumo- 
 thorax, in the third the gaseous contents of the pleural cavity were 
 aseptic at the time of the opei*ation. 
 
 Operations upon Abdominal Echinococci in which, besides the 
 Parasite, the Fibrous Sac was removed more or less 
 completely. 
 
 In a few recorded cases, the tibi-ous capsule of the parasite has been 
 removed. Sometimes this kind of operation has been adopted in 
 consequence of an error of diagnosis, in others the procedure has been 
 forced upon the operators by tlie exigences of the case. 
 
 In one case, operated on by Spiegelberg (Archiv. Jur Gyncekologie, 
 1870), a woman, aged 42, had a retro-peritoneal echinococcus cyst 
 connected with the omentum, the large and small intestine, and the 
 right kidney, which was mistaken for an ovarian cyst ; the fibrous 
 capsule and a poi'tion of the right kidney were removed. The patient 
 died of collapse twenty-six hours after the operation. 
 
 In a second case, opei'ated on by the same surgeon (Spiegelberg, 
 Archiv. Jur Gyncek., 1872), a woman, aged 30, had a large abdominal 
 hydatid of retro-peritoneal origin. This was treated by abdominal 
 section, partial removal of the filjrous sac, and suture of the remnant of 
 that structure to the lips of the parietal wound. After prolonged 
 suppuration of the remains of the sac, the patient recovered. 
 
 * Cited by Hearn. Kytfte.-! Jli/datiijues du Poumon et de la Plevre. Paris 
 Thesis, 1875, patje 131. 
 
 t St. George's Hospital Reports. Vol. IV., pages 272 and 305. 
 
 I Cited in Madelung. Jieltrage Mcckhtnhurfiischer Aerzte zur Lelire von der 
 Echinococccn-Knnihheit. Stuttgart, 1885. No. 18, page 85.
 
 376 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 In 1878, Knowsley Thornton {Medical Times and Gazette, Nov. 16, 
 1878, page 565), operated on a pregnant woman, aged 32, for the 
 removal of supposed ovarian tumours, which proved to be hydatids of 
 the omentum and pelvis. Two bunches of cysts were removed, but 
 some were left untouched. The patient recovered. 
 
 FitzGerald {Australian Medical Journal, May 15, 1880, page 206), of 
 Melbourne, in 1880, removed the fibrous capsule, together with the 
 bladder-woi'm, in the case of a large abdominal hydatid connected with 
 the omentum and liver. The tumour was regarded as an ovarian cyst. 
 The patient recovered. 
 
 Whitcombe [Australian Medical Journal, October 15, 1885), performed 
 a somewhat similar operation upon a large abdominal hydatid of retro- 
 peritoneal origin. The patient died nine hours after the opei-ation. 
 
 Another large abdominal hydatid, connected with the left kidney, 
 was extirpated by Hinckeldeyn, in 1880.* The patient, a female, 
 aged 42, died of haemorrhage, caused by the rupture of the left renal 
 artery in the removal of the fibrous sac. 
 
 I have assisted Dr. Way, of Adelaide, at an operation in which 
 several hydatids, connected with the peritoneum and omentum, wei^e 
 successfully removed. One lai'ge growth closely simulated an ovarian 
 cyst. 
 
 In one case, Spiegelbergt operated upon a hydatid cyst of the 
 spleen by " extirpation." The patient died seventeen hours later. 
 
 General Summary. 
 
 It is almost impossible, at present, to accurately estimate the real 
 value of tliose operations for the cure of hydatid disease, in which the 
 mother-cyst is not removed, viz., tapping operations, the use of 
 parasiticide injections and electrolysis, inasmuch as the apparent cure, 
 which often follows, is frequently found to be illusory after the lapse of 
 a short time. 
 
 As regards tapping operations, there is reason to believe that they 
 fail to cure the patient in fully 40 per cent, of the cases in which they 
 have been tried ; indeed, it is probable that the actual proportion of 
 failures is much greater than is represented by that number. 
 
 Taking aspiratory punctures and ordinary tapping opei'ations 
 together, the deaths amounted to neai-ly 18 per cent., but the mortality 
 following aspiratory puncture, whether single or multiple, was only 
 about half tliat of punctures with an ordinary fine trochar. 
 
 Speaking generally, the greater the number of punctures required in 
 a given case, the smaller is the probability of the cure of the patient by 
 tapping alone. 
 
 Simple puncture, although generally devoid of risk, has been known 
 to cause sudden death, sometimes apparently from shock, sometimes, 
 however, in the case of pulmonary hydatids, from suttbcation by the 
 fluid contents of the bladder-worm. The objection to puncture as the 
 mode of treatment for internal hydatids, however, lies less in the 
 occasional perils of the operation than in its frequent inefiicacy. 
 
 * Cited in Madelung. licitrofie Mfckletihurpisclicr Acrzte zar Lehre von dcr 
 Echinococcen-Kranklirit. Stuttgart, 1885, page 135. 
 
 t Cited by Mosler. Ueher Milz-Echinococcus mid seine Bchandlung. Wiesbaden, 
 1884, page 24.
 
 HYDATID OP THE BRAIN. 377 
 
 Of the use of pai'asiticide injections into the sac, and the employment 
 of electrolysis, it may be asserted that there is at present no evidence 
 in favour of these methods of treatment that does not apply equally 
 forcibly to simple puncture, and, moreover, each possesses drawbacks 
 of its own. 
 
 The question of choice between the various forms of radical operation 
 is, at any rate for abdominal hydatids, simple, for their mortality is 
 widely different, as a reference to the following table will show : — 
 
 Mortality of various Radical Oj^erations. 
 
 Caustics ., ,. .. .. .. 33 '68 per cent. 
 
 Canule-a-dcmeure .. .. .. .. 2666 ,, 
 
 Simon's method . . . . . . . . 48"00 ,, 
 
 Volkmann's method . . . . . . 19-05 ,, 
 
 Lindemann's method (abdominal sections) 10*29 ,, 
 
 Do. (thoracic incisions) 29"41 ,, 
 
 With regard to hydatids of the liver or of the lung, which have ruptured 
 into the pleura, thoracentesis is the only resource which offers itself. 
 
 Unruptured echinococcus cysts of the convexity of the liver present 
 gi'eat difficulties in their successful treatment, for thoracic incisions 
 show a high rate of mortality. 
 
 Palmouary Hydatids. 
 The risks and disadvantages of punctures in these cases have been 
 already discussed, and the results of radical operations are so favourable, 
 that but little difficulty can occur in the clioice of treatment in ordinary 
 cases. 
 
 HYDATID OF THE BRAIN— REMOVAL BY OPERATION 
 —DEATH AFTER FOUR DAYS. 
 
 By J. C. Verco, M. D. Lond., F. R. C. S. Eng. 
 
 Honorary Physician, Adelaide Hospital. Honorary Medical Officer, Adelaide 
 Children's Hospital, Sonth AnstraHa. 
 
 P. B., a;t. 10 years 11 months, male, was first seen by me on Nov. 17, 
 1888, when the following history was elicited : — From infancy he has had 
 an unusually large head ; he began to walk when from twelve to eighteen 
 months of age, cjuite as early as his brothers and sisters; he was cleanly 
 in his habits as a little child ; he had no trouble during dentition ; he 
 attended school like the rest of the family, and was rather brighter and 
 quicker at his lessons than the others ; he was very liable to attacks of 
 croup until seven years of age, but other than that, had no illness. 
 About five months ago, he began to complain of pains in his head. His 
 mother fancies this might be caused by an injury to his head, received 
 in a fall from a tree eight months ago, but he made no complaint at tlie 
 time. The headache has increased gradually, and for about three
 
 378 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 months he has had screaming at night, due to the pain. Till a month 
 ago, his screams were dreadful; but during the last month the headache 
 has not seemed so severe. It has not been very definite in its seat, but 
 has seemed to be worse on the right side. For about five months he 
 has complained of feeling tired, and has been sighing all day long; and 
 though getting up during the day, he has walked about with his head 
 somewhat on one side (his mother thinks leaning over to the right 
 shoulder), and has had to lie down again. Daily he has seemed less 
 capable, and during the last two or three weeks has not risen from his 
 bed. Three weeks ago, he had three tits. All the mother knows of the 
 fii'st one is, that she left him on the couch, and when she returned, after 
 a few minutes, she found him fallen on the floor, while he was quite 
 ignorant as to how he came there. In the second one, he lay 
 unconscious for a few minutes only on the couch, with working of his 
 face, not of his limbs. The third was similar, and occurred after the 
 interval of a few days. One day he seemed to have some difficulty 
 in speech ; he wanted his breakfast, but was unable to find words to 
 ask for it properly. Vomiting has not been frequent ; it was first 
 noticed about four months ago, only once or twice a week for about 
 a month ; he has had no emesis for three months, but sometimes feels 
 sick. His appetite has been remarkably good throughout, often he is 
 quite ravenous, and calls out at night for food. Grinding of his teeth 
 has been noticed, but it has not been very marked. His bowels have 
 been confined ; during the past week he has had no control over them. 
 For the same period, too, he has had incontinence of urine ; it does not 
 dribble away from him ; sometimes he knows when he wants to pass it, 
 but his mother has to be very quick, or it is passed into the bed. At 
 other times he tells her he wants to micturate, but though she waits 
 upon him, he is unable to void his urine. 
 
 Present Coudiiion. — He is a very well nourished boy, and large for 
 his age, with thick l)lack hair, dark brown eyes, and a rosy colour in his 
 face. He lies on liis left side. This is the side he prefers, as is evident 
 from the excoriation, ulceration, and bleeding of his left ear from 
 pressure. The forehead is ])rominent, and the head very large — 
 measuring twenty-four inches in circumference. When it is moved, he 
 screams with pain, apparently in the neck. The head is very tender, 
 especially towards the back, but even moving the fingers amongst the 
 hair appears to cause pain. There is enlargement of the veins in the 
 temporal regions. As he lies — drowsy, but not really asleep — the right 
 palpebral fissure is slightly larger than the left. On laughing, or 
 crying, the right side of the mouth is drawn back slightly but distinctly 
 more than the left ; and on lifting the upper eyelids, there is a 
 noticeably greater resistance on the right side than on the left. His 
 eyesight is very dim ; this has been only coming on during the last few 
 days. He could see a pencil in my hand at about ten inches distance. 
 The pupils are moderately dilated, and do not react well to light. There 
 is no deviation of the optic axis. Tliere is double optic neuritis, the 
 margins of the discs being l)lurred, and the discs radiately marked and 
 abnormally white. When he sleeps, his pupils are equal and contracted. 
 He can hear a watch on both sides at about six inches distance. His 
 headache to-day is chiefly frontal, nearly constant. He is said not to 
 have been free from it for a whole day since he took ill. Only rarely has
 
 HYDATID OF THE BRAIX. 379 
 
 he had it at the back. Wlien very severe he would lie on the couch on 
 his face, as this position appeared to give him ease. There is 
 hypersesthesia to touch and pressure over the upper part of tlie right 
 front chest. Two or three weeks ago he began to complain of pains^ 
 across the front of the chest, increased by speaking or breathing, but 
 without cough. Tliese have been absent now for two days. There is 
 no aj^preciable loss or diminution of sensation on either side of the 
 body from head to foot. He calls his left hand his weak one, and does 
 everything with his right ; but if his right is held, and he is told to use 
 his left, he can. He is unable with either hand to move the index of 
 the dynamometer. He can move both his legs and feet and thighs in 
 bed. Temperature 101° ; pulse 120, regular; re.spirations 24, irregular 
 and sighing. 
 
 Nov. 19. — To-day he is quite blind, cannot tell light from darkness; 
 temperature 101. 
 
 Nov. 20. — Pulse 120, regular ; temperature 100° ; much grinding of 
 teeth, 
 
 Nov. 21.— Pulse 10-1, regular, soft, full; respirations 24, regular; is 
 sleeping ; temperature OOvS. Bowels not moved since 17th. Slept 
 fairly well last night, did not scream once. To-day, complains of pain 
 in the right side of the head, about an inch and a half to the right of 
 the middle line, and a little in front of the coronal suture. 
 
 Nov. 23. — Pulse 124, regular; respirations 24; temperature 102'4°. 
 Yesterday was much more drowsy, and twice his mother thought he was 
 abovit to die — his eyes fixed, and his left forefinger was stiff and point- 
 ing. Today she says he is more sensible. Now he lies seemingly fast 
 asleep, but yet brushes away the flies away from his face with his right 
 hand. Bowels opened after purge. 
 
 Nov. 24, 5 p.m. — Pulse 112, regular; respirations 28; temperature 
 101°. Tongue white, moist, fur. It is questionable whether he can 
 taste. To-day, for the first time, I have been able to get his hair all off, 
 because the jjain he suffered when she atteuipted to remove it, caused 
 his mother to desist. Now, on looking at the head from the front, there is 
 seen a slight bulging in the right temporal region and anterior parietal; 
 and looking at it from the vertex, where also it is detectable, it is seen to 
 begin a little to the right of the middle line, a1)0ut the coronal suture, 
 to involve the back part of the right frontal, on the top of the head, 
 the temporal part of the fi'ontal, and the front part of the parietal, the 
 centre of the bulging being along a line running obliquely V)ackwards 
 and outwards, and just about midway between the external auditory 
 meatus, and sagittal suture. The vertex of the head was flat, the 
 occipital regions voluminous. None of the sutures or fontanelles were 
 opened or soft to the touch. 
 
 Nov. 27. — Pulse 128, respirations 30, temperature 101 'G", perspiring. 
 Blister came yesterday on tlie left external malleolus, from pressure — 
 large one to-day on right heel. On right buttock a large one has broken, 
 and left a bleeding surface. During the last two days, I have been 
 persuading the mother to allow an operation for opening the head. 
 
 Nov. 28. — Pulse 128, respirations 30, temperature lOl'. He heard 
 what was said yesterday, though seemingly asleep, and during the night 
 was discussing with her the meaning and result of operation. Yesterday, 
 he thought raspberry roll was raw meat ; to-day he could recognise it.
 
 380 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA, 
 
 and could taste salt. Dr. Thomas saw him with me in consultation, and 
 agreed as to the justifiability and desirability of operation ; so the 
 patient was removed to the Adelaide Children's Hospital, North 
 Adelaide, on the 29th. His head was shaved, and wrapped in lint 
 soaked in carbolic acid, and the bed-sores on both ears and feet and 
 buttock properly dressed. 
 
 Nov. 30. — Mr. Cookson anaesthetised the patient with ether, and 
 with the assistance of my colleagues, Mr. Hayward and Dr. Lendon, 
 I turned forward a semicircular flap of the scalp, so as to expose the 
 centre of the bulging part of the cranium. Here I removed a button of 
 bone with an inch trephine. The skull was very thin. On exposing 
 the dura mater, it bulged, and was very tense and elastic; and when it 
 Avas divided by a crucial cut, the brain substance pressed out. An 
 aspirator needle thrust in entered a cavity, and a slightly turbid liquid 
 flowed out. This was caught and examined at once, giving a dense 
 white precipitate with a solution of nitrate of silver ; but a precipitate 
 also with nitric acid. The presence of albumen, indicated by the latter 
 test, discounted the evidence of sodic chloride, obtained from the former, 
 and made it uncertain whether the fluid was hydatid. But a sudden 
 sto]>page in the flow, and a peculiar tap given to the canula, such as is 
 perceived when a piece of membrane flaps against its end in the aspira- 
 tion of a hydatid, increased the probability of the presence of a parasite. 
 A pair of dressing forceps was therefore pushed along the ti'ack of the 
 canula, and the thin layer of brain tissue toni through by opening it. 
 The finger could then be introduced into an enormous cavity, within 
 which could be detected unruptured cysts. The fluid was allowed to 
 run out by turning the head on its side, and the daughter-cysts washed 
 out by a stream of solution of boracic acid, pumped in through a flexible 
 catheter. Finally the mother-cyst presented at the orifice, and was 
 withdrawn, partly by the traction of forceps, and partly by the lotion 
 introduced behind it. After the emptying of the cavity, it was filled 
 with lotion again, and this, when collected, measured sixteen ounces. 
 The deei)er boundaries of the cavity could not be reached by the finger. 
 It extended forward and inward from the trephine hole towards the 
 base. The thin layer of brain tissue around the opening did not collapse, 
 indicating probable slight adhesions between the membranes here ; hence 
 the free way into the cavity was not lost on ren)oval of the cyst. There 
 .seemed to be a thin bounding membrane between the cyst and the brain. 
 A large drainage tube of red rubber was introduced, and the flaj), 
 divided in the middle for its passage, was stitched all round with catgut 
 sutures, and tlie wound dressed with iodoform powder and a layer of 
 salicylic wool. The air of the room was disinfected by the carbolic acid 
 steam si)iay during the operation. Was somewhat collapsed after the 
 operation. Slei)t heavily. 
 
 At 2 i).m., temperature 104"2° ; sponged with cold water. 4 p.m. — 
 Temperature 10-1:'2' ; antifebrin gr. ij given. Left arm rigidly flexed 
 at elbow, bringing the hand to the shoulder ; right eyelid closed, left 
 partly open. Home conjugate deviation of eyes to left, but with clonic 
 nystagmus movements to the middle line, and slightly to the right of it ; 
 right pupil larger than the left. 7 p.m. — In breathing, right nostril 
 dilates more than the left; eyes quiet. Tem))erature 101'4°. Swallows 
 milk. 8 p.m. — Breathes heavily. Kesjnrations 36, pulse 136, tempera-
 
 HYDATID OF THE BRAIN. 381 
 
 ture 102°. Tremors of riglit arm, lasting a few seconds; can use it. 
 Ti'enior of right leg. 9 j).ni. — Pulse 160, respirations 40, tem])erature 
 101 "4°. Dressed under spray ; dressing soake-d through with watery 
 slightly blood-stained fluid. AEovement of the head causes tremors of 
 right arm, and evident pain. 12 p.m. — Pulse IGO, respirations 40, 
 temperature 102-4°. Eyes still deviated to left ; breathing heavily. 
 Enema of egg and milk retained. 
 
 Dec. 1, 4 a.m. — Pulse 160, respirations 40, temperature 103-6°. Gr. ij 
 antifebrin, did not swallow it; urinated into the bed. 8 a.m. — Pulse 
 168, respirations 44, temperature 10.3". Left pupil has been contracted 
 some hours; right dilated. Left side of face hot and flushed; right 
 cheek cold. Kight arm stiff, adducted at shoulder, extended at elbow, 
 extended at the basal joint of the index, flexed at the further joints. 
 9.30 a.m. — Enema, with antifebrin gr. ij ; and again at 1 1 a.m. 12 noon. 
 — Pulse 152, respirations 36, temperature 103-6". Wound dressed, still 
 abundant wateiy discharge ; slight left extei'nal squint ; swallows 
 liquids. 4 p.m. — Pulse 136, respirations 36, temperature 104°. Has had 
 gr. ij antifebrin every hour. Left squint gone; slight riglit external 
 squint; eyes widely open; right cheek hot, left cold. 9 p.m. — Tempe- 
 rature 103°. Has liad antifeb. gr. ix, in three doses. Wound dressed ; 
 inner end of drainage pushed up close under cranial vault ; probe passed 
 along it, does not enter a large cavity, but impinges against soft 
 substance; little sanious fluid runs out. Tube replaced by a smaller 
 one. 
 
 Dec. 2, 1 a.m. — Pulse 132, respirations 27, temperature 104-4°. Left 
 side of face flushed in patches; urinated ; antifebrin gr. iv given. 2 a.m. 
 — Temperature 104-2° ; gr. iv repeated. 5 a.m. — Temjierature 103°. 
 8 a.m. — Temperature 104-4°, pulse 146, respirations 29. Left cheek 
 very hot, right cool. 10 a.m. — Temperature 103-8° ; has had three 
 doses of 4 grs. of antifebrin, one every hour. Wound : oedema of all 
 the back part of the scalp, with tenderness; prominence with elastic 
 tension of the flap over the trephine hole; the drainage tube spon- 
 taneously rises out of its track; re-introduced. No sugar or albumen 
 in urine; swallows well. 12 noon. — Pulse 128, respirations 28, tempe- 
 rature 101°. Cheeks pale and cool; pupils nearly equal, slightly turned 
 to the left. 3 p.m. — Temperature 100-4", pulse 136, respirations 24. 
 6 p.m. — Temperature 102-4°. Both arms relaxed; left pupil dilated; 
 right contracted; l)0th cheeks cool. 8.30 p.m. — Temperature 103-6°. 
 Pupils equal; taken 20 oz. of fluid in the twelve hours; wound 
 dressed; antefebrin gr. iv given. 12 p.m. — Pulse 136, respirations 28, 
 temperature 99-8°. 
 
 Dec. 3, 2 a.m. — Temperature 104°. Right eye nearly closed, left half 
 open; eyes directed to the right; antifeb. gr. iv given. 4 a.m. — Pulse 
 160, respirations 40, temperature 105-8°. Face flushed in patches; 
 antifebrin gr. iv given, but was vomited. 6 a.m. — Temperature 104-2°. 
 Quivering of the whole body for a few seconds ; face flushed ; pupils con- 
 tracted; bowels moved. 10 a.m. — Pulse 136, respirations 36, temperature 
 lOr. Swallows not .so well; wound dressed; tube removed and not 
 replaced; small hernia of apparently blood clot; cedema with tenderness 
 over back of head; slight redness around the wound. 12 noon. — Pulse ' 
 144, respirations 40, temperature 101-4°. Swallows well; eyes central 
 again, after deviation to left. 5 p.m. — Temperature 104-2°, pulse 160,
 
 ■382 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 respirations 44. Antifeb. gr. iv; wound dressed; redness less; pro- 
 trusion little more marked; cannot swallow. 6 p.m. — Temperature 
 103-6°. Left cheek hot, right cold; eyes turned to left. 7 p.m. — 
 Temperature 102°. 8 p.m. — Temperature 103°. Both cheeks cold; 
 antifeb. gr. iv. 9 p.m. — Temperature 104°. Urinated, and bowels 
 opened ; nutrient enema given, with antifeb. gr. iv. ; right eye moving, 
 left quiet. 12 p.m. — Temperature 104'8°. Injection of antifeb. gr. iv; 
 right cheek cold, left hot. 
 
 Dec. 4, 2 a.m. — Pulse 180, respirations 50, temperature 105-4°. Lower 
 jaw stiff; twitching of left hand. 4 a.m. — Temperature 105-4°. Enema 
 of antifeb. returned. 7 a.m. — Temperature 106-4^ Deviation of eyes 
 to right ; perspiring. Has had two enemata of antifeb. g. iv. 8 a.m. 
 — Temperature 108-4°. Died at 9 a.m. He did not recover sufficient 
 consciousness after the operation to speak, although until the last day 
 he was quite sensitive to irritation anywhere, and would move his hand 
 towards the place touched. He was sponged every hour during the first 
 two days, and then packed in wet towels every hour till death. 
 
 Post-mortem, six hours after death. The measurement of the head 
 was found to be twenty-four inches in circumference, and sixteen 
 .and a half inches over the vertex from one external auditory meatus 
 to the other. The centre of the vertex was eight and a quarter inches 
 from each aperture of the ear ; so that although the bulging on the 
 right side of the head was a]:)})arent to the eye, it was not measurable. 
 The trephine wound was four and a half inches vertically above the 
 -aperture of the right meatus, and obliquely four and a half inches above 
 and behind the right external angular process of the frontal, and three 
 and a half inches from the sagittal suture. There was some edematous 
 infiltration of the back of the scalp, and in the right temporal 
 region. There was a slight hernia of blood clot. The flap was not 
 adherent to the cranial bones. The skull was considerably thinned ; 
 the trephine wound had perforated it where most attenuated. None 
 of the sutures had sejmrated. The dura mater was rather more 
 firmly attached than usual ; especially was this the case on the right 
 side, from above the trejihine wound to the petrous portion of the 
 temporal. On opening the dura mater, a consistent layer of buttery 
 lymph covered the brain throughout, while a thinner watery fluid 
 was in considerable quantity. The dura mater could be easily removed 
 from the brain beneath, excei)t at a spot on the right side, about two 
 and a half inches below the trephine hole. Here it was firmly adherent 
 to the subjacent parts, and an attempt to separate it with the scalpel 
 opened the cyst cavity, with the fil>rous wall of which it had intimately 
 coalesced. The cyst presented on the right side of the brain, on 
 the outer and on the inferior aspect, where over an area of about 
 four inches by two it was uncovered by brain substance, and was 
 translucent, but tough and membranous. This part seemed to be in 
 the Sylvian fissure. Posteriorly, it was adherent to the temporo- 
 sphenoidal lobe, which it very slightly overlapped, and had pushed 
 backwards. On the cerebral surface, the Rolandic fissure, the 
 ascending pari(;tal and ascending frontal convolutions, and the first, 
 second and third frontals were quite distinct ; but they were displaced 
 u})wards, so that the lower extremity of the fissure of Rolando was 
 situated nearly four inches vertically above the end of the temporo-
 
 HYDATID OP THE BRAIN. 383 
 
 sphenoidal lobe. The third frontal convolution was not perfect at 
 its lower part, for in the posterior extremity of this, at a si)ot about an 
 inch and a half in front of and below the lower end of the fissure of 
 Rolando, was the perforation made at the operation. Here the brain 
 tissue was not more than an eighth of an inch thick. Below this point, 
 and behind it, there is scarcely any brain substance. In front, the 
 brain tissue gradually thickened from the thinnest pellicle, and so also 
 towards the junction of the otiter and inferior surface of the frontal 
 lobe. On examination of the interior of the sac, it was found to be 
 lined throughout with a continuous tough fibrous membrane, completely 
 shutting it off from all the cavities of the brain. It had been opened 
 at the operation almost at its highest ])oint. It was discovered to have 
 hollowed out the anterior end of the brain. The brain tissue above it 
 was fully an inch in thickness ; along the front surface, about half an 
 inch ; along the median aspect, where the frontal touches its fellow, 
 about a quarter of an inch ; along the inferior external margin, about 
 half an inch, thinning out on the external surface and the orbital surface 
 to nothing, as it passed backwards. The diameter of the cyst was about 
 four and a half or five inches. 
 
 The finger in the cyst passed backwards and downwards, apparently 
 into the substance of the right temporo-sphenoidal lobe, which appeared 
 to be hollowed out, as well as displaced downwards and backwards. On 
 tracing up the Sylvian or middle cerebral artery, it was found to pass 
 on the inner side of the cyst ; that is to say, the sac of the hydatid lay 
 between the dura mater and the Sylvian artery, and could be felt 
 hollowing out the temporo-sphenoidal lobe for a full inch and a half 
 posterior to the line of the artery. 
 
 The hydatids evacuated consisted of a considerable amount of thick 
 gelatinous translucent mother-cyst, studded with opaque, white, elevated, 
 closely-set spots. These under the microscope, appeared to be mam- 
 millated projections of the same laminated texture as the rest of the 
 membrane, and did not display any differentiated structure. There 
 were numerous daughter-cysts of various sizes, up to that of a small 
 walnut. There was also noticed, among the first products in wasliing 
 out the cavity at the operation, before the removal of the mother-cyst, a 
 mass of fibrous flocculent material, containing very minute cysts, and in 
 which a gentleman present suggested a resemblance to the choroid 
 plexus. It could be spread out as a thin, tangled-looking membrane. • 
 The microscope revealed no areolar tissue nor epithelial elements, but 
 tangled threads of homogeneous material matted together, in places 
 enclosing, and at others bearing on their surface, microscopic cysts of 
 various size. These had walls of homogeneous tissue, sometimes dis- 
 playing finely concentric laminated structure throughout ; at others, 
 and this generally in the larger ones, only at the circumference ; while 
 the interior was gi-anular, or contained large oval dark granular bodies, 
 with an almost black eccentric spot. Some were apparently minute 
 daughter-cysts, without any, or with only liquid, contents ; others con- 
 tained formed elements, })resumably scolices. There were, in other 
 parts, easily recognised In-ood capsules, with scolices in varying number.s 
 in their interior, or projecting singly or in masses from their exterior, or 
 with nipple-like protrusions from their circumference. Hooklets and 
 granular matter in abundance were dispersed over the whole field.
 
 384 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 The foregoing case is recorded, and brought under the consideration 
 of the Congress, as being the first in which a diagnosis of probable 
 hydatid has been made, and its complete removal effected by operation. 
 
 The diagnosis in the present case lay between effusion into the 
 ventricles, hydatid cyst, solid tumour, and abscess. 
 
 In favour of hydrocephalus, was the history of a very large head from 
 infancy; but against it were the absence of all symptoms till seven 
 months ago, their rapid progress since that date, the elevated tempe- 
 rature, the one-sided paresis, and the unilateral bulging of the head. 
 
 In favour of hydatid, was the asserted increase in the size of the head 
 of late, the unilateral pain, the unilateral bulging, the one-sided paresis, 
 the duration of seven months. The age of the patient was consistent 
 with this supposition. In Dr. Thomas's list of cerebral hydatids, read 
 at the session of the Congress held in Adelaide, of the cases in which 
 the age is given, none occurred up to seven years of age, twenty-two 
 between the ages of seven and fifteen, and only twenty-two during all 
 the other periods of life. The situation, too, favoured hydatid ; for this 
 is half as covnmon again on the right side as on the left. The constant 
 elevation of temperature was against hydatid, for in a previous case 
 under my own care it was absent, as also in other recorded instances. 
 
 Intra-ci'anial sarcoma suggested itself, because of the signs pointing 
 to the existence of some tumour. But sarcomata are by far most 
 common during the fourth decade of life, and the bulging would be 
 improbable if the tumour sprang from the brain tissue; and if it 
 originated in the cranial bones, it would be less uniform, and give 
 evidence rather of a thickening of these structures; the temperature also 
 opposed this theory. 
 
 The diagnosis of an abscess would rest on the unilateral cerebi'al 
 symptoms, and the persistent feverishness. But there was no efficient 
 known cause for suppui^ation, for though there was a history of a fall, 
 yet it occasioned no head symptoms at the time, and had occurred a 
 long while before any such arose. Bulging of the cranium is not a 
 characteristic of cerebral abscess. 
 
 Hydatid of the brain, therefore, seemed to furnish the most complete 
 explanation of the case, and it was further just possible that suppuration 
 of the cyst might be the occasion of the pyrexia. 
 
 The localisation was simplified by the protrusion of the skull on the 
 right side, most marked at a point about four inches above the right 
 auditory meatus. With this situation agreed three localising symptoms, 
 namely, the i)aresis of the left arm, the paresis of the left face, and the 
 pointing of the left index finger, Avith spasm of the left arm, in two 
 convulsive seizures; these would indicate mischief about the ascending 
 frontal, and the posterior ])art of the frontal convolutions. 
 
 From the position and connexions of the cyst, it probably originated 
 in the lower and back part of the frontal lobe; in its growth it hollowed 
 out this lobe, chiefiy in an inferior and posterior direction. It thus 
 pushed the three frontal convolutions upwards, as well as those about 
 the Rolandic area upwards and backwards. It then appeared in the 
 Sylvian fissure, and crossing over this, external to the middle cerebral 
 artery, pushed the vessel inwards towards the centre of the brain. 
 Growing backwards still fHirther, it pressed against the temporo- 
 spheuoidal lobe, displacing it posteriorly, and appearing to hollow it out.
 
 HYDATID CYST OF THE ZYGOMATIC FOSSA. 385 
 
 clown almost to its tip. Tlie situation of the Sylvian artery seems to 
 indicate that the hydatid developed in the frontal lobe, and crossed the 
 fissure to the middle lobe; and did not originate in the brain substance 
 in the Island of Reil, or between the two lobes, and then spread both 
 tbrwaids and backwards. In this case, the artery would most probably 
 have been on the exterior surface of the cyst. 
 
 Death resulted from general cerebral meningitis. The layer of plastic 
 lymph in the arachnoid sac was so extensive, thick, and consistent, that 
 it is well nigh impossible for it to have originated subsequent to the 
 operation, only four days before. Moreover, at the seat of operation, 
 there was adhesion between the membranes and the thin layer of brain- 
 tissue, practically preventing the opening of the arachnoid sac at this 
 point. Again, the hydatid had not suppurated, hence some inflammatory 
 mischief, such as a meningitis, must have existed prior to the operation 
 to account for the persistent pyrexia. The supposition of meningitis 
 explains also the acute pain experienced on moving, and on px'essing the 
 head, and the rapid retrogression in the patient's condition during the 
 week preceding the operation. Hence, I conclude that a meningitis 
 existed prior to my first visit, and simply progressed after the surgical 
 interference, without being materially affected thereby, and accounted 
 for the fatal issue. 
 
 NOTES OF A CASE OF HYDATID CYST OF THE 
 ZYGOMATIC FOSSA. 
 
 By J. R. M. Thomson, M.B., Ch.B. Melb., York, Western Australia. 
 
 J. M., aged 56, came under my notice on the 26th October last, 
 suffering from a tumour in the temporal region, of which he gave the 
 following history : — Early last May he first noticed a " lump " about an 
 inch from the outer border of the right eye ; it gradually increased, till 
 it attained its present size. It has never been painful. He has never 
 had any stiffiiess of the jaw. As the lump increased in size, he began 
 to notice a swelling inside the mouth, between the jaw and the cheek, 
 opposite the back teeth. 
 
 On the 26th October, the condition is as follows : — There is a tumour 
 occupying a space extending from about the centre of the temporal fossa 
 to an inch below the zygoma, and almost from the ear to the orbit. It 
 is very tense, and the skin covering it is shiny. There is no pain nor 
 tenderness. I made an exploratory puncture with a hypodermic syringe, 
 and drew off" a few drops of turbid fluid, the needle being blocked with 
 a piece of hydatid membrane. 
 
 On October 30th, I made an incision from one end of the tumour to 
 the other. I had to cut through the temporal fascia, whicli was unusually 
 tough. I then emptied the tumour, which consisted of a hydatid cyst 
 crammed with daughter-cysts in all stages of development, living and 
 dead. The zygoma was completely eroded for about half an inch from 
 
 Ic
 
 386 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 its junction with the malar bone. The cyst extended deeply into the 
 zygomatic fossa. The wound was drained, and treated in the ordinary 
 way. 
 
 It seems remarkable that the growth of a hydatid cyst should have 
 such force as to erode bone, while it had the 0])portunity of enlarging 
 by expanding a softer structure ; but it would appear, in this case, at 
 any rate, that the hard unyielding bone was less resistent than the 
 elastic fibrous structure of the temporal fascia. The choice of locality 
 in this case is also peculiar, especially as its growth was evidently from 
 the surface into the deeper structures. I have not been able to find a 
 similar case recorded. 
 
 CASE OF MULTIPLE HYDATID CYSTS, TREATED BY 
 THORACIC INCISIONS— RECOVERY. 
 
 By Joseph C. Verco, M.D. Lond. 
 
 Joint Lecturer on Medicine in the University of Adelaide. Honorary Physician, 
 
 Adelaide Hospital. 
 
 And Alfred Austin Lendon, M.D. Lond. 
 
 Lecturer on Forensic Medicine in the University of Adelaide. Honorary 
 Assistant Physician, Adelaide Hospital. 
 
 In view of the proposed discussion on " Hydatids," it was thought 
 that the following case might be of interest, illustrating, as it does, 
 the most recent method of dealing surgically with this disease. It is 
 believed to be the only recorded instance where a radical operation has 
 been jjerformed through the chest wall upon separate cysts in two lobes 
 of the liver, and also where a cyst, believed to be in the left lobe, has 
 been deliberately operated upon in this manner : — 
 
 Charles D. C, fet. 14, was admitted into the Adelaide Hospital under 
 the care of Dr. Verco, on November 24, 1886. His previous history 
 was briefly as follows : — He was born at Robe, and when he was two 
 years old his parents removed to Narracoorte, where he lived till he 
 reached the age of thirteen years, both these places being situate in the 
 south-eastern district of South Australia, where hydatid disease is very 
 prevalent. When eleven years of age, he is said to have had inflamma- 
 tion of the lungs, from which he completely recovered. Shortly after 
 removing to Port Adelaide, when thirteen years old, he is said to have 
 had a second attack, which left him with a permanent cough. In March 
 188G, he had considerable haemoptysis; and in June, an enlargement of 
 the left side of the abdomen was noticed, which temporarily subsided 
 after a second attack of haemoptysis, which was accompanied by the 
 expectoration of "skins." His medical attendant (Dr. Mitchell) came 
 to the conclusion that he had ruptured a hydatid cyst of the lung. In 
 August, however, the abdominal tumoui' rcai)peared, and subsequently 
 increased in size rapidly, while the cougli and expectoi'ation of hydatid 
 debris continued up to the date of admission.
 
 MULTIPLE HYDATID CYSTS, TREATED BY THORACIC INCISIONS. 3S7 
 
 On admission, he was desciiljed as being pale and emaciated, tliough 
 not feverish, but the pulse was rapid, and the respirations were forty 
 per minute, and shallow. He was unable to lie down in bed, as the 
 cough was aggravated by the recumbent posture. The lower part of the 
 chest was considerably bulged out on the right side, but on the left side 
 the prominence was much more abdominal than thoracic. The lower 
 border of the abdominal tumour could be traced from an inch below the 
 costal margin in the right mammary line, to about two inches above the 
 umbilicus in the median line, and to nearly the level of the umbilicus in 
 the left mammary line. The hepatic dulness commenced at the fifth 
 interspace in the right niaunnary line, the left front of the chest was 
 dull on percussion below the third i-ib, and the whole of the left axilla 
 was also dull. Posteriorly, there was dulness over both lower lobes of 
 the lungs, more marked, however, on the left side, where it reached to 
 nearly the angle of the scapula. Over these dull regions, the respiratory 
 sounds were either much weakened or abolished. Tlie cardiac apex beat 
 was in the sixth space, rather outside the left nipj^le line, and the 
 impulse could be seen and felt over a wide area. The pulmonary signs 
 showed relative flattening and deficient expansion at the left apex ; but 
 on the other hand, impaired percussion resonance, blowing breathing, 
 and adventitious sounds at the right apex, both in front and behind, 
 indicating, in Dr. Verco's opinion, the existence of a cavity containing 
 a ruptured hydatid cyst, and the source of the haemoptysis and 
 expectoration before mentioned. Dr. Verco further thought that the 
 tumour of the left side of the abdomen and thorax was probably a 
 pulmonary hydatid, and that the lower part of the right side of the 
 chest was occupied by a distinct hydatid cyst, which might be either 
 pulmonary or hepatic. 
 
 On December 24th, the left side was aspirated in the anterior axillary 
 line, at about the level of the nipple, and ^ xv of clear hydatid fluid with- 
 drawn. On December 31st, another slight haemoptysis occurred, followed 
 on January 5th, 1887, by the expectoration of a piece of membrane, 
 together with J ss. of pus; another haemoptysis is reported on February 
 3rd. On February 11th, the right side was aspirated in the eighth 
 interspace, and ^ xlij of clear hydatid fluid drawn ofl". From the date of 
 admission, he steadily improved in his general health, and when 
 discharged on April 26th, the cyst did not appear to have refilled. 
 
 He was again an inmate of the hospital for six weeks, during the 
 months of August and September 1887, and owing to the illness of Dr. 
 Verco, was under the care of Dr. Lendon. During this time he hafl 
 hectic fever ; the cough and expectoration were considerable, and 
 abundant rales were audible at the right apex. Hence it was doubtful 
 whether he might not have phthisis in addition to the hydatids. 
 
 On November Sth, 1887, he was re-admitted under Dr. Lendon's 
 care. The abdominal and thoracic physical signs had not altered much, 
 but there was orthopncca, and so considerable was the emljarrassment 
 of the breathing that, in spite of the unfavourable condition of his right 
 apex, which it was still feared might jjossiljly mean phthisis (for he had 
 had a severe haemoptysis a week before), it was decided, after consulta- 
 tion with Drs. Davies Thomas and Way, to operate. There was a 
 diflerence of opinion as to the precise locality of the cyst which occupied 
 the left side of the abdomen and thorax, but Dr. Lendon was inclined to 
 
 Ic 2
 
 388 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 think that it was connected with the left lol)e of the liver, rather than 
 with the spleen or omentum, and certainly that it was not pulmonary; 
 and moreover, that it would be Letter to operate upon this cyst first, in 
 order, if possible, to relieve the dyspnoea, as it was much the larger cyst 
 of the two, and for fear that it might be less accessible if the cyst on the 
 right side (now presumed to be hepatic) were evacuated first. Accordingly, 
 on November 20th, the boy was placed under the influence of ether, and 
 Dr. Lendon proceeded to operate, with the assistance of the above- 
 mentioned colleagues. After a confirmatory aspiration in mid-axilla, a 
 portion of the ninth left rib was excised, the pleural cavity opened, and 
 slight pneumo-thorax caused thereby. The diaphragm was incised, and the 
 spleen which was presenting was retracted backwai-ds, and the omentum 
 lifted forwards. The cyst was now obvious, but quite inadherent; for 
 certainty, it was again punctured with the aspirator needle, and then 
 stout loops of silk were passed through in order to bring it up to the 
 external wound, when it was freely incised, and the contents— slightly 
 opalescent fluid, and an enormous mother-cyst — evacuated. The edges of 
 the sac were stitched to the deeper structures of tlie wound, but not to 
 the skin. A large drainage tube was inserted into the sac, and a smaller 
 into the pleural cavity. Only modified antiseptics were employed, and 
 on the fourth day the pleural tube, being blocked with solid lymph, was 
 left out as being no longer necessary. Bile-stained serum was discharged 
 through the large tube, which was left out on the ninth day after the 
 operation. Very little constitutional disturbance followed the operation, 
 the temperature being noi-mal after three days, and a gradual improve- 
 ment of the respiratory sound was noticed over the left back. The 
 patient left for the Convalescent Home on December 20th, to recruit for 
 the second operation. 
 
 On Deceml)er 27th he was re-admitted, ^\'ith the sinus discharging a 
 considerable amount of bile, although a probe could only be passed in 
 about one and a half inches. His general condition was still far 
 from satisfactory. There were signs of active mischief at the right 
 apex, and there were well marked hectic symptoms, but as the hepatic 
 tumour had increased in size, so as now to reach quite to the 
 umbilicus. Dr. Lendon decided again to operate. On January 12th, 
 1888, under ether, an aspirator needle was introduced into the right 
 mid-axilla, and pus withdrawn. Part of the eighth rib was excised, and 
 the pleui-a found to be partially adherent. The diaphragm was cut 
 through, and the cyst seized and dealt with in the same manner as on 
 the opposite side, five pints of fluid being evacuated. There was much 
 less disturbance than even after the former operation, the pleural tube 
 being left out on the fifth day, and tlie larger tube a few days later. 
 The sinus on the left side finally closed early in February, and that on 
 right side early in April, the boy having left the hospital some weeks 
 previously (March 9th) in excellent health, excepting the persistent cough. 
 
 Dr. Verco had meanwhile resumed charge of his wards, and the 
 ]iatient was admitted for the fifth and last time on April 3rd, 1888, 
 having been ailing for the previous week with pain in the right shoulder, 
 and having coughed up about half a tumblerful of pus. He was found to 
 be again feverish, but this was explained by the development of signs 
 of fluid in the upper part of the right back, which an aspiration 
 showed to be jjurulent. Accordingly, on April Gth, under ether,
 
 INJECTION OF PERMANGANATE OF POTASS FOR HYDATIDS. 389 
 
 Dr. Verco again explored the chest by an incision in the ninth right 
 interspace, in the scapular line, without excision of a portion of ril). On 
 introdufing his finger into the chest, he detected the abscess bulging 
 fioui al)ove downwards; the aspirator needle was again inserted and 
 used as a director, and the abscess freely opened, when a large quantity 
 of pus was evacuated, without, however, any hydatid membrane or 
 cysts ; a drainage tube was then inserted. It was evident that this 
 collection of pus was contained in the upper pai't of the chest; and 
 it is probable that it was connected with the cavity at the right apex, 
 as the signs of activity in this cavity soon disaj^peared. This last sinus 
 liealed about the end of INIay, after the patient had left the hospital, and 
 from this date all dyspnoea, cough, and expectoration ceased entirely. 
 Since June, he has been at work as a clerk. 
 
 On Nov. 17th, 1888, he was examined by Dr. Lendon, who found 
 him to be in robust health, and free from cough, dyspnoea, or 
 expectoration, although at the right apex there were marked signs of 
 consolidation (deficient expansion and percussion resonance, bi'onchial 
 breatliing with prolonged exjjiration, and increased resonance on 
 .speaking and whispering), more evident in front than behind. There 
 was no abdominal enlargement, and the hepatic dulness was normal in 
 its limits ; the cardiac apex beat was in the normal situation, but 
 the impul.se was diffused over an extensive area. The whole chest, 
 with the exception of the right ajiex, expanded remarkably well, and 
 the other physical signs were, louglily speaking, normal, excepting that 
 the breath sounds were weak at each base posteriorly. The wounds 
 were all soundly healed, Init the skin was puckered and adherent to 
 the periosteum, which had formed new bone, so that it would have 
 been difficult for one unacquainted with the case to believe that so 
 extensive excisions of ribs had been practised. 
 
 TREATMENT OF HYDATID DISEAkSE BY INJECTION OF 
 PERMANGANATE OF POTASS. 
 
 By W. P. Whitcombe, M.R.C.S.E. 
 
 Amongst the many and different methods of treating hydatid disease, 
 it has long seemed to me that some means of destroying the walls of the 
 cysts (both parent and daughter) was much required, having, of course, 
 due regard to the safety of the patient. But it was not till May 1885 
 that I liecame acquainted with any solvent for them. In a paper read 
 for me before the Victorian Branch of the British Medical Association, I 
 described a case of multiple hydatid, occurring in my hospital practice, 
 which (piite as a dernier ressort I treated by laparotomy, the case 
 proving fatal. During the operation some three gallons of cysts were 
 removed, and at the post-mortem examination, some two gallons more 
 were taken from different parts of the abdomen. Thus we had an 
 excellent opportimity of seeking for an agent capable of acting as a 
 solvent. Our then resident surgeon directed the dispense ;■ to try and
 
 390 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 find something which would thus act, and in a few days, after tryinaj 
 many different things, he discovered that a solution of jierinanganate of 
 potass had this power, and since then it has been my common practice 
 to inject solutions of this salt into hydatid cysts containing, as is often 
 the case, large numbers of daughter cysts, and as a rule with good 
 results. In illustration of this plan, I will give a short resume of the 
 last case treated by me in this way : — On •22nd July, 1888, I was called 
 to see J. G., ajt. 24, by occupation a letter-carrier, i)reviously a healthy 
 man. He was feverish, and comjilaining of pain and tenderness in left 
 hypogastrium. After a few days' attendance, the pain being somewhat 
 relieved, I diagnosed a large hydatid cyst in left wall of the liver. 
 This I aspirated, but could only obtain a few drachms of the characteristic 
 fluid, the parent cyst being literally crammed with daughter-cysts. On 
 2nd August, I tapped with a lai'ge trocar, leaving the canula in the 
 wound, and introducing through it a drainage tube. Through this but 
 little fluid escaped, and therefore in about three days I commenced 
 injecting solutions of potass permanganate at first, but very little could 
 be forced in. This was repeated every other day for about a fortnight, 
 the result being that by the end of the month the whole of that cyst 
 and its contents were dissolved, and had come away, leaving a small 
 unhealed sinus. It was then found that there was another cyst in the 
 right lobe of the liver. This was treated in like manner, and in about 
 three weeks this had also come away, also leaving a sinus. These 
 sinuses were perfectly healed by lltli October, and the })atient went to 
 the seaside for cliange of air, returning to his duty by the end of 
 November. Such has been the plan I have pursued during the past 
 two years. I have always endeavoured at first to evacuate the cyst by 
 simple tapping, with or without aspii-ation, as I have found that this 
 treatment has been sufficient to effect a cure in the majority of cases 
 met with — I think I may safely say in all cases where the cyst has been 
 simple, and not containing any daughter-cysts. And I am now con- 
 vinced that, in the injection of a solution of permanganate of potass, we 
 have an agent which will in almost all the severer cases destroy the 
 cysts, without the slightest danger to the patient, and will thus effect a 
 perfect cure. 
 
 UPON THE OCCASIONAL PRESENCE OF BILIRUBIN IN 
 HYDATID CYSTS. 
 
 By JouN Davies Thomas, M.D., F.R.C.S. 
 
 On October 17, 1SS8, 1 operated by abdominal section upon an 
 enormous hydatid of the abdomen in a man aged 25. When the 
 abdomen was opened, it was found that it was nearly filled with a huge 
 3chinococcus cyst. The fibrous sac was inseparably adherent to the 
 abdominal wall in front, whilst posteriorly it seemed to line the 
 abdominal parietes, so that it was a mystery where the intestines lay. 
 It also reached to the bottom of the pelvis, between the rectum and 
 bladder, both of which must have been compressed,
 
 OCCASIONAL rUKSKNCK OV IJILlllUUlN IN HYDATID CYSTS. 391 
 
 Above, its u})per limit could bo reached with the fingei-, at about the 
 margin of the thorax, on the left side of the median line ; but on the 
 right, the sac extended to the under surface of the liver, far beyond the 
 reacli of the finger. I felt assured that tlae parasite had originated 
 at the under surface of the right lobe of the liver, and had grown 
 downwards to the pelvis, almost entirely filling the abdomen. The 
 mother-cyst was dead, and had been ruptured before the oj)eration. It 
 was also stained deep green, apparently from bile. The daughter-cysts, 
 which were present to the number of thousands, were of all sizes, from 
 that of a large pin's head to that of a medium sized apple. The 
 nuijority contained clear transparent contents, and were tense and 
 plump ; but a great niiniber were flaccid, collapsed, with opaque walls 
 and j)uriform (not })urulent) contents. They were for the most i)art 
 unruptured. Inside many of these dead, but still entire, daughter-cysts, 
 I found flakes of matter resembling in colour red sealing-wax, but of 
 soft consistence. 
 
 Upon microscopic examination, I found that the flakes in question 
 consisted of a collection of ruddy crystals, having the fundamental 
 shape of oblique rhombic prisms. Some were pi'esent as isolated 
 crystals, but the majority were accumulated into irregular masses, in 
 which, however, it was easy to recognise the forms of the component 
 crystals. Mixed with these coloured crystals were acicular fatty 
 crystals and numerous oil globules of all sizes. The latter were, no 
 doubt, products of the degeneration of the cyst contents. 
 
 The quantity of the red matter procurable was very small, so that a 
 quantitative analysis was impossible ; but it possessed the following 
 chemical characters : — Insoluble in water and in cold alcohol ; soluble in 
 ether, and very readily so in chloroform ; from the chloroform solution 
 there were deposited, by the volatilisation of the solvent, small oblique 
 rhombic prisms of yellowish-red tint, quite like those found in the 
 original red matter, and acicular crystals apparently of some fatty acid, 
 as well as rhombic plates of cholestearin ; both the latter were 
 colourless. The chloroform solution gave the distinctive colours of 
 bile ])igment with Gmelin's test, and this was particularly well marked 
 ui)on the addition of chloroform containing a trace of free chlorine. 
 tSpectroscopically examined, the solution was found to extinguish to a 
 great extent the blue end of the spectruu), but there were no absorption 
 bands in the rest of the spectrum. Examination by polarised light 
 showed the ci'ystals to be double refracting. 
 
 From the preceding data, it is clear that the matter in (question was 
 bilirubin. I must acknowledge with thanks the kind assistance given 
 nie by Professors Eennie and Bragg, as well as by Dr. Whittell, in 
 determining this point. The j)resence of bilirubin has been previously 
 noticed in connection with hydatid cysts. For example, Bristovve 
 (Path. Soc. Trans., Vol. IV., }). 166) mentions a case of degenerated 
 hydatid in the left lobe of the liver, in every part of which numerous 
 vermilion spots were found. These spots consisted of colourless plates 
 of cholestearin mixed with ruby-coloured, more or less regularly 
 rhomboidal, crystals. 
 
 In June 188G, Dr. Springthorpe read a paper before the Medical 
 Society of Victoria u[ion an interesting case, in which a very large
 
 392 INTEHCOLOXIAL MEDICAL CONGKESS OP AUSTKALASIA. 
 
 amount of this body was found in an abdominal cyst. It is not clear 
 to me whether this cyst was originally of hepatic origin or not, and this 
 important point does not seem to have presented itself to the writer of 
 the paper. Apparently, however, the cyst in point was not considered 
 to have taken its rise from the liver, for Dr. Springthorpe evidently 
 attributes the presence of the bilirubin to altered blood effusion ; but, as 
 lie remarks (p. 254, Australian Medical Journal, June 15, 1886) it 
 would require about thirty ounces of blood to yield this quantity of 
 pigment, and this loss of blood could hardly fail to assert its occurrence 
 ioy marked symptoms. In my own case, there could be no doubt that an 
 effusion of bile had taken place into the sac, and had not only killed 
 the mother-cyst, but had also passed by endosmosis into many of the 
 daughter-cysts, destroying them also. In process of time the colouring 
 matter of the bile was precipitated as bilirubin in the interior of the 
 daughter-cysts invaded. I believe that some flakes of bilirubin were 
 present free in the mother-cyst, but of this I cannot be certain, for 
 daughter-cysts may have ruptured during the operation, and so have 
 given rise to what appeared to be flakes in the mother-cyst. 
 
 DISCUSSION ON HYDATID DISEASE, 
 
 A discussion was then instituted ; and on the suggestion of the 
 Chairman (Dr. Stirling), it was agreed that, as far as possible, seeing 
 that so little time was available, the speakers should confine themselves 
 to questions concerning the surgical treatment of liydatid disease. 
 
 Dr. Sydney Jones (New South Wales) said : — I have listened with 
 intense interest to the papers which have just been read, and particu- 
 lai'ly so as to the surgical treatment of hydatids. We in New South 
 Wales do not see hydatids so frequently as our favoured brethren in 
 South Australia, still the disease in our colony is not infrequent ; and 
 there, as elsewhere, the most favoured localities for the disease ai'e 
 primarily the liver, and secondarily the lung. I do not propose to occupy 
 your time in discoursing on the various methods of treatment which 
 have been adopted by myself in New South Wales in years gone by ; I 
 should siniply like to record what is the ultimate opinion at which I have 
 ai'rived after consideration of cases that have come under my observation 
 for many years ])ast. I may say that my methods of treatment, and 
 those, I think, of my fellow pi-actitioners, dwindle down to two — tii'st, 
 aspiration ; secondly, direct incision, with stitching of the sac to the 
 parietes. I am not disposed to give up asj)iration Mt toto, as I think the 
 tendency of the pape.rs which we have just heard would induce us to do, 
 I cannot shut my eyes to the fact that in years gone by I have operated 
 upon scores of cases of hydatids of the liver by simple aspiration, and I 
 have every reason to believe that, in the vast majority of those cases, an 
 absolutn cure has taken ])lace. At any rate I have lived long enough, 
 having bocu in practice twenty-five years, to have had frequent o])por-
 
 DISCUSSION ON llVDATIl) DISKASK. 393 
 
 tuiiity of watching' tlio cases that were operatud oti by iiio many years ago, 
 and it is only within tlie hist six months tliat I saw two of those cases, 
 and from the time of operation up to tlie present day, not a solitary sign 
 or symptom of hydatids had occurred, and I do not think it is fair to say 
 that the cyst itself may refill after an interval of ten years. Who shall 
 say, when such a thing occurs, that there is not a formation of a fresh 
 liydatid cyst? Who is to pronounce that such a thing is not possiljle, 
 nay even ])robable 1 Then, Sir, the conclusions at which I have arrived, 
 and which I now cx]>ress, are that in all cases of liydatid cyst, other than 
 those of the thoracic cavity, which I exclude for the ))resent, our first 
 duty is simple asjnration. In a large nund^er of cases, of course, we 
 shall be unable to draw off" any quantity of fluid that will have any 
 material eifect on the vitality of the [)arasite. Those are cases in which 
 the parent cyst is completely packed with daughter-cysts. Such cases as 
 those have occurred to me pretty frequently, and I must say, much more 
 frequently of late years than they did in previous years. In such cases 
 as that, of course, simi)le aspiration will be perfectly u.seless, and if I find 
 such a result, I am prepared at once to proceed with the o])eration of 
 cutting down and stitching the sac to the parietes, and opening and 
 draining in the usuiil way, evacuating all the daughter-cysts, and wash- 
 ing out, and inserting a very large drainage tube ; but as I said before, 
 tho.se are cases that one will meet with every now and again, but there 
 are other numerous cases in which one will Ije able to evacuate two or 
 three pints of clear hydatid fluid. I am confident that, in the vast 
 majority of such cases, an absolute cure will result. I am fully aware 
 of the risk of aspiiation in thoracic cases, and I therefore have some 
 hesitation in aspirating such cases because of the risk, which has been 
 so well pointed out by Dr. Thomas, of rapid suffocation, which is the 
 sj)ecial risk to which those cases are exposed ; still, if I have a case where 
 there is distinct bulging of the thoracic wall, I should not hesitate for 
 one moment to use the hypodermic syringe, which I think we ought to 
 use in more instances than we do, and withdraw a portion of the 
 contents of the cyst. Finding it to be hydatids, I should then consider 
 it my duty to cut down and stitch the ]Julmonary and parietal ])leur{e 
 together, and open and drain in the usual way. I have discarded 
 altogether the other oi)erations which have been referred to, such as 
 retained canula, caustics, injections, and all such like. I think the 
 whole thing is naiM'owed down to the two operations which I have just 
 described, and I think it will be of infinite regret to us all, if we discard 
 the simple and almost perfectly safe operation of aspiration. I say 
 perfectly safe from my own experience, because not a solitary death has 
 ever occurred in my practice from simple aspiration. 
 
 Dr. Rendle (Brisbane) said : — Although I cannot boast of a very 
 large personal experience of hydatids, yet I was very anxious to 
 have an opportunity of saying a few words on the subject, and this 
 morning, when I spoke to a friend, saying that I was coming here to 
 listen to the papers on the sul)ject, he said " That is a well-worn 
 subject ; there is nothing new on that." I am very glad to say I was not 
 of that opinion, and I am still less of that opinion, now that I feel that 
 I have learnt a great deal in listening to the papers which have been 
 rend to-day : and T think the great lesson, in spite of what my .senior, 
 Mr. Sydney Jones, has said, that most of us, if not all, will take away
 
 394 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 from this meeting to-day, is the great importance and the great 
 advantage of the treatment by free incision and drainage. I think no 
 one can forget the large number of cases where putrefaction occurs, and 
 this is one of the greatest dangers in the treatment of this class of 
 disease. No doubt we are able to protect ourselves from that more by 
 operation and free incision than l)y any other operation, however careful 
 we are in the process of aspiration. There can be no doubt, although 
 we do not introduce any foreign element, yet the very fact of the beings 
 dying after the operation shows that they themselves are a source of 
 putrefaction, and consequently of danger to the host. Another great 
 advantage of the operation by incision is, that one is better able to see 
 where one is going, and better able to regulate the size of the operation 
 according to the need as it arises, and a greater freedom from injury to 
 the intestines and other structures, and a greater certainty of confirming 
 our diagnosis, before we have gone too far in our treatment. Another 
 thing tliat struck me was the condemnation of the subsequent injection. 
 I could not understand why that was condemned ; and I was very 
 pleased to hear Dr. Thomas explain that it i)revented the collaps- 
 ing of the cyst, and the occurrence of adhesions, both of which 
 circumstances are so desirable. With all due respect to Dr. Sydney 
 Jones, I think it would more satisfactory if, instead of making 
 sweeping statements about the treatment, he had brought a few statistics 
 of his cases to show the actual number that have really recovered, 
 and the time of observation after aspiration, and also the number of 
 cases in which putrefaction has or has not occurred. 
 
 Mr. FitzCtEUald said that the subject of hydatid disease had always 
 been of great interest to him, and that his interest had not diminished, 
 but rather increased, during thirty years of jiractice. He had not 
 intended to speak, but on some ]ioints he could give definite information. 
 Firstly, it was (juestioned whether tai)ping effected a permanent cure. 
 Over twenty-five years ago, a lady in Melbourne came under his care suffer- 
 ing from gastralgia. He diagnosed the case as one of hydatid of the liver, 
 and with difficulty obtained the patient's consent to paracentesis. Dr. Bird 
 was present at the operation. The aspirator was not used, simply the 
 ordinary trocar. Between ten and twelve ounces of fluid were removed. 
 The pii,tient lost all pain. Five years later, she died of apo})lexy. A 
 ])ost-mortem examination was obtained. The mother cyst was found 
 rolled up in the collapsed adventitia, but not adherent to it. He had 
 seen many cases subsequently, which showed that when simple tapping 
 was performed with success the sac contracted to very small dimensions, 
 and then fiecpiently remained permanent, with relics of the true echino- 
 coccus structures encapsiiled within it. He almost always tapped in the 
 first insttince, but seldom used the asi)irator. Aspiration, when pushed 
 too far, had, within his knowledge, caused death by h?emorrhage. He 
 remembered only one case in which simple tajjping caused death. 
 That occurred twenty-six years ago, in the Melbourne Hospital, in a 
 patient under the care of the late Dr. Wilkie. The hydatid was deep 
 in the liver, and long trocars weie not then in general use. A short 
 trocar was inserted without result. Dr. Wilkie objected to the use of 
 a longer instrument; deatli ensuf^d. At the auto])sy, it was foiuid that 
 tlie sac h;i(l boon ])onetrat('d, but the mothoi- cyst had been pushed 
 inwards by the trocar, and separated froui the adventitia; haemorrhage
 
 DISCUSSION 0\ HYDATID DISRASK. 395 
 
 had occurred into tlie s])ace so formed. He had seen no otlior case in 
 which death could be attributed directly to tapping. Undoubtedly, 
 tapping frequently revealed the presence of multitudes of daughter 
 cysts. Free incision and thorough drainage were then required, and 
 death often followed the neglect of these procedures. But, even in 
 these difficult cases, the preliminary tai)ping did no harm, while in the 
 simpler cases it sufficed for a cure. Surely then, it was not correct 
 surgery to neglect an operation attended with no danger, which was 
 thoroughly effective in a lai'ge number of instances, on the ground that 
 in a minority of cases it needed supplementing l)y incision, evaoiation, 
 and drainage. During tlie discussion, reference had been made to 
 symptoms of shock after tapping. In one instance, he was treating, in 
 conjunction with Dr. Bird, a case of multiple hydatid. The patient, a 
 man from Queensland, was over 70 years old. The abdomen was full 
 of cysts. One after another was tapped and emptied, till a cyst over 
 the great end of the stomach was punctured. Pulse and breathing 
 at once ceased, and the patient fell as if dead. He lay in a trance 
 for eleven days. Probably some great .sympathetic reflex had been 
 excited. However, he gradually recovered, and years later had no sign 
 of liydatid disease. He (Mr. FitzGerald) further said that, when he 
 determined to incise a hydatid cyst, he inserted a number of hare-lip 
 pins, so as to .secure adhesions. If the abdomin;il wall was flaccid, he 
 pinned the cyst to the wall ; if it was thick, he simply inserted the pins 
 into the cyst cavity ; if the cyst was tense, he diew off a small quantity 
 of fluid in the flrst instance. He left the ])ins in for twenty-four to 
 forty-eight hours, though adhesions were in reality obtained in five or 
 six hours. It was nearly fifteen years since he first incised and removed 
 the whole parasite. But he insisted that this lai-ger operation should be 
 restricted to cases requiring it. The recovery after sim])le tapping was 
 sometimes startling in its rapidity. About seven years ago he saw^, 
 with Dr. Williams, a case of large single cyst of the liver. Eight 
 pints of fluid were removed. Within fourteen days, the patient was in 
 the saddle in the hunting field. Two years later the |)atient reported 
 liimself, and there were no signs of hydatid disease. Eighteen years 
 ago, a railway ])orter presented himself with partial right hemiplegia, 
 pain in the right arm, bulging and intense pain around the left ear. 
 The finger in the ear detected slight crackling and semi-fluctuation on 
 pressure. Eight ounces of fluid wei-e withdrawn with a fine trocar. 
 Complete recovery followed. 
 
 Dr. S. D. Bird said that it had fallen to his lot to see a lai'ge number 
 of hydatid cases dating as far back as 1861, when he saw, in the 
 Melbourne Hospital, the late Dr. Motherwell and Dr. Hudson (now 
 present) tap many such in the liver, with the ordinary fine trocar and 
 canula, with perfect success ; and he was informed by those gentlemen 
 that they had heard no complaints of recurrence in the great majority 
 of cases. A good example, amongst hundreds that might be quoted, of 
 tlie efficacy of simple tapping, was that of a little girl from the Western 
 district, who was so treated by Mr. FitzGerald and himself for a cyst in 
 the liver in the year 1872, with complete recovery as usual; but 
 the following year a cyst in tlie right lung made its appearance, which 
 was treated in the same way with the same lesult, and some years 
 afterwards, the young lady when presented at Coint caused a notable
 
 39G INTERCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 sensation by her remarkable beauty. Sometimes violent convulsive 
 cough, with expulsion of membranes and blood, followed tapping the 
 lung, and even pneumothorax, but he h;id never seen death or 
 permanent injury, or indeed any other result than cure follow this 
 treatment. On the other hand, the use of the aspirator was distinctly 
 dangerous. Several sudden deaths had been caused by it, even in the 
 most skilled hands; and it also hindered, instead of aiding, the emptying 
 of the c\\st, by sucking portions of membrane into the canula, thus 
 giving rise to delay and trouble. For oUl suppurating cysts of the 
 lung, a different treatment was required. In all )>robability, adhesions 
 to tlie chest wall ali'eady existed, and all that was necessary was to 
 introduce the largest trocar and canula that would pass between the 
 ribs, leaving the latter in for a few days, and frequently washing out 
 with antiseptics. The wound being now freely enlarged laterally 
 with a probe-pointed bistoury, the whole of th^. parasite was easily 
 removed with a little assistance, and a radical cure was effected. 
 He had never found it necessaiy to resect any portion of rib, though 
 some of the cysts had been of enormous size, and weighed over 
 a pound after removal. In none of the.se cases had there been 
 septicfiemia, or any warning of it ; the constant result had been ladical 
 cuie in about three weeks, though sometimes separation of the cyst 
 wall from its nidus was delayed much longer than this. So far from 
 hydatid of the lung being a difficult disease to cure, he had found it 
 more safely and readily curable here tlian in any other internal organ 
 — except, perhaps, the liver — piovided the treatment was not hurried, 
 and the aspirator was not used. He had reported a great many of 
 these cases in the Aitstralian Medical Joiornal in past years, but of late 
 had not done so, as he had nothing new to tell — all the cases ending in 
 the same way. The only cases, in his opinion, in which immediate 
 cutting operations for hydatid within the thorax were justifiable, were 
 those in which the parasite occupied the cavity of the pleura, either by 
 rupture from the lung or elsewhere, or by primary development. These 
 were much more serious cases. Many years ago, he removed a large cyst 
 which had burst from the lung into the pleura, leaving a fistulous 
 opening and pneumo-thorax ; complete recovery followed after a pro- 
 longed course of treatment ; but some months afterwards, during an 
 attack of pneumonia from exposure, the fistula re-opened, and after a 
 tedious illness the patient died of exhaustion. Primary hydatid of 
 the pleura was very rare ; he had only seen two cases, in both of which, 
 after operation, a secondary development of hydatid took place in the 
 pericardium, and of course caused death. If adhesion to the chest wall 
 did not exist in an old suppurating hydatid, his practice had been to 
 tap with a moderate-sized trocar, and leave the canula in for a few 
 days, when adhesion was sure to form. His experience of these plans 
 of treatment of lung hydatid (and the same was equally applicable 
 and successful in the liver), led him to enteitain very grave doubts as 
 to the proi)riety and .safety of ])rimary cutting operations in non- 
 suppurating cysts, involving such serious procedures as resection of ribs, 
 incision of sound lung, stitching of pleura, and so on, reconnnended and 
 ])ractised by Dr. Gar<lner. In fact, it seemed to him that the same 
 criticism was applicable here as was made by the French on the 
 jjalaclava charge. Tlicy said of it ; — " O'est magnifique, mais ce n'est j)as
 
 DISCUSSION ON HYDATID DISEASE. 397 
 
 la guerre !" wliicli we might paraphrase by allowing that such opera- 
 tions were bold in design, and in Dr. Gardner's hands no doubt 
 brilliantly performed, but were they sound or prudent practice, when 
 the experience of hundreds of cases in this colony show us that we have 
 other means of cure, slower indeed, l)ut just as sure, and entirely devoid 
 of risk ? 
 
 Dr. Nicholson (Benalla) said : — In the main my experience as a 
 private practitioner completely coincides with that of Dr. Jones, of 
 Sydney, and with those who bclie\e that aspiration is the safest, and by 
 far, in the majority of cases, the best treatment for these cases so far as 
 at present known. I, as a country practitionci-, have an opportunity of 
 watching man}' of my patients during a good many years, having lived 
 Lwenty-tive years in this colony. I also have had the history of cases 
 which have been operated on by Dr. Bird and Mr. FitzGerald, that fully 
 bear out the view, that in by far the majority of cases the aspirated 
 hydatid does not return. I wish to say I have a method of treatment, 
 which I desire to lay before you — a new method, I think. I wish to 
 peptonise those things, and pi'oduce an easily ditFusible peptone, and so 
 remove them from dangerous places where the knife could not reach 
 them. I look upon the hydatid cyst as simply no more nor less than 
 a perfect dialysing apparatus, and it takes from the blood the saline 
 materials. Some say there is no such thing as absorption in this con- 
 nection. I have seen cases treated by Mr. FitzGerald with iodides, and 
 I have analysed fluid from those cases, and have invariably found 
 iodine ; but in the very last case I had, of which I have the analysis in 
 my hand, the jiatient was taking nitrate of jtotash, and to such an extent 
 was the hydatid fluid permeated by the nitrate of potash, that the dried 
 extract would burn like tinder. As I said before, my method is simply 
 to render the contents of the cyst soluble, or dialysable, by the injection 
 of acidified glycerine solution of pepsine. 
 
 Dr. Batchelor said: — I should like to say a few words on this 
 subject, because we have a good number of cases in New Zealand. I 
 think the statistics I'ead really prove very little about the operations, 
 but rather show the valuelessness of statistics ; because from what I 
 have heard, I certainly judge that some cases, where the puncture has 
 been performed, have been pncked out indifferently, whereas the opera- 
 tions have been performed by skilled surgeons ; and if Dr. Gardner 
 pjunctured a hundred cases, and incised a hundred cases, I think he w-ould 
 find that his results from puncture would bear very favourable com- 
 parison with the other. As to the question of washing out the cavity, 
 I quite agree with Dr. Thomas, if the first incision is done thoroughly, 
 and the wound is kept aseptic, I cannot see what advantage you get by 
 washing. Of course, if you allow germs in, you must wash them out ; 
 but once get the wound aseptic, the same rule applies to this as to 
 empyema. Such washing is objected to by the best authorities ; and if 
 it applies to the thoracic cavity, how much more must it apply to the 
 abdominal walls. As to incision of the chest, I take an entirely different 
 view from Dr. Thomas. He says, I understand, that in cases where 
 there is dulness on the surface, and the sac is near, in that case he would 
 incise. Well, I should say that I should puncture that case, because 
 you do not go through lung tissue at all • but if you pass through lung 
 tissue where the air gets in, it seems to me you have a very ready mode
 
 398 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 for tlie cavity being infected. On the contrary, I should feel inclined 
 to incise where the cavity was in the interior of the lung. 
 
 Dr. Charles Smith said : — I wish to bring before the Congress a 
 method of treating hydatid of the lungs, which I have tried in two 
 instances with success, and although so small a number of cases does not 
 justify a general conclusion, T think the principle is good, and that 
 fuither treatment of the same kind is desirable in the interests of 
 patients and of science. The method I speak of is what is called the 
 desiccating method, when applied, as it has long been, to the treatment 
 of pleuritic eii^ision. I deprive the patient of all fluid for twenty-four 
 hours, exce^^t the small quantity given with the medicine. During the 
 next twentj^-four hours I allow half a i)int only, and if the })atient can 
 be kept to this for five days, I do so, but a good deal of determination 
 is required on his part. At the same time, I give half a teaspoonful of 
 common salt in half a wineglassful of water every four hours, not with 
 the idea of acting directly on the hydatid, but with that of increasing 
 the density of the blood, and thereby aiding the rapid desiccation of the 
 cyst; or I use pot. iodid. instead, but with the same effect. In one case, 
 the hydatid was expectorated four weeks after the treatment was used; 
 in another, the expectoration of the cyst conmienced the week after; and 
 this, I believe, was not simply a coincidence, for the case had been some 
 months under my observation, and was not a very large one. There 
 were special reasons for deferring an operation. I hope that others will 
 give this method a further trial, as I intend to do, and that they will 
 report the result. If successful in the case of the lungs, it may prove 
 to be so also in that of other organs; but in my two cases, the cysts were 
 expectorated. Whether simple drying iip may occur in other cases, 
 remains to be proved. The rapidity of the desiccation is an important 
 element in the method — another branch of the subject. I have had an 
 opportunity of tracing the gradual growth of a hydatid cyst from its 
 very commencement, until it reached the capacity of about two quarts. 
 It was in the breast, and therefore free to grow without any great 
 pressure, and the time occupied was ten years. I think, therefore, that 
 in ordinary situations, a cyst of the size of an orange would be of two 
 years' growth. In the first case treated, the patient continued the salt 
 and water for nearly forty-eight houis, when it had to be discontinued 
 on account of tendency to vomit; the deprivation of fluid was continued. 
 In the second case, where pot. iodid. was given, gr. v were given evei'y 
 four hours, and continued for five days, and afterwards three times a day 
 for several weeks. In fixture cases I shall prefer the pot. iodid., as it 
 does not cause vomiting. In other respects, the diet is as usual, as much 
 dry food as is desired being allowed. 
 
 Dr. Springthorpe said that he desired to bring forward two points 
 of some importance. Firstly, the necessity for some concerted pre- 
 ventative measures. In 18S5, he urged the importance of .some action 
 upon the Central Board of Health in Victoria. The outcome was the 
 issue of an instructive leaflet, of which some thirty thousand were 
 circulated throughout the colony. No doubt, much good followed the 
 dissemination of the information therein given, but much remained 
 to be done. He urged that this Congress should bring under the notice 
 of the different Governments, the necessity for taking preventive 
 measures, by the inspection of dogs in the more infected areas, &c.
 
 DISCUSSION ON HYDATID DISEASE. 399 
 
 Secondly, he drew attention to the difficulty, if not the impossibility, of 
 diagnosing hydatid fluid in the absence of hooklets, scolices, and 
 membrane, from some forms of ovarian fluid. The low specific gravity, 
 the absence of albumen, and the jjresence of abundant chlorides, are not 
 diagnostic of hydatid fluid, they characterise also the fluid of parovarian 
 cysts. Of this, he gave two examjiles ; one was mistaken for hydatid, the 
 other was correctly diagnosed- — both were parovarian cysts. Case 1. — 
 Fluid slightly alkaline, sp. gravity 1002-2; chloride of sodium, &,c. l-i 
 in the 1000 ; no albumen ; mucilaginous matter also present. Case 2. — 
 Fluid alkaline, sp. gravity 1011; chlorides, 6*75 per 1000; albumen, 
 only a trace; solid constituents, 12-12 per 1000. Mr. Kruse, the 
 analytical chemist, is responsible for the analyses. In Case 2 the 
 results of tapping were manifest ; on examination of the fluid after the 
 tapping, the analysis was: — Sp. gravity, 1023; chlorides, 7-65 per 
 1000 ; albumen, 30-25 per 1000; solid constituents, 45-50 per 1000. 
 
 Dr. Gakdxer, in reply, said : — I feel that I am an advocate of a 
 cause that seems to have very few adherents in this assemblage, 
 therefore, possibly, I may be at a disadvantage. When we hear a 
 physician like Dr. Bird telling us that he cures so many cases with 
 simple tapping, it may well cause one to pause in any radical 
 recommendations, knowing his reputation for scientific accuracy. Mr. 
 FitzGerald, of whom no one has a higher appreciation than myself, tells 
 us too that he has had large success in aspiration of hydatids. Well, I 
 would venture to point out to this Congress that what we want is that 
 men should lay on the tabic their statistics, the number of cases they 
 have tapped, the results of the tapping, the accidents they have had, 
 and the number of years that they have watched over the cases 
 afterwards, before laying their results before us ; for I venture to think 
 that the man who undertakes to say that tapping for hydatid cysts is a 
 panacea, has a greater amount of work and more prolonged investiga- 
 tions to do than the man who cuts into the lung or liver and removes 
 the cyst. The one can say he has cured his patient, the other has 
 to pass through years of observation before he can say he has done 
 so, and I venture to think we have to look more to country practitioners 
 for this detailed information. The country practitioner, with only one 
 rival in the town or possibly none at all, knows every case of hydatid 
 disease in the town, knows exactly when he tapped and how often he 
 tapped it, and he can tell us the result ten years afterwards ; those are 
 the men who must come forward and settle this question, for it cannot 
 be done by simple assertion and the record of a few isolated cases. 
 There are many other points one would like to discuss, and certainly 
 the subject is a veiy tempting one, but I must say that my previous 
 experience of tapping and what I have read about the bad results of it, 
 what I have seen in cases of hydatid cysts packed with daughter-cysts, 
 which could not be removed in any way, has been confirmed. Those 
 are the cases in which aspiration is perfectly powerless, and there I 
 think aspiration is unlikely to be so successful as it is in an ordinary 
 case of empyema. There is just one other point. Hydatid cyst of the 
 lung may exist for a long time in the lung, and occasionally causes 
 l)artial necrosis of the ribs. I venture to think that aspiration will 
 be usually powerless in that condition. Even resection of the ribs 
 and removal of the cyst will not kill the cause. What is to be done ?
 
 400 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 It is absolutely necessary in those cases, as I had to do tlie other 
 day, to perform Estlander's operation — resecting a large number of ribs. 
 If you merely resect the ribs, and expect the cavity to fill, I know 
 by bitter experience what may result. In one case I allowed myself to 
 leave the periosteum, and in six weeks every one of the six or eight ribs 
 I had taken away had formed bony unions at the other end ; the 
 consequence was that the cavity I had tried to obliterate was in the 
 same condition as before ; so where there is pressure against the ribs, 
 it is absolutely necessary to excise both the periosteum and the pleura 
 to get a successful result. 
 
 The Chairman said : — I should be sorry to vacate this chair without 
 expressing my indebtedness, and without offering my congratulations, 
 to those gentlemen who have contributed their papers and their 
 sjDeeches to the elucidation of this question ; and it will certainly be 
 permitted to me, as a South Australian, to recognise with pleasure, that 
 those gentlemen who read the three first papers on the treatment of 
 hydatid, are fellow colonists and colleagues of my own. I trust, there- 
 fore, that without impropriety, I may feel it to be an especial pleasure 
 to be in the position to offer the congratulations I do. Generally, the 
 discussion has done what we wanted it to do. It has brought out 
 differences of opinion between those who are best qualified to express an 
 opinion on this peculiarly Australian subject. It is the old question of 
 tot homines, tot sententiw, and, although it might have been more satisfac- 
 tory if the eminent gentlemen who have contribiited to the discussion 
 could have agreed with more absolute unanimity that such and such a 
 course was the best one, yet the preliminary step to unanimous opinion is 
 necessarily a fair statement of the differences existing. We have seen 
 in this discussion the beginning of a healthy differentiation of opinion, 
 and it is impossible not to recognise that the opinion which has been 
 expressed by what I may now call the Adelaide school, is not generally 
 received. I cannot myself, after what I have seen of the successful 
 [)ractice of Dr. Gardner, and after what I know of the large area of 
 statistics that have been collected by Dr. Thomas, help announcing 
 myself an adherent of the practice which they have advocated ; and yet it 
 is fair for me to ask, and fair for those gentlemen to claim, that those 
 who object to the treatment they are advocating, shall place upon the table 
 collections of statistics, prepared with eqiial care, and showing definitely 
 certain results. We all know how fallacious impressions are, and 
 although we cannot but concede the greatest respect to the opinions of 
 gentlemen who have had such large experience as those who have taken 
 a contrary view to Dr. Gardner, it is impossible not to see in their 
 statements the one thing wanting, namely, some sort of statement, in 
 black and white, as to what really their results have been. With these 
 renuirks, I repeat again my congratulations to all who have taken part in 
 this very satisfactory meeting, and the result of it will go forth to the 
 world as presenting a picture, such as it is, of what is the best practice 
 of the best men in Australia in regard to this peculiarly Australian 
 disease.
 
 SECTION OF HYGIENE. 
 
 PRESIDENT'S ADDRESS. 
 
 By H. N. MacLaurin, M.D., LL.D. 
 
 President of the Board of Health of New South Wales. 
 
 COMPARATIVE VIEW OF THE MORTALITY OF THE 
 DIFFERENT COLONIES FROM CERTAIN DISEASES. 
 
 When I was requested to undertake the honorable duty of presiding over 
 the Section of Public Health in this Congress, I felt at first a good deal 
 of difficulty in deciding upon the subject to which I should call your 
 attention in this preliminary or introductory address. If I had 
 consulted my own convenience alone, I should have probably selected 
 the condition of public health, legislation, and administration in New 
 South Wales, as being the matter with which I am the most familiar. 
 But it seemed to me that, while this would naturally be of the highest 
 importance to myself and to my fellows from the oldest colony, it could 
 yet hardly be regarded as of sufficient interest to gentlemen from the other 
 colonies, to justify me in making it the subject of an address which 
 ought to be of a somewhat comprehensive and general character. I was 
 further induced to look in another direction for my text by learning, 
 that from at least two gentlemen of New South Wales, the members of 
 the Section will have the privilege of hearing papers on the sanitary 
 laws and administration of that colony, both generally and with 
 particular reference. 
 
 After casting about in every direction, it seemed to me that I could not 
 do better than try to lay before you a short sketch of the Health 
 condition of the various colonies of Australasia, including New Zealand, 
 as deduced from the registration of mortality during the last few years. 
 This will, at all events, be an attempt to lay a foundation for the labours 
 of the sanitarians, by showing what the diseases really are which cause 
 death in the various communities, and consequently, what are the 
 directions in which sanitary influences a:*e most required. It is true 
 that the materials at my command, being entirely drawn from mortality 
 
 Id
 
 402 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 tables, cannot give a complete presentation of the actual diseased 
 conditions of the colonies, for no account is taken of those cases of 
 disease which recover. But there are no materials in existence from 
 which such complete information could be obtained; and I think that, 
 on the whole, the mortality of a colony may be taken, for the present 
 at least, to furnish a sufficiently accurate approximate estimate of the 
 amount of disease of the colony. The plan adopted by me for this 
 purpose, has been to select from the statistical report of the various 
 colonies the forty most prevalent causes of death in three successive 
 years, excepting in Western Australia, for which I was in possession of 
 materials for only the year 1886. For the other colonies, the years 
 selected were 1884, 1885 and 1886, excepting in the case of New 
 South Wales, in which I had to take the years 1883, 1884 and 1885, 
 as the complete returns for 1886 were not published in time for my 
 inquiry. 
 
 The diseases have first of all been arranged in order of frequency, 
 giving the total number of deaths from each registered cause. They 
 have then been distributed, so as to show the prevalence of each cause of 
 death diiring the different quinquennial periods of life; and, moreover, 
 percentages have been calculated showing — firstly, the ratio of deaths 
 from each cause to 100,000 of the estimated mean population published 
 in the year to which the table refers; and secondly, the ratio which the 
 number of deaths produced by each cause bears to the total number of 
 deaths registered in the colony for the year. In addition, where the 
 information was sufficient for the purpose, I have distributed the causes 
 of death as far as possible between urban and rural districts, giving 
 in each case similar percentages to those which were calculated for the 
 whole colony. Owing to the insufficiency of the information at my 
 command, this has been possible for Australia only in the cases of New 
 Houth Wales and Victoria, and even in those, the method has not been 
 altogether so satisfactory as I could wish. Thus, in New South Wales, 
 I am able to give tables for Sydney, for its suburbs, and for the country 
 districts generally; but I am not able to separate from the country such 
 important centres of population as Newcastle, Goulburn, or Bathurst, 
 which are consequently included in the country, thereby somewhat 
 influencing the character of the mortality return. Similarly, for 
 Victoria, I am able to distribute the return into two parts, one 
 embracing Melbourne and its suburbs, and the other the remainder of 
 the colony, including the country districts, as well as such large and 
 important centres of population as Ballarat, Geelong, Sandhurst and 
 other great towns. There can be no doubt, that by this the apparent 
 mortality of the country districts of these colonies is somewhat increased, 
 owing to the influence of the large countrj^ towns; but, at all events, it
 
 president's address — SECTION OP HYGIENE. 403 
 
 is possible to ascertain the liealtli condition of the great cities of 
 Melbourne and Sydney, and to frame an estimate of that of the country 
 parts sufficiently approximate to be not devoid of interest to us. 
 
 It will be readily understood, that the taking out of this information 
 lias been very laborious. For the single colony of New South Wales 
 nearly 1000 calculations were required, all of them being of an intricate 
 and comi)lex character; and for the other colonies similar calculations, 
 although not in such large numbers, had also to l)e made. It would 
 have been quite imj»ossible for me, taken iq) as my time is with 
 numerous other engagements, to have carried out this very intricate 
 piece of work by myself; and I have here to express my hearty 
 obligations to l\Ir. Sager, the Secretary of the Board of Health of 
 New South Wales, to whose i-eady and kindly co-operation it is due 
 that I am able to place these tables before you. 
 
 Apart from the mechanical difficulty necessarily attached to such an 
 enormous series of calculations, another difficulty has arisen from the 
 fact that the nosological system adopted is not quite the same for all the 
 colonies, and in some cases seems to have been modified in particular 
 colonies in the course of the period under consideration. And while I 
 am on this subject, I would also point out the great advantage that 
 would I'esult, from a sanitai-y point of view, if measures were taken in 
 all the colonies to ensure the compulsoiy notification and registration of 
 at least the more important infectious diseases. We know from our 
 tables the mortality which results from typhoid fever, scarlet fever and 
 measles, but we have no means at present of estimating the misery 
 which arises from the very numerous cases of such diseases which, 
 however, do not end in death. It is easy for medical men to conceive 
 the grief and pain arising from these causes, as well as the absolute loss 
 to the community, even from a pecuniary point of view; but I am 
 afraid that the importance of this matter has not yet been brought 
 home to the public mind. If we were able to show in an exact form 
 the actual suffering and loss which result from the infectious diseases 
 alone, we might liO[)e to be able to arouse the attention of the i)ublic, 
 and to convince them of the necessity of introducing those sanitary 
 reforms which the profession of medicine have l)een so long, and for the 
 most part inefiectually, demanding. 
 
 As in almost every other part of the world, consuuqjtion of the lungs 
 figures in most of our returns as the greatest single cause of death. It 
 is first in the colonies of New South Wales and Victoria for the whole 
 period, and in South Australia for one year. In Queensland it occupies 
 the second place ; in Tasmania the third place, excepting for one year, 
 when it is second ; and in the sparsely -peopled territory of Western 
 Australia, it is only the tenth in the order of fatality. In New Zealand 
 
 Id 2
 
 404 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 it is at the head of the list for two years of the period, and for the 
 third it is bracketed an equal first with accidental causes. Where I 
 have been able to separate approximately the urban and rural districts 
 (i.e., in New South Wales and Victoria), it will be found to head the 
 list in Melbourne and suburbs, and in Sydney. In the country districts 
 of Victoria and the suburbs of Sydney, it is found to take second place, 
 excepting one year, when it is third ; but in the rural districts of New 
 South Wales, it holds only the third place, being exceeded by old age 
 and accidents. 
 
 What is the relative prevalence of phthisis in the various colonies? 
 To answer this, I have prepai-ed the accompanying table for the year 
 1885, the latest common to all the colonies for which I had materials, 
 excepting Western Australia, for which I have only materials for one 
 year, viz. 1886. It gives the number of deaths per 100,000 living in 
 each colony or district which I have been able to separate : — 
 
 Table I.— 1885. 
 
 District or Colonv. 
 
 Pkr 100,000. 
 
 New South "Wales 
 
 115-71 
 
 Sydney 
 
 222-37 
 
 Suburbs 
 
 197-46 
 
 Country 
 
 75-77 
 
 Victoria 
 
 141-94 
 
 Melbourne and Suburbs . . 
 
 -239-16 
 
 Eest of Victoria 
 
 88-62 
 
 Queensland 
 
 186-23 
 
 Tasmania . . 
 
 108-38 
 
 South Australia . . 
 
 96-01 
 
 New Zealand 
 
 89-65 
 
 Western Australia (1886) 
 
 68-21 
 
 seen from this table, that the dis 
 
 ;ricts under c 
 
 divide themselves into two classes, according to the prevalence of the 
 disease. In the fii'st, containing in order Melbourne, Sydney, suburbs 
 of Sydney, and whole colony of Queensland, the percentage of cases is 
 high, approaching to the average of the thickly-peopled countries of the 
 old world. In the second division the percentage is low, the oi'der 
 being Tasmania, South Australia, New Zealand, Victoria outside 
 Melbourne and suburbs, country parts of New South Wales, and lastly 
 Western Australia, in which there were only twenty-seven deaths in all 
 from phthisis, or at the rate of 68 per 100,000 living. In the last case, 
 however, we should most likely consider the numbers involved too small 
 to form an accurate standard, especially as the return is given for only 
 one year. 
 
 Another method of regarding tlie |)reA'alence of this disease is to 
 estimate the ratio of deaths from phthisis to those from all causes. A
 
 president's address — SECTION OF HYGIENE. 405 
 
 table containing this information for all the colonies for the same 
 period (i.e. 1885, excepting Western Australia, 188G) is here given : — 
 
 Table IL— 1885. 
 
 Colony. 
 
 Ratio to 
 Deaths from 
 ALL Causes. 
 
 New South Wales 7-lC 
 
 Sydney 11-00 
 
 Suburbs i 7*80 
 
 Country 5-73 
 
 Victoria 9*63 
 
 Melbourne and Suburbs .. .. 11*87 
 
 Rest of Victoria .. .. ..i 7'54 
 
 Queensland . . . . . . . . 9*51 
 
 Tasmania .. .. .. .. .. 7"12 
 
 South Austraha 7-70 
 
 New Zealand . . . . . . . . ' 8'45 
 
 Western Australia (1896) . . . . i 3-35 
 
 As in the former table, Melbourne and Sydney head the list. In 
 Melbourne, the ratio of deaths from phthisis to those from all causes 
 being 11 "87, and in Sydney 11*00 ; these are followed by Queensland, 
 9"51 ; Victoria, as a whole, 9 '63 ; New Zealand, 8 "45 ; suburbs of 
 Sydney, 7*80, and South Australia, 7wO ; and gradually in a descending 
 scale until we reach Western Australia, with 3.35. Here I may 
 mention as a curious fact that, from an examination of the death returns 
 of the Australian Mutual Provident Society for a period of thirty 
 years, and of the Mutual Life Association of Australasia for a ])eriod of 
 twenty years, I find the ratio which claims arising from deaths by 
 phthisis bear to claims from all other causes whatsoever to be almost 
 exactly the same in both societies, viz., 12*4 per cent. When we 
 consider the very great care taken by both of these Associations in 
 examining persons who propose to them for assurance, and when we 
 take into account the identity of the pei-centage of loss to each Society 
 from phthisis, I think we may infer that this ratio of 12*4 per cent, 
 may be taken as the percentage of deaths from phthisis which may 
 be expected among any number of healthy adults, principally males, 
 distributed over the greater part of Australasia. At first sight, 
 considering that the ratio of deaths from phthisis to deaths from all 
 other causes for the whole colony of Victoria is only 9 "63, and for 
 the colony of New South Wales is only 7"16, it would look as if 
 the life-insurance comjianies cut a very poor figure with their 12'4, 
 in spite of all the trouble they take to exclude unhealthy lives. But 
 this is only apparent, for we must bear in mind that the life-assurance 
 companies rarely accept proponents under the age of fifteen, and for the 
 most part their entrants are several years older. They thus escape the
 
 406 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 very serious causes of death which operate for the most part in infancy 
 and early childliood ; and therefore phthisis, which is chiefly a disease 
 of adult life, figures very highly among the death-dealing causes in 
 the assured population. In order to make this more clear, I have 
 taken out the ratio which deaths from phthisis bear to deaths from 
 all causes occurring above the age of fifteen in the colonies of Victoria 
 and New South Wales, and the results are as follows : — In Victoria, 
 percentage of deaths from phthisis to deaths from all causes over 
 fifteen years of age is 15 '43, and in New South Wales, 13 '40. Hence 
 we see that the assurance companies' result is i-ather better than 
 the average of Victoria, and a shade better than that of New South 
 Wales ; and this confirms the opinion that most intelligent men have 
 held, that the true use of medical examination for a life-assurance 
 company is not to provide a class of entrants much above the average in 
 the expectancy of life, but rather by the exclusion of diseased and 
 unhealthy lives to prevent the expectancy of the whole class of entrants 
 in any year falling below the average. I have calculated a similar 
 ratio for Queensland, and find it to be 16 "01. 
 
 When we come to compare the condition of Australia with that 
 of the countries of the old world, we cannot but be struck with the 
 comparative immunity from consumption which a considera'ble pro- 
 portion of this country enjoys. If we take the trouble to glance 
 down the very elaborate table given by Hirsch in the third volume 
 ofhis "Handbook of Geographical and Historical Pathology," we shall 
 be pleased to find that the rural parts at least of Australia occupy a 
 position with respect to tliis disease which will compare very favourably 
 with most other countries in the globe. Even Queensland, which is- 
 much the worst of our colonies as a whole, would stand very well 
 among European countries, being practically the same as Switzerland, 
 in which the death-rate from phthisis is very low for Eui'ope, and 
 to some parts of which phthisical patients are occasionally sent by 
 medical advice. And the more favoured colonies (at all events in 
 the country parts) will compare favourably with the rural portions. 
 of north-west Africa, which have long been celebrated for comparative 
 immunity from phthisis. 
 
 It is but riglit, however, to bear in mind, on the other hand, that the 
 urban portions of Australia possess no such immunity, and that 
 Melbourne and Sydney show a very considerable proportion of 
 phthisical deaths — the former city, with its suburbs, showing 2-39 
 deaths per 1000 persons living, a proportion which, according to 
 Hirsch, is nearly equal to that of many European cities, although, of 
 course, much below many German and Austrian towns, in which 
 phthisis seems to assume the proportions of a real plague.
 
 president's address — SECTION OF HYGIENE. 407 
 
 It is useless to shut our eyes to the fact, that consumption has got 
 a footing amongst us, and that it is now one of our most important 
 causes of death. How it is to be checked in its advances, and, if 
 possible, lessened in its prevalence, are among the most important 
 sanitary problems of the day. 
 
 It would take too long if I were here to go into this question. I 
 would ventui'e, however, to draw your attention to two matters : — -First, 
 that phthisis is essentially a disease of towns, especially of great towns, 
 and that, consequently, improvement of the hygienic conditions of great 
 towns, more especially in ventilation, free space, and, not least, in good 
 morals, will necessarily tend to the diminution of the phthisical death- 
 I'ate ; Second, the discoveries of the last few years with respect to the 
 bacterial origin of })lithisis ought surely to awaken the public from the 
 apathy with which they continue to consume the flesh of tuberculous 
 oxen, and the milk of tuberculous cows. That these tuberculous animals 
 do present the characteristic bacilli of tubercle, there is no doubt. I 
 suppose I must admit that I cannot jjoint to a case in which the 
 transfer of the bacillus from the ox or cow to the human being, by 
 feeding, has been actually demonstrated ; but the identity of the 
 morbific cause in the ox and the human being is quite sufliciently 
 probable to raise a suspicion strong enough to justify us in preventing 
 any risk of the kind. There has been a good deal of traflicking in 
 tuberculous cattle, at least in New South Wales, whether for slaughter- 
 ing or dairy purposes ; and one measure which was most urgently 
 required in that colony is a law rendering penal all traflicking in such 
 diseased animals for any purpose whatsoever. Such a law would be 
 of great service in preventing the sjiread of consumption among our 
 population. 
 
 This view would be strengthened if we inquired how the Jews in 
 Australia fared in regard to phthisis. It was well known that the 
 greatest care was taken by the Jews to avoid the consumption of meat 
 which was in any way tainted by disease. The Jews in Australia 
 showed a great immunity from phthisis. Mr. Davis states that in the 
 Jewish population of New South Wales, numbering 4000, he can 
 only call to mind one death from phthisis in three yeai-s. Taking the 
 average for the whole colony of New South Wales, the expected deaths 
 in 4000 persons for this period would have been 13*68 ; and as Jews 
 for the most part live in cities, we might fairly expect the death-rate to 
 be higher than for the whole colony. Instead of the rate expected, we 
 find, however, only one death, and a consequent saving of (say) twelve 
 lives in this number of persons in three years. I do not say that 
 this saving of life is entirely due to the avoiding the use of tuberculous 
 meat, but I take leave to maintain that I am justified in crediting
 
 408 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 this cause with a good deal of the beneficial result. Perhaps it will 
 be still more striking if I point out the saving of life in the colony 
 which would ensue if the Jewish average were maintained for the 
 whole population. In 1885, 1095 persons died of consumption in New 
 South Wales, being at the rate of 115-51 for each 100,000 of the 
 population. If the Jewish rate had been general, only 79 would have 
 died, being a saving of over 1000 lives in one year. 
 
 It may, of course, be alleged that this death-rate among the Jewish 
 population ought not to be taken as being absolutely accurate, and that 
 therefore it is hardly fair to compare it strictly with the general death- 
 rate of the colony. Possibly this may be so, but even after making 
 every allowance for mistaken diagnosis, and for any other probable 
 source of en-or, I cannot but feel convinced that the alleged immunity 
 of the Jews from phthisis, does, on the whole, really exist, at all 
 events in New South Wales, and that their condition in respect to 
 this disease contrasts very favourably with that of the general popu- 
 lation. 
 
 As for Melbourne, I cannot give you exact figures, but I learn from 
 Mr, Davis, on the authority of Mr, Meyer, and Dr, Brownless, the 
 respected Chancellor of the Melbourne University, that little or no 
 phthisis exists among the Jews in that city. 
 
 It might be worth while to notice that the country districts of 
 New South Wales, where the phthisis rate is low, are for the most 
 part devoted to the rearing of sheep ; while Queensland, where the 
 rate is high, is, at all events in the coast divisions, almost exclusively 
 devoted to the raising of cattle. 
 
 Surely there is sufficient energy among us to lead us to try to reduce 
 the general death-rate to that of the Jewish community, and the 
 first step in this direction is in my opinion to put an absolute end to the 
 use of meat from tuberculous oxen, and of milk fi'om tuberculous cows. 
 
 Although consumption is nominally the most important cause of 
 death from the numerical point of view, still we may say that in reality 
 it must give jilace to certain of the diseases of infancy and childhood. 
 To show that this is the case, it is necessary to make certain changes in 
 the mode in which the diseases of infancy have been registered, and to 
 classify them in groups by adding together diseases which, though 
 nosologically separate, are yet so closely allied, as to constitute 
 practically different varieties of one great disease. Thus, atrophy and 
 diarrhoea of infancy, teething, want of breast-milk, and the like, may 
 be fairly considered as varying manifestations of infantile mal-nutrition, 
 and similar groups may be formed from the fatal nervous, and pul- 
 monary diseases of children. If we then proceed to add together the 
 various diseases constituting each of these jnincipal groups, we sJia
 
 PRESIDENTS ADDRESS — SECTION OF HYGIENE. 
 
 409 
 
 find our tables assume a somewhat different character. Herewith, I 
 give three tables in which these diseases have been ananged in the 
 manner indicated : — 
 
 Infantile Diseases. 
 Class A.— NUTBITIVE. 
 Total Deaths of Persons under 5 Years of Aye from the undermentioned 
 Causes in the Axistralasian Colonies during the year 1885. 
 
 
 
 
 
 VaME Oh 
 
 Colony. 
 
 
 Disease. 
 
 5 . 
 
 
 a 
 
 c3 
 
 ce 
 
 
 cS . 
 
 
 
 'A 
 
 1 
 > 
 
 t 
 
 s 
 
 1 
 
 < 
 
 
 Ill 
 
 Total. 
 
 Atrophy and Debility 
 
 1058 
 
 865 
 
 363 
 
 107 
 
 287 
 
 268 
 
 
 2948 
 
 Diarrhoea and Dysentery 
 
 78] 
 
 802 
 
 431 
 
 94 
 
 268 
 
 337 
 
 
 2713 
 
 Enteritis 
 
 243 
 
 181 
 
 64 
 
 11 
 
 45 
 
 99 
 
 
 643 
 
 Teething 
 
 324 
 
 111 
 
 180 
 
 35 
 
 79 
 
 101 
 
 
 830 
 
 Tabes Mesenterica . . 
 
 269 
 
 96 
 
 58 
 
 
 49 
 
 51 
 
 . , 
 
 523 
 
 Gastritis and Stomach 
 
 
 
 
 
 
 
 
 
 Disease 
 
 178 
 
 219 
 
 45 
 
 
 7 
 
 13 
 
 , , 
 
 492 
 
 Liver Disease . . 
 
 2 
 
 13 
 
 15 
 
 
 10 
 
 18 
 
 , ^ 
 
 58 
 
 Peritonitis 
 
 18 
 
 8 
 
 2 
 
 1 
 
 6 
 
 5 
 
 
 40 
 
 Cholera 
 
 81 
 
 38 
 
 23 
 
 4 
 
 16 : 
 
 10 
 
 172 
 
 Want of Breast-milk . . 
 
 79 
 
 115 
 
 28 
 
 20 
 
 29 
 
 29 
 
 , , 
 
 300 
 
 Thrush 
 
 59 
 
 19 
 
 16 
 
 9 
 
 10 
 
 17 
 
 •• 
 
 130 
 
 Total . . 
 
 3092 
 
 2467 
 
 1225 
 
 281 
 
 806 
 
 978 
 
 •• 
 
 8849 
 
 Percentage to Deaths 
 
 
 
 
 
 
 
 
 
 from all causes . . . 
 
 20-23 
 
 17-17 
 
 19-65 
 
 13-80 
 
 20-21 
 
 16-08 
 
 •• 
 
 18-44 
 
 CL.4SS B.— NEKVOUS DISEASES. 
 
 Total Deaths of Persons under 5 Years of Age from the undermentioned 
 
 Causes in the A ustralasian Colonies during the Year 1885. 
 
 
 
 
 : 
 
 ■^AME OF 
 
 Colony 
 
 
 
 
 Disease. 
 
 a; 
 
 06 
 
 1 
 > 
 
 13 
 
 ■ a 
 ce 
 
 a 
 
 1 
 
 _C3 
 
 Z 3 
 
 
 Total. 
 
 Apoplexy 
 
 
 4 
 
 
 1 
 
 3 
 
 4 
 
 
 12 
 
 Convulsions . . 
 
 820 
 
 312 
 
 346 
 
 141 
 
 155 
 
 153 
 
 
 1927 
 
 Cephalitis 
 
 235 
 
 179 
 
 41 
 
 16 
 
 45 
 
 42 
 
 
 558 
 
 Paralj-sis 
 
 5 
 
 1 
 
 2 
 
 
 1 
 
 1 
 
 , , 
 
 10 
 
 Hydrocephalus 
 
 73 
 
 116 
 
 26 
 
 9 
 
 48 
 
 46 
 
 
 318 
 
 Brain Disease . . 
 
 5 
 
 21 
 
 26 
 
 15 
 
 27 
 
 38 
 
 . , 
 
 132 
 
 Epilepsy 
 
 15 
 
 11 
 
 7 
 
 
 •• 
 
 4 
 
 
 37 
 
 Total .. 
 
 1153 
 
 644 
 
 448 
 
 182 
 
 279 
 
 288 
 
 • ■ 
 
 2994 
 
 Percentage to Deaths 
 
 
 
 
 
 
 
 
 
 from all Causes 
 
 7-54 
 
 4-48 
 
 7-18 
 
 8-94 
 
 6-99 
 
 4-74 
 
 .. 
 
 6-24
 
 410 
 
 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 Class C— RESPIRATOEY DISEASES. 
 
 Total Deaths of Persons under 5 Years of Age from the undermentioned 
 
 Causes in the A ustralasian Colonies during the Year 1885. 
 
 
 
 
 ] 
 
 !f AME OF 
 
 Colony 
 
 
 
 
 Disease. 
 
 
 o 
 
 "2 
 1 
 
 _C3 
 
 5 
 1 
 
 
 
 Western 
 
 Australia 
 
 (1886). 
 
 Total. 
 
 
 z 
 
 > 
 
 O" 
 
 ^ 
 
 < 
 
 N 
 
 
 Pneumonia 
 
 236 
 
 260 
 
 31 
 
 16 
 
 84 
 
 106 
 
 
 733 
 
 Bronchitis 
 
 397 
 
 288 
 
 84 
 
 48 
 
 98 
 
 168 
 
 
 1083 
 
 Congestion of Lungs . . 
 
 69 
 
 83 
 
 41 
 
 23 
 
 10 
 
 28 
 
 .. 
 
 2.54 
 
 Whooping Cough 
 
 108 
 
 162 
 
 28 
 
 16 
 
 87 
 
 87 
 
 
 488 
 
 Pleurisy 
 
 8 
 
 7 
 
 1 
 
 1 
 
 ^ 
 
 3 
 
 .. 
 
 22 
 
 Influenza 
 
 56 
 
 29 
 
 10 
 
 3 
 
 1 
 
 5 
 
 •• 
 
 104 
 
 Total .. 
 
 874 
 
 829 
 
 195 
 
 107 
 
 282 
 
 397 
 
 .. , 2684 
 
 Percentage to Deaths 
 
 
 
 
 
 
 
 
 
 from all Causes 
 
 5-72 
 
 5-77 
 
 3-13 
 
 5-25 
 
 7-07 
 
 6-52 
 
 
 5-59 
 
 From these it will be seen that, in the case of the nutritive diseases 
 of childhood, tlio warmer colonies, viz., Queensland, New South Wales, 
 and South Australia, have a decidedly greater mortality ; whereas, in 
 the colder colonies — Victoria, New Zealand, and Tasmania—infantile 
 mortality from nutritive disorder is less. On the other hand, from 
 respiratory diseases Queensland shows a great immunity ; but South 
 Australia here, also, has an unfortunate pre-eminence. In nervous 
 diseases, exemplified by convulsions, cephalitis, and so forth, Tasmania, 
 contrary to our expectation, shows the greatest fatality, followed by 
 New South Wales, Queensland, and South Australia. Taking it 
 altogether, it must be observed that in all the classes of diseases of 
 infancy, Victoria and New Zealand are decidedly the most healthy. 
 
 Old age is fourth in New South Wales, is thirteenth in Queensland, 
 eighth in Victovin, first in Tasmania, fifth in South Australia, and 
 in Western Australia, third. In the country parts of most of the 
 colonies, it seems, as a cause of death, to be much on an equ.ility with 
 accidents. 
 
 There are many matters connected with these tables which it would 
 be exceedingly interesting to inquire into ; but in a brief sketch like 
 the present, detailed inquiry necessai-ilv would be somewhat out of 
 place, my object being to give a few of the most salient points, which 
 are obvious on a cursory glance. I niust, moreover, remember that the 
 time at our disposal is but limited, and that there are also limits to your 
 patience, on which I must not encroach too much. I shall, therefore, 
 refrain from going regularly down the columns, and shall now confine
 
 PRESIDENTS ADDRESS — SECTION OF HYGIENE. 
 
 411 
 
 myself to considering one or two of the most important diseases, espe- 
 cially those which are generally considered the most amenable to sanitary 
 influences. Of these, typhoid fever is certainly one of the principal, 
 whether we consider its prevalence, the amount of public attention it 
 excites, or the influence which sanitary improvements are believed to 
 have in checking it. The exact details of the prevalence of this disease, 
 during the three years under consideration, will be found set forth at 
 length in the larger tables which I have caused to be prepared. For 
 convenience I have, as in the case of phthisis, selected the latest year 
 for which a retui-n common to all the colonies is in my possession, viz., 
 1885 ; and I have drawn up a short table, giving at a glance a compara- 
 tive view of the mortality from typhoid fever in the various colonies 
 during that year. And it is to be borne in mind that this is only an 
 account of the mortality from typhoid, and that the real sickness from 
 typhoid — that is to say, the number of persons affected by this disease 
 ■who recovered from it, or at all events who did not die from it — cannot 
 in any way be ascertained, there being no materials for the purpose, but 
 must be simply estimated as a matter of speculation by each of us, in 
 accordance with his experience of the fatality attendant upon the disease 
 in diffei'ent places. 
 
 Typhoid Fever, 1885. 
 
 Name of Colony or 
 District. 
 
 Ordf.r of 
 Fatality. 
 
 Total Deaths. 
 
 Rate per 
 
 100,000 OF 
 
 Population. 
 
 Percentage 
 OF Deaths. 
 
 New South Wales . . 
 
 12th 
 
 503 
 
 53-06 
 
 3-29 
 
 Sydney . . 
 
 9th 
 
 93 
 
 71-31 
 
 3-53 
 
 Suburbs 
 
 9th 
 
 130 
 
 85-28 
 
 3-37 
 
 Country 
 
 11th 
 
 280 
 
 42-10 
 
 3-18 
 
 Victoria 
 
 10th 
 
 424 
 
 43-48 
 
 2-95 
 
 Melbourne and Suburbs 
 
 12th 
 
 183 
 
 52-98 
 
 2-63 
 
 Country 
 
 9th 
 
 241 
 
 38-27 
 
 3-25 
 
 Queensland 
 
 3rd 
 
 541 
 
 169-90 
 
 8-68 
 
 South Australia . . 
 
 11th 
 
 145 
 
 45-34 
 
 3-64 
 
 New Zealand 
 
 IGth 
 
 128 
 
 22-32 
 
 2-10 
 
 Tasmania . . 
 
 18th 
 
 30 
 
 22-42 
 
 1-47 
 
 "Western Australia (1886).. 
 
 16th 
 
 13 
 
 32-84 
 
 1-61 
 
 From this table it will be seen that Queensland is by far the greatest 
 suffei'er from this disease of any of the colonies. In that tropical 
 province, typhoid occupies the second place in the list of fatality, 
 causing 541 deaths in the j'ear, an absolutely greater number than in 
 any other colony ; the relative mortality was at the rate of 169-9 per 
 100,000 of the population, and the percentage to deaths from all causes 
 was 8*68. Taking the other years in my tables, it appears that in 1884 
 the results were rather worse, and in 188fi rather better ; we may, 
 therefore, assume that the results of 1885 give not an unfair idea of the
 
 412 INTEKCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 mortality from typhoid fever in Queensland. It is certainly very high, 
 quite sufficiently so, I think, to attract the attention of sanitary inquirers 
 in that Colony. Leaving Queensland, which occupies an unenviable 
 position by itself, we shall find that the death-rate in even the most 
 populous of the other colonies is much lighter, although there can be no 
 doubt that in some there is still a good deal of room for improvement. 
 New South Wales is the worst, with its death-rate for the whole colony 
 of 53-06, which rises in Sydney to 71-31, and in the suburbs to 85-28. 
 These figures, especially the last, are far from creditable ; but I am glad 
 to say that public attention has at last been called to this matter, and 
 various measures have been adopted, or are in process of adoption, with 
 a view to reducing the mortality from this disease. Of these, I may 
 mention the Dairies Supervision Act, which was passed in 1886, and is 
 now gradually being extended to different parts of the colony. I should 
 also notice that the Government have in prepai-ation a comprehensive 
 scheme of sewerage for the western suburbs of Sydney, which have 
 hitherto been left to their own devices in this important matter. 
 
 The somewhat sensational reports which from time to time appeared 
 in the newspapers last summer as to the prevalence of typhoid fever in 
 Victoria, would lead us to suppose that there had been at that time a 
 considerable increase, within a comparatively recent period, in the 
 prevalence of this disease in that colony. I am, of course, not in a 
 position to give the number of deaths for 1888, but for 1887 there were 
 631, whereas in 1885 there were only 424, being at the rate of 43-48 
 per 100,000; Melbourne and suburbs being credited with 183 of these 
 deaths, at the rate of 52-98 per 100,000 of the population. 
 
 It would appear from these figures, that of late typhoid fever has been 
 increasing in severity in Victoria. What may be the reason of this, I 
 shall leave to those to say whose business it is to manage the health 
 affairs of the colony. 
 
 South Australia appears to be, as regards this disease, much on a 
 level with Victoria and New South Wales, the mortality being 45-34 
 per 100,000. But when we come to consider the island colonies, we 
 find a very different, and much more agreeable, state of matters, the 
 death-rate falling in New Zealand to 22-32, and in Tasmania to 22-42, 
 per 100,000. Here, then, is a problem for the sanitarians, which I 
 trust they will lose no time in attacking, viz. : — How to reduce the 
 169-9 of Queensland — not to speak of the smaller figures of the other 
 Australian colonies— to the very desirable 22-32 of New Zealand. 
 
 The last disease with a notice of which I shall trouble you to-day, is 
 one which has always attracted great attention in the different parts of 
 Australia, viz., diphtheria. In accordance, as I believe, with the views 
 of the best authorities, I have associated croup with it. I attach hereto
 
 PRESIDENTS ADDRESS — SECTION" OF HYGIENE. 
 
 413 
 
 a table, giving a coni])arative view of the prevalence of the disease in 
 the diflerent colonies for the year 1885, already selected, excepting, 
 as usual, Western Australia, for which I have only one return, viz., 
 
 1886 :— 
 
 Name ok Colony ok 
 District. 
 
 Order of 
 Fatality. 
 
 Total Deaths. 
 
 Rate per 
 100,000 OF 
 Population'. 
 
 Percentage 
 of Deaths. 
 
 New South Wales . . 
 
 10th 
 
 582 
 
 61-38 
 
 3-76 
 
 Sydney . . 
 
 
 46 
 
 35-27 
 
 1-74 
 
 Suburbs 
 
 
 91 
 
 59-70 
 
 2-35 
 
 Country 
 
 
 445 
 
 66-90 
 
 5-06 
 
 Victoria 
 
 14th 
 
 332 
 
 34-05 
 
 2-31 
 
 Melboui-ue and Suburbs 
 
 , , 
 
 129 
 
 37-35 
 
 1-85 
 
 Country 
 
 
 203 
 
 32-24 
 
 2-74 
 
 Queeuslaud 
 
 9th 
 
 208 
 
 65-32 
 
 3-34 
 
 South Australia . . 
 
 7th 
 
 188 
 
 58-79 
 
 4-71 
 
 New Zealand 
 
 10th 
 
 172 
 
 29-99 
 
 2-83 
 
 Tasmania . . 
 
 13th 
 
 50 
 
 37-37 
 
 2-45 
 
 Western Austraha . . 
 
 23rd 
 
 9 
 
 22-74 
 
 1-12 
 
 From this it appears that, if whole colonies be taken, Queensland has. 
 again a bad pre-eminence, heading the list with a death-rate of 65-32 
 per 100,000, to which New South Wales comes, as a veiy close second, 
 with 61-38. If we leave out from the latter the figures for Sydney 
 and suburbs, we find that the country districts of New South Wales 
 surpass the whole colony of Queensland, the death-rate amounting to 
 66-90 per 100,000. This is another illustration of the well-known 
 principle, that diphtheria is a disease rather of the country than the 
 town. An apparent exception to this is shown by the .suburbs of 
 Sydney, which, with the high ratio of 59-70, approach closely to the 
 rural rate. This excessive prevalence of diphtheria appears to me to be, 
 to a considerable extent, due to the absence of any systematic method 
 of getting rid of the fiecal accumulations within these suburbs, a defect 
 which, I am glad to say, is likely very soon to be remedied. South 
 Australia, with its ratio of 58-79, follows close on New South Wales ; 
 and the three colonies named are in a distinctly worse position as 
 regards mortality from diphtheria than any of the other colonies. Thus 
 in Victoria, the rate was only 34*05 ; in Tasmania, it was 37'37 ; in 
 New Zealand, it was just under 30 ; while in Western Australia, it was 
 a little over 22 per 100,000. 
 
 The diffei'ence in these figures is sufficiently striking, and here again 
 plenty of scope is offered for the exertions of sanitarians. 
 
 Tliere are very many other matters of interest connected with these 
 tables to which I might draw your attention; for example, the 
 prevalence of diflTerent diseases in different quinquennial periods of life 
 would afford us a most interesting suljject of study. But time will not
 
 414 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 fillow me to enter into tlie suljject with further detail; and in fact, as 
 you will see, I have not been able to do more than deal with it in the 
 most superficial way, touching merely on the matters which were most 
 obvious on the surface. But even such cursory consideration as we 
 have been able to give to-day, is quite sufficient to show that there is an 
 ample field in these colonies for the exercise of all means for the 
 improvement of the public liealth. 
 
 In conclusion, I venture to express the hope that our sanitarians will 
 leave no stone unturned until they succeed in lowering the death-rates 
 from preventable diseases in all the colonies — at all events to the 
 minimum level which our tables show to exist in the most salubrious of 
 our districts. 
 
 And I am sure that I cannot give utterance to this aspiration more 
 apijropriately than befoi'e the present audience, composed as it is of the most 
 distinguished practitioners of medicine from all the Australasian colonies, 
 and more especially of those who take particular interest in matters of 
 public health. This great Congress of the profession, so successfully 
 organised by our Victorian friends, ought to lead to the most beneficial 
 results in every branch of medicine, and certainly not least are the 
 hopes entertained from our action in the department of public health. 
 Medical men have always been honourably distinguished by the great 
 interest they take in sanitary matters, and it is to us that the public 
 naturally look for guidance and advice in such questions. It is our duty 
 to make plain to everyone what are the shortcomings of our community 
 in questions of public health, and to show how these shortcomings can 
 be remedied. No better opportunity can be conceived than this 
 Congress affords for the proclaiming of our views, and it is difficult to 
 over-estimate the influence for good which it will have with the public, 
 who are never backward in acknowledging with respect any honest 
 effort to advance the interest of the community.
 
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 Cause of Death. 
 
 
 
 3 
 
 Dysentery and Diarrhcea ... 
 
 Phthisis 
 
 Typhoid Fever 
 
 Accidents 
 
 Atrophy and Debility 
 
 Convulsions 
 
 I'neuiuonia 
 
 Diseiisus of Circulatory System 
 
 Teething 
 
 Heuiitteiit Fever 
 
 <»UIAgC 
 
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 Lung Di.sease, &c 
 
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 Hrain Disease, <fcc. 
 
 Cephalitis 
 
 Tuberculosis anil Scrofula ... 
 
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 ;:;,i;5l3i25SSrtS?i§ii'i5S'NC'iSi?iTOm«TOTOmTOmmTO-* 

 
 422 
 
 INTEHCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
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 from 
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 71 
 
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 Convulsions 
 
 Disejises of Circulatory .System 
 
 Pneumonia 
 
 Croup and Diphtheria 
 
 Teething 
 
 Lung Disease, &c 
 
 Bronchitis 
 
 f>l.l Age 
 
 Premature Birth 
 
 Liver Disease, kc. 
 
 TuVierculosis and Scrofula . . 
 
 Enteritis 
 
 Tabes jMesenterira 
 
 Cephalitis 
 
 Disease of Stomach 
 
 Alcoholism 
 Chilbirth and .Metria 
 Brain Di.sease, A:c. 
 
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 Cancer 
 
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 Paralysis, <tc 
 
 Ileus 
 
 Pleurisy 
 
 Syphilis 
 
 Suicides 
 
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 Epilepsy 
 
 
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 >rH 71 o:-t.m:c I- xc^CrH 71 co-.j' in ^ot'-x^CrH 71 co^vncot-* 
 
 ^"-. 
 
 
 
 
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 PRESIDKNTS ADDRESS — SECTION OF HYGIENE. 
 
 423 
 
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 ,H««^u5«i-oo<r.or-jicg222;:;S2S53SS5?iSSo3?iS«««"«S^«?S^§
 
 424 
 
 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
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 C^OCOI>-C50'?lCOOOOf-tC300i5^r-ICO(MCOC-lNi-ICOC03;t'?0'^0.-ICJCCt>-(Mr-tC3l^^-tOO 
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 o 'i-H -CO -i-H -oii-t •-^uo'z: 
 
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 coco ■* rH CO 
 
 1 CO nH . O 01 
 
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 O -t* I-H 01 -«)i-H(N -C^CO 't- 'COOl '-^t^ -rHira 
 
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 •sjreaXoi oi S tiioaj 
 
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 ■ in o s oq CO 
 
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 33 
 
 rHeiM^l-IOJ-COOOrHS^W^OOr^COSgSSS^SSSSSgSS^SSSwMSgSgS
 
 430 
 
 IKTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 "^S 
 
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 O in -* (M rl C: CO 1- O -^ O in L.-5 u'i ^ >J< (?■: r7 7-1 !N CI 5-1 r-. rM rl I- 1-1 f-. rl rH r-l r-1 
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 •sjBa.C 59 o; 09 ino.i^ 
 
 s.rB8X 09 0% gg rao.i^ 
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 s.re8<( gs O!) 08 i«o.i^ 
 
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 = -43 Sf S -.^ :« -2 5 >-.. 
 
 r ?. 55?:i'"i 
 
 2- -S 
 
 rH(MC01<inOt--COCiOrHTir5-l'in-0 1>-a)OOrH(MeO'fl<in«5 1— COC50rH(MPT«in0 1^COCV< 
 rHrHiHi-trHrHrHrHrHiHC^-MiM^-ltMIMtNlMlMC^COCOCOCOCOCOCOCOCOCO'
 
 PRESIDENTS ADDRESS — SECTION OP HYGIENE. 
 
 431 
 
 li 
 
 
 s? 
 
 s 
 
 8 
 
 O 
 1 
 
 Percentage 
 to Deaths 
 
 froru 
 all Causes. 
 
 igi-l^t^-iit5-J--*C5-MC.15.)r)jli^^lrti^i^A(rH 
 
 C5 
 
 lit 
 
 
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 "3 j; 
 
 S33lS2^»^»^"*^~"^"^^^^*2i5SSSSS2=''='===^====°°^'-= 
 
 
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 gC<3« •■-•■^(NeOCOMOKM -NIN . • •X'N • -rHi-l . .« . -rl . • -rJ-rH -t-HM . . 
 
 ;o 
 
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 MM» ■Mei-J-i.l.-lOOSS .Mr-I • • •■* • • • -CO • - - -r-lrHH,-| . -rH - - -M 
 
 i 
 
 S.IV9S 01 <n S9 niojj 
 
 eOrH-'i-lrlrt- •- -. ... . . j2 
 
 -sitoX eg ckj 09 moj j 
 
 CM^ •I-^«I^--^J"l-l^^rXl>.r1lneO •(N(N(>J . ■ .Wi-I . . .r-l .e-Ji-IC^e-l .rH .11 • . . o 
 •-" <N • rtMPH . ... .... g 
 
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 -sjcaX se 0% 08 tnaTj 
 
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 . C^ .• . ... .. , ... . .. .... ... 
 
 
 •B.reaiC 
 
 g <n gg rao.t,j 
 
 •gOeO.-l ; ; -IS-Mr-l .,-1 ;r1i-" .WOrl • • . -M •rOrl .r-l . . -rH . . .r1 .T) . 
 
 g 
 
 -MBSjC c 
 
 Z 0% 05 raoj^ 
 
 •00 O -r-l -r-liaiOi-lr-l • .CJ<N . .1--3 .r.1 . -r-l • .O . . . -rHrHIM . . .rH • . . 
 
 § 
 
 -sa«a.{ OS 0^ gx moaj 
 
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 g 
 
 •sjtoX 01 «n S nioi,i 
 
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 • •-•Oi-lt»-^00r-IO -rH .COO«OCOCOOOii5li5lOi-l -O • •CSf-ICOrHr-l « ■ICCSCOCO-HrH 
 •r-t -*OCS-*^Jt-l- -WrHC^eOrH T-tlMrHf-l-rH*. .. 
 
 s 
 
 
 
 < 
 
 Old Age 
 
 Phthisis 
 
 Disucisos of Circulatory fcsystein 
 
 Convulsions 
 
 Atrophy and Dohility 
 Diarrhfoa and Dysentery 
 
 Bronchitis 
 
 Accidents 
 
 Pneumonia 
 
 Cancer 
 
 Apoplexy 
 
 Paralysis 
 
 Croup and Diphtheria 
 
 IJrain Disease, <tc 
 
 Congestion of the Lungs 
 Teething .. 
 
 Cephalitis 
 
 Tyi)hoid Fever, A:c 
 
 Privation 
 
 Measles 
 
 Liver Disease, &c 
 
 Childbirth and Jfetria 
 Kidney Disease, &c. .. 
 Hydrocephalus 
 
 Hepatitis 
 
 Asthma . . . . 
 
 Gastritis and Stomach Disease 
 Lung Disease, &c 
 
 Cystitis 
 
 .laundice. Gallstone, ifec 
 
 Thrush 
 
 Influenza, &c 
 
 Pleuris-y 
 
 Total 
 
 •A'^nB^vj JO .lapao 
 
 — •M:-;-;'i-':Oi-cor:Oi-.i'M«-i-intoi~ooC50rH-MM-)ii.-3-it^MC30i-i<M222l22{S9SS!2 
 
 r-Hr-ir-i,-lrHr-trHrHr-lr-lc1'MClC-l(M(MC^CI'MC-ICCCO«W:CCOWMCOCO-V |
 
 432 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 
 CO "" 
 
 00 ■:g 
 
 -^"^ 
 
 IS =■ <3 
 
 - '^ 5 
 
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 ■S.IB3.C 09 Oi 09 luo-i j; 
 
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 SJB3JC 08 o; SS rao.i^ 
 
 fi^Ba^ gg Oi OS iMO.T J 
 
 B-njaX OS Oi gx wio.i^ii 
 
 g.iBaX gx Oi 01 rao.x^ 
 
 •s.iB3i£ 01 Oi g rao.15 
 
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 — -Mi^r-t-.-tr-IOOmi-C505-*COrHt^05'M<MMOU^rHi-ICOCO(MOOTj*-^'<*Ot^«COMOOMMCi 
 
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 t^OOCa30I-t-OiO-*-*WMOT<M(MIM<Mr1i-Ci-l — rHi-Hi-l 
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 3 9:/,== 
 
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 j-i3«p-i1PHO<HWapH(iHoQi-4?=euWH»5<<aC3Hi^QH 
 
 ; : 60 : 
 
 ; ® 60- 
 
 -.5 •" " 
 
 ; : : :S£ : : : 
 
 "tso; 
 
 : :.a ci : |».2 
 
 S a=i 3 o to2 
 
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 PRESIDENTS ADDRESS — SECTION OF HYGIENE. 
 
 433 
 
 Return of Deaths from the Forty most Prevalent Causes in the Colony of 
 
 Western Australia during the year 1886. Arranged in the order nf 
 
 fatality, showing the Death-rate per 100,000 of the mean pojmlation 
 
 from each cause, and the percentage of deaths from each cause to the 
 
 deaths from all causes. 
 
 ^ 
 
 Cause of Duatii. 
 
 Whole Colony. 
 
 3 
 
 
 
 Percentage 
 
 o 
 
 
 Total 
 
 Rate per 
 
 to Deaths 
 
 u 
 
 
 DeatliS. 
 
 100,000. 
 
 from all 
 
 ■2 
 
 o 
 
 
 
 
 Causes. 
 
 1 
 
 Accidents . . 
 
 67 
 
 169-26 
 
 8-31 
 
 2 
 
 Wliooping Cough . . 
 
 61 
 
 154-10 
 
 7-57 
 
 3 
 
 Diseases of the Circulatory System 
 
 59 
 
 149-05 
 
 7-32 
 
 4 
 
 Old Age 
 
 56 
 
 141-47 
 
 6-94 
 
 5 
 
 Diarrha?a and Dysentery . . 
 
 63 
 
 133-89 
 
 6-57 
 
 6 
 
 Convulsions 
 
 48 
 
 121-26 
 
 5-95 
 
 7 
 
 Atrophy and Debility 
 
 47 
 
 118-73 
 
 5-83 
 
 8 
 
 Bronchitis . . 
 
 29 
 
 73-26 
 
 3-60 
 
 9 
 
 Pneumonia . . 
 
 29 
 
 73-26 
 
 3-60 
 
 10 
 
 Phthisis 
 
 27 
 
 68-21 
 
 3-35 
 
 11 
 
 Enteritis 
 
 19 
 
 47-99 
 
 2-36 
 
 12 
 
 Paralysis 
 
 17 
 
 42-95 
 
 2-11 
 
 13 
 
 Dropsy 
 
 16 
 
 40-42 
 
 1-98 
 
 14 
 
 Cancer 
 
 15 
 
 37-89 
 
 1-86 
 
 15 
 
 Premature Birth . . 
 
 14 
 
 35-37 
 
 1-74 
 
 16 
 
 Typhoid Fever 
 
 13 
 
 32-84 
 
 1-61 
 
 17 
 
 Influenza, &c. 
 
 13 
 
 32-84 
 
 1-61 
 
 18 
 
 Apoplexy 
 
 12 
 
 30-31 
 
 1-49 
 
 19 
 
 Liver Disease 
 
 12 
 
 30-31 
 
 1-49 
 
 20 
 
 Want of Breast Milk 
 
 9 
 
 22-74 
 
 1-12 
 
 21 
 
 Teething 
 
 9 
 
 22-74 
 
 112 
 
 22 
 
 Congestion of the Lungs . . 
 
 9 
 
 22-74 
 
 112 
 
 23 
 
 Diphtheria and Croup 
 
 9 
 
 22-74 
 
 1-12 
 
 24 
 
 Tabes Mesenterica . . 
 
 8 
 
 20-21 
 
 -99 
 
 25 
 
 Hydrocephalus 
 
 8 
 
 20-21 
 
 -99 
 
 26 
 
 Epilepsy 
 
 8 
 
 20-21 
 
 •99 
 
 27 
 
 Childbirth 
 
 7 
 
 1718 
 
 •87 
 
 28 
 
 Brain Disease, &c. 
 
 6 
 
 15-16 
 
 •74 
 
 29 
 
 Remittent Fever . . 
 
 5 
 
 12-63 
 
 •62 
 
 30 
 
 Hepatitis 
 
 5 
 
 12-63 
 
 •62 
 
 31 
 
 Nephria 
 
 5 
 
 12-63 
 
 -62 
 
 32 
 
 Erysipelas . . 
 
 4 
 
 10-10 
 
 •50 
 
 33 
 
 CephaUtis . . 
 
 4 
 
 10-10 . 
 
 •50 
 
 34 
 
 Asthma 
 
 4 
 
 10-10 
 
 •50 
 
 35 
 
 Nephritis 
 
 4 
 
 10-10 
 
 •50 
 
 36 
 
 Kidney Disease 
 
 4 
 
 10-10 1 
 
 •50 
 
 37 
 
 Cyanosis 
 
 4 
 
 10-10 1 
 
 •50 
 
 38 
 
 Alcoholism . . 
 
 3 
 
 7-58 1 
 
 •37 
 
 39 
 
 Gastritis 
 
 3 
 
 7-58 ! 
 
 •37 
 
 40 
 
 Laryngitis . . 
 
 Total .. .... 
 
 3 ( 
 
 7-58 
 
 -37 
 
 
 728 . 
 
 183-91 1 
 
 90-22 
 
 If
 
 434 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 A RECORD OF THE PRESENT SANITARY STATE OF 
 
 NEW SOUTH WALES. 
 
 By J. AsHBURTOX Thompson, M.D. Brux. 
 
 Dipl. Public Health, Cambridge. Chief Medical Inspector of the Board of Health. 
 Deputy Medical Adviser to the Government of New South Wales. 
 
 The idea of getting from each pi'oviiice of Australasia a statement as 
 to its present sanitary condition, occurred to the Secretary of this 
 Section, Dr. Springthorpe, and with wisdom equal to the happiness of 
 his suggestion, he proposed no title for the several contributions. 
 Accordingly, I have chosen a title for my own share; I call it 'A 
 Record of the Present Sanitary State of New South Wales." As 
 to what, in my opinion, should be included under the phrase "sanitaiy 
 state," that will appear from what follows; but as to the rest of the 
 title, I beg of you to observe its wording, and to note that while I 
 endeavour to record the facts as they stand to-day, I do not offer any 
 comment upon them, nor any criticism. Nevertheless, the bare state- 
 ment need not be put forth without a word to clothe it, although 
 to none here, in all probability, is any such word necessary. We, 
 denizens of new counti'ies, know well what difficulties of ways and 
 means are raised by the low rate of specific population which prevails 
 everywhere, except over some compai-atively small ai^eas of our larger 
 cities, and how often (for this among other reasons) even our advice has 
 to be framed rather with regard to executive probabilities, than witli 
 legitimate aspirations in view. But the speculative sanitarian is little 
 prone to give such considerations their due weight; and it, thei'efore, 
 seems in place to remind him that if he sees shortcomings, we too are 
 a,ware of them; if he sees reason to enjoin amendment, we labour for it. 
 
 Now, perhaps the best way of beginning a statement, of whicli 
 perspicuity should be a characteristic, and which must yet consist 
 mainly of detail, will be to give a few facts as to 
 
 Population and Area. 
 
 The area of the whole province is 310,700 square miles, and it is 
 divided and sub-divided into electoral districts, counties, and munici- 
 palities. The total estimated population at the end of 1887 was 
 1,042,919, being in the proportion of tliree and one-third persons to the 
 square mile, on the hypothesis of equal distribution. But the people 
 are, in part, collected in cities, towns, and hamlets; and are generally 
 referred to as living either in the metropolitan districts, or in the 
 country. The metropolitan registration division has an area of about 
 25G square miles, and is estimated to carry thereon 350,866 persons, or 
 34 per cent, of the total population. But these are so distributed, that 
 all but a small proportion live within one or other of the thirty-four 
 municipalities which are compinsed in tlie division, and which are 
 referred to as the metropolitan districts, and these measure, altogether, 
 aV)out 111 square miles. They have an average density, therefore, 
 of about five persons to tlie acre; but there is a great difference 
 between the specific population of the several municipalities. One of
 
 THE PRESENT SAXITAHY STATE OF NEW SOUTH WALES. 435 
 
 tliem, which has an area of twenty-seven acres only, lias a density of 
 142; the city, of foity-six ; others, of thirty-six and eleven; while one 
 of the most recently incoi-porated, has about nine acres to each inhabi- 
 tant. Sixty-six per cent, of the total population live in the country, or 
 in country towns. In the Reo-istrar-General's returns, the people living 
 under these two distinct conditions are not distinguished, but are dealt 
 with together under the one heading, "country districts." In order to 
 get an idea of the proportions in which these are distributed between 
 town and country, reference nnist be made to the last census I'eturns. 
 In 1881, about one-third of the total population lived in the metro- 
 politan districts, about a tiftli lived in country municipal districts, and 
 about one-half lived under sti-ictly rural conditions. Very possibly 
 these proportions may not exactly apply to the present population, but 
 they serve the purpose for whicli they are referred to well enougli. 
 The next important point to be touched seems to be the kind of 
 
 Local Government 
 under which the people live. This is exclusively municipal. The more 
 populous places are erected into municipalities, and these are 
 divided into boroughs and municipal districts. The distinctions between 
 these are based on population and area. A borough may not have a 
 population of less than one thousand persons, nor an area of more than 
 nine square miles ; nor nmst any point be more than six miles in a 
 .straight line from any other; while the quantities mentioned in the 
 case of municipal dist)'icts are five hundred persons, fifty square miles, 
 and twenty linear miles. It will thus be seen that the terms 
 " incorporated population "' and " suburban population " are not 
 synonymous. 
 
 The powers conferred on Municipal Councils are mainly in respect of 
 water supply, sewerage, lighting, road-making and abatement of 
 nuisances, not necessary to be particularly described in this place; but 
 they are referred to again below in speaking of " Public Works " 
 and " Sewerage." They may combine with adjacent districts, raise a 
 general rate of Is. in the £, and a farther rate or rates for the special 
 purposes just mentioned to an amount not exceeding another Is., and 
 they may borrow money to an amount not exceeding the totr.l 
 estimated i-evenue for the next five years. 
 
 For tlie first fifteen years of incorporation, nuniicipalities are subsi- 
 dised by the central Government by quinquenially decreasing grants 
 from tlie consolidated revenue. 
 
 A separate Statute called " The Nuisances Prevention Act," which 
 may l^e proclaimed in any district, and in general is so proclaimed, 
 although there are exceptions, relates mainly to the regulation of 
 privies; but it also requires Councils to appoint Inspectors of Nuisances. 
 These ofiicers seldom possess any special education for their impoi'tant 
 duties, and, in any case, their usefulness is discounted by their being 
 removable at the sole discretion of the Councils employing them. The 
 only other officer whom it is necessary to refer to here, is the Surveyor, 
 with whom Councils genei'ally provide themselves. These do a gi-eat 
 deal of valuable work ; but, on the other hand, it is easy to point out 
 instances in which the expenditure in their department has, for one 
 reason or another, been wasteful, or even fruitless 
 
 If 2
 
 436 INTERCOLONIAL MEDICAL CONGRESS OB' AUSTRALASIA. 
 
 The Corporation of Sydney has, of course, larger revenues and more im- 
 portant duties than others; it has also rather fuller powers. Especially, 
 it may make by-laws for the inspection and prevention of the sale of 
 unwholesome and adulterated food. It is required by the " Act of 
 Incorporation " to appoint a city Officer of Health, and tlie latter is 
 required to report monthly, and also to regard the occuri'ence of 
 infectious diseases in the suburbs, so as to advise the Mayor as to the 
 steps to be taken to prevent their entry to the city; and his other 
 duties may be defined by by-law, though this has never been done. He 
 is allowed private practice, and his salary is ^250 a year. 
 
 Municipal Councils are subject to no superior authority, except in 
 the case of the "Dairies Act," which they are the local authorities to 
 administer, under supervision of the Board of Health. If the 
 "Nuisances Prevention Act" be proclaimed within a district, and if 
 the Council fail to execute it, the Government may suspend the latter, 
 and administer their district; but this, manifestly, is a power which 
 would be exercised only in case of extreme urgency. 
 
 A brief reference to the 
 
 Laws Touching the Public Health 
 
 must now be made; but, as there is no "Public Health Act," little can 
 be said about them in an essay not devoted to an analysis of them. 
 The more important are referred to vmder the special sections to which 
 they belong. Here, I believe, it is only necessary to mention two of 
 them — " The Adulteration " and " The Dairies Supervision" Acts. 
 
 The Corporation of Sydney has a special Act amending its Act 
 of Incorporation, by which a penalty not exceeding ,£50 may be 
 inflicted on any person selling, or exposing for sale within the city, 
 any butter, meal, bread, or other article of food, knowing the same to 
 1)6 adulterated. There is also a general Act dated 1879, the authorities 
 to execute which are constables authorised in that behalf upon occasions 
 l)y the Inspector-General of Police, and clauses in several Acts relating 
 to bread and flour, malt liquor, and to spirituous and fermented liquors. 
 Under the general Act, successfvd proceedings have seldom, if ever, been 
 taken. Upon the whole, analysis of foods and drugs is a matter that 
 meets with little attention, except in connection with the Custom 
 House ; while analyses of water are undertaken mainly in connection 
 with pviljlic works or institutions, " The Dairies Supervision Act," and 
 sanitary investigations made by the Health Department. All of these 
 it is the duty of the Government Analyst (wlio is an officer of the 
 Medical Adviser to the Government) to perform. The " Dairies 
 Super\'ision Act" came into operation at the beginning of 1887. 
 INlunicipal Councils ai-e the local authorities to administer it within their 
 districts, police magistrates or senior officers of police outside muni- 
 cipalities, both being under the supervision of the Board of Health, to 
 wliom they are directly responsible. On becoming law, it applied to the 
 metropolitan police disti'ict, and it has since been extended to the whole 
 of the counties of Cumberland, Argyle, Camden, Northumberland, 
 (Gloucester and Durham. While it is far from containing all the 
 provisions asked for 1)y the officers of the Health Department, it 
 nevertheless confei-s important powers. And, although the supervisory 
 duties of tlu! Board of Health in respect of it are seriously hampered.
 
 THE PRESENT SANITARY STATE OF NEW SOUTH AVALES. 437 
 
 by tlie absence of power to enforce by fine 1)y-l!iws they nuxy make 
 under it, it lias yet been tlie means of considerable impi-ovement in 
 dairy premises — more especially, perhaps, in the metropolitan districts, 
 and in respect of water supply. 
 
 It will now be perceived that there is not, in New South Wales, any 
 Health service such as in many other countries is properly indicated 
 by that phrase. Nevertheless, the Government provides a 
 
 Health and Medical Departiment, 
 
 which pel-forms for the wliole country very many of those duties which, 
 under a national organisation, are performed by local boards, under 
 supervision of a central authority. This department includes a Chief 
 and a Second Medical Officer, a Board of Health, a Secretary, the 
 necessary clerical staff and offices, and certain establishments. 
 
 The Chief Medical Officer holds the posts of Health and Emigration 
 Officer, and of Medical Adviser to the Government (and in the latter 
 capacity he is, by the " Sale of Poisons Act," a member of the Board of 
 Pharmacy, whose duty it is to register pharmacists who are duly 
 qualified according to that act); he is allowed private ^^ractice. The 
 Second Medical Officer holds the posts of Deputy Medical Adviser to the 
 Government, Chief Medical Inspector of the Board of Health, and 
 Examining Medical Officer to the Civil Service; he is the Executive 
 Officer of the Department, and his whole time is devoted to his duties. 
 The Health Officer is concerned with maritime quarantine alone, and 
 he is an officer of the Treasury; he has a Boarding Medical Officer, who 
 resides at the Boarding Station; a Health Officer for the port of 
 Newcastle, and a Superintendent of Quarantine, with a staff; he has 
 statutory powers under the "Quarantine Act and Amending Acts."' 
 The Medical Adviser is attached to the staff of the Chief Secretary, 
 and he has general duties, which are advisory on matters referred to 
 him by the Government. He has, also, special duties, which are: — 
 supervision of the Coast Hospital; providing, controlling, and paying 
 for hospital accommodation for the destitute sick from the vote for the 
 maintenance of sick paupers; payment from the medical vote of claims 
 for medical services rendered to coroners, courts of petty sessions, the 
 police, salaries of gaol visiting surgeons, other salaries, and fees for 
 public vaccination; supervision of Government medical officers, and 
 payment of claims for all medical services rendered to the Government, 
 by special direction. He has two special Government Medical Officers 
 for the districts of Sydney and Parramatta, whose whole time is 
 devoted to their duties; two medical officers at the Coast Hospital, and 
 an analyst. He has no statutory powers. 
 
 The Board of Health 
 
 is under the Treasurer. It was created in 1881 by the "Infectious 
 Diseases Supervision Act," to carry out, subject to any orders and 
 to any general regulations made by the Executive Council, the powers 
 of isolation conferred on the Health Officer by Section 2 of tlie jarincipal 
 Quarantine Act, and to define or extend the boundaries of any districts 
 then or thereafter placed under charge of a Government medical officer. 
 Under the Section mentioned, the restrictions of maritime (}uaiantine 
 are applied by the Board to members of the shore pojjulation and their
 
 438 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 liouses, when they are infected with small pox. By the Act of 
 Appointment, the Board is to consist of not less than six memljers, and 
 these are appointed l)y the Executive. In practice, there ha^'e always 
 been four official members, namely : — the Health Officer, the Under-Secre- 
 tary for Finance and Trade, the Inspector-General of Police, and the 
 Mayor of Sydney; and there are four unofficial members, of whom one 
 is a layman, while other three are chosen from the ranks of the practis- 
 ing medical profession. Originally, the Boaixl elected its own chairman ; 
 l:)ut later, the presidency was made a matter of appointment by the 
 Executive. All, except the official members, receive a fee for their 
 attendance at meetings, and the latter are summoned by the President 
 as seems necessary. The Board has statutory powers, as mentioned 
 above, and in 1886 became the authority to super^"ise the administra- 
 tion of the "Dairies Act," then jDassed. In addition, it advises on 
 matters submitted to it by the Executive ; and, in practice, the Health 
 Officer refers to it matters connected with maritime quarantine. Its 
 officers are a Chief Medical Inspector, a Secretary, an Inspector under 
 the "Dairies Act," and a Veterinarian. There remain to be mentioned, 
 in this connection, Government Medical Officei's and Public Vaccina- 
 tors; but tlie latter will be better dealt with under the special heading 
 of Public Vaccination. Besides the two special officers already men- 
 tioned, whose whole time is devoted to their duties, there is a general 
 class of Government Medical Officers distributed over the country. 
 These are appointed by the Executive; they are in correspondence with 
 the Medical Adviser, who issues instructions to them, desiring them to 
 report any prevalent or epidemic sickness they may observe. But they 
 are unpaid by salary; they are remunerated by fees for duties actually 
 performed in connection with the police, with coroner's courts, and for 
 any special service they may render, at request of the Medical Adviser; 
 and, in virtue of their appointment, they have a right of preference for 
 employment on such duties over other practitioners residing in the 
 same district. The organisation thus described is supplemented by two 
 establishments. 
 
 The Quarantine Station 
 
 is situated on the northern of the two promontories which form the 
 entrance to Port Jackson. Six hundred and se\'enty acres are there 
 enclosed by a fence which runs from tlie waters of the Harbour to 
 the cliffis whicli face the ocean; and the rest of the boundary includes 
 the watei' as far as one cable's length from the shore. The permanent 
 staff consists of the Superintendent (wlio has statutory powers) and 
 seven men, and it is expanded on occasions by temporary aid. Com- 
 munication with tlie Health Department is kept up by telephone, and 
 by telegraph wlienever the yellow flag is flying. Thei'e is accommodation 
 in wooden liouses on stone foundations foi- about three liundred persons, 
 in several enclosures, and this is extensible by erection of marquees, 
 for which permanent platforms are provided. The hospital enclosure 
 accommodates about sixty ; and there is a hospital ship which, in two 
 deck i)a\ilions, carries tliirty beds. Water is derived from the neutral 
 ground — which consists of weathered sandstone and sandstone rock, 
 cai-rying a sliort brusliwood — and it is conducted by suitable races to a 
 reservoir holding a million gallons, whence it is distril)uted to every
 
 THE PRESENT SANITARY STATE OF NEW SOUTH WALES. 439 
 
 part of tlie establislnneut by gravitation. The laundry is supplied with 
 steam from a forty horse-power boiler ; the disinfector is a Eraser's 
 liot-air apparatus, and tliese, with stores and offices, stand at a quay. 
 For conmiunication with ships or with the city, a steam-launch (specially 
 fitted to carry the sick) is provided. Emigrant ships carrying six 
 liundred passengers ha^"e been cleansed, disinfected, all clothing, &c., 
 washed, and admitted to pratique within thirty-six hours. This 
 establishment is under control of the Health Officer. 
 
 The Coast Hospital 
 
 is nine miles from the city by i-oad, and stands on a reserve of five 
 lumdred acres, whose boundai-ies are so arranged as to include the 
 watersheds of three small but constant creeks, which has a frontage to 
 the Pacific of about a mile and a half, and whose soil consists of sand 
 mid sandstone rock, carrying a short brushwood. The buildings are of 
 MOod and iron, the wards being in separate pavilions of one story ; 
 witer from the creeks mentioned is distributed by gravitation from 
 ekvated tanks, to which it is raised by windmills ; drainage is provided 
 for slop water only, which passes by outside yard gullies through glazed 
 piping to the sea ; and garbage is cast over a cliff, whence it disappears 
 alnost immediately. Pan closets are used ; they are emptied once or 
 twee a day as seems necessary, and the contents are buried three- 
 ([uarters of a mile away in the sand overlying another promontory. 
 Thi number of beds is two hundred and forty-seven ; the nursing staff 
 corijists of a matron and twenty nurses ; the Ambulance staff of four 
 men, fourteen horses, and five vehicles. The patients are (1) the 
 des-titute sick (but see Hospital accommodation) ; (2) cases of typhoid 
 fe\er from all classes (and about one-half of all the cases receiving- 
 hospital treatment in Sydney are dealt with here) ; (3) cases of the 
 other infectious fevers admitted from all classes for the sake of isolating 
 th?m (but see Infectious Diseases) ; (4) male lock cases to the number 
 of twenty -six ; (5) and, in an isolated building, lepers, of whom there 
 are at present one Australian white, and ten Asiatics. This hospital is 
 entirely supported by Government ; and the cost per bed per annum is 
 iJ42 14s. Hd., plus the special expense of the ambulance service, which 
 ^s £o 4s. 3|d. This establishment is under control of the Medical 
 Adviser. The same officer carries out the arrangements for the 
 performance of 
 
 Public Vaccination, 
 
 which is provided at the Government expense, but which is not 
 compulsory. In Sydney there is one station, which is open one day a 
 week. Fortnightly supplies of humanised lymph are received from 
 England, and these ai'e supplemented by local cultivations, but the 
 immber of applicants does not suffice to keep up arm-to-arm vaccination. 
 In the country, medical men may be appointed public vaccinators 
 for the districts in which they reside, and Government medical officers 
 are always so appointed, as well as others. Applicants under ten years 
 of age may be vaccinated free of cost, but this general regulation 
 has been relaxed in time of epidemics (when there is always a largely 
 increased number of applications), and vaccinations at all ages, as well 
 as re-vaccinations, have been then paid for — the fee is 2s. Gd. for each
 
 440 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 successful vaccination of persons residing within five miles of the 
 vaccinator's residence, 3s. 6d. beyond that distance. The English 
 instructions to public vaccinators are issued. Reports are made 
 quarterly ; these furnish name, age, sex, and result only ; there is 
 no subsequent inspection of results. 
 
 I append two tables, whicli show for the metropolitan and country 
 districts respectively, the births, the deaths under one and from one 
 to five years, the number of successful public vaccinations under one 
 and from one to five years, and the total number of successful public 
 vaccinations at all ages, for each of the five years 1883-7 : — 
 
 Metropolitan Districts. I 
 
 
 Births. 
 
 Deaths. 
 
 Vaccinations. 
 
 Year. 
 
 Under 1 
 
 lto5 
 
 Under 1 
 
 1 to5 
 
 Total. 
 
 
 
 Year. 
 
 Years. 
 
 Year. 
 
 Years. 
 
 1883 
 
 10,290 
 
 1680 
 
 715 
 
 Ill 
 
 127 
 
 289 
 
 1884 
 
 11,872 
 
 2041 
 
 886 
 
 142 
 
 341 
 
 631 
 
 1885 
 
 12,266 
 
 2292 
 
 842 
 
 87 
 
 145 
 
 343 
 
 1886 
 
 13,132 
 
 2275 
 
 794 
 
 116 
 
 190 
 
 452 
 
 1887 
 
 13,415 
 
 1892 
 
 732 
 
 229 
 
 338 
 
 826 
 
 Country Districts. 
 
 
 Births. 
 
 Deaths. 
 
 
 Vaccination 
 
 s. 
 
 Year. 
 
 Under 1 
 
 1 to 5 
 
 Under 1 
 
 1 to5 
 
 Total. 
 
 
 
 Year. 
 
 Years. 
 
 Year. 
 
 1 Years. 
 
 1883 
 
 20,991 
 
 1910 
 
 999 
 
 153 
 
 269 
 
 593 
 
 1884 
 
 22,074 
 
 2244 
 
 993 
 
 1095 
 
 i 2682 
 
 6429 
 
 1885 
 
 22,777 
 
 2304 
 
 1174 
 
 322 
 
 1 693 
 
 1850 
 
 1886 
 
 23,152 
 
 2360 
 
 958 
 
 239 
 
 450 
 
 1301 
 
 1887 
 
 23,816 
 
 2042 
 
 865 
 
 261 
 
 1015 
 
 2187 
 
 A rough calculation shows that of 173,785 children whose birtlis 
 were I'egistered in New South Wales during the five years 1883-7, 
 about 140,000 (without allowance for emigration) remained alive and 
 unvaccinated at the close of that period. This sum must be reduced 
 Ijy the numbers privately vaccinated, of which no record is kept ; but 
 tlie best enquiry I can make warrants the supposition that these are 
 but few, and perhaps on the whole insignificant. The proportion of 
 unvaccinated persons at all ages must be very large indeed. 
 
 I now pass on to certain special subjects, of which the fir.st to be 
 considered is 
 
 Public Water Supplies. 
 
 Eleven country towns, and the Hunter River district, which contains 
 a large population in several adjacent towns, have public waterworks ; 
 while in three otliers, construction is at present going on. Tlie water 
 in all these cases is taken from streams, and in nine of them requires 
 pumping ; services are constant, and filtration is employed in only three 
 instances. The maximum possible delivery of the works, taken together, 
 is about fifteen million gallons per diem. Construction has usually
 
 THE PRESENT SANITAKY STATE OF NEW SOUTH WALES. 
 
 441 
 
 been undertaken by the Government, with moneys lent to the niunici- 
 p.alities, on security of the woi-ks and rates, at G per cent. ; this is 
 devoted to payment of interest, and to reduction of capital account in 
 the proportions of two-tliirds and one-third respectively. In four cases, 
 however, the work was undertaken by the Councils themselves, under 
 approval of the Government. Tlie total cost of finished works has 
 been about £650,000 ; and on completion, they are handed over to the 
 Municipal Councils, who are required mei-ely to pay to the Government 
 annually the sum due on the calculation mentioned above. 
 
 The supply of water for Sydney and the other metropolitan districts 
 is taken from a catchment area of 354 square miles, wliich is situated 
 about sixty miles away, and which includes the water-sheds of the 
 Upper Nepean, the Cordeaux, and the Cataract rivers. Some small 
 proportion of this area was alienated before thei'e was thought of 
 devoting it to this purpose ; but it consists of sandstone rock mainly, 
 and carries only a short lirushwood, so that it is not cultivated, nor fit 
 for any agricultural purpose. There are no inhabited dwellings on it. 
 The waters of the rivers mentioned are impounded and united by very 
 difficult works, and are led by tunnels, open canals, and joipe-aqueducts, 
 for a distance of thirty-eight miles to Prospect. There, a reservoir has 
 been formed, by throwing a dam across a grass-covered valley, of which 
 the actual capacity is 10,812 million gallons, and the effective capacity 
 7110 million. Thence the flow passes by an open canal lined with 
 diorite ashlar masonry, and five miles long, to Potts' Hill, where it 
 enters a distributing reservoir of 100 million gallons capacity, thi'ough 
 screening tanks ; and thence it travels in pipes (which are to be dupli- 
 cated) a farther distance of eleven miles to a resei-voir at Crown Street, 
 within the City of Sydney. The discharging capacity of the canal to 
 Potts' Hill is 50 million gallons daily. Tliis is a gravitation service, 
 without filtration. The Prospect dam commands the whole of a very 
 large extent of countiy, except a few uninhabited hill-tops ; and thus it 
 will be possible to supply from it several towns lying at reasonable 
 distances from the pipe-line. So also, the Crown Sti'eet reservoir 
 commands the greater part of the populous area to be served from it 
 However, a proportion of the population, being that wliich lives in the 
 disti'icts of Waverley, Woollahra, and parts of Paddington near the 
 centre, and the more distant and less thickly populated suburbs of 
 Ashfield, Ryde, and North Shore, are, or will be, served from pumping 
 stations situated at Ci'own Street and at Ryde respectively. 
 
 The following are two analyses, by the Government Analyst, of the 
 metropolitan water, the first being taken before it enters the Prospect 
 dam, the second from a city main : — 
 
 
 Grains per Gallon. Parts pef 
 
 Million. 
 
 Date of 
 Collection. 
 
 Description. 
 
 Total 
 
 Solids. 
 
 Chlorine 
 
 Nitrogen 
 
 as Ni- Free Albu- 
 trates & Ammonia. Ammonia. 
 Nitrites. 
 
 Oxygen ' Oxygen 
 absorbed absorbed 
 in li min in 4 hours 
 at 80° F. at S0° F. 
 
 March 19, 
 1888 . . 
 
 Feb. 15, 
 1888 . . 
 
 From above 
 
 the dam.. 4-97 2-1 
 From a city 
 
 main . . 7-01 2-4 
 
 Noue None -06 -21 -22 
 0-1 None -1 -6 -92
 
 442 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 At the end of 1888, about 75,000 houses were connected, and the 
 average consumption per head was believed to be about forty gallons. 
 The service is constant, meters being required only when the water is 
 used for other than domestic purposes ; and direct communication 
 between water-closets, &c., and service pipes, is forbidden. In a 
 large proportion of the houses which have for many years been served 
 with water by an older and insufficient scheme however, the cisterns 
 which were then necessary, have been retained ; while in very many 
 houses which stand outside the limits of the old scheme (as well as in 
 others within those limits), the underground brick and cement tanks or 
 surface wells formerly used, have not been filled up, although town water 
 has been laid on to them. In the latter case, therefore, until a 
 considerable time has elapsed (unless power should be given to compel 
 the abolition of such soui^ces, as soon as they are ascertained to yield 
 polluted waters), the diminution in rates of mortality from typhoid and 
 some other diseases which the new supply may reasonably be expected 
 to effect, will not be fully realised (cf. Sewerage and Scavenage, 
 infra). 
 
 The Sydney Water Supply is under control of the Metropolitan Water 
 and Sewerage Board, constituted by the " Metropolitan Water and 
 Sewerage Act," of 1880, but not appointed until the beginning of 1888, 
 by an Amending Act ; at present it deals with water alone. The cost 
 of the works hitherto completed has been about £2,500,000, and the 
 total cost will probably be more than £.3,000,000. Charge is made by 
 a rate which is 8d. in the £, struck on the ratable value of property as 
 fixed for municipal purposes ; and it is regulated by the annual sum 
 necessary to pay interest on capital expenditure, to defray working 
 expenses, and to provide for extensions. 
 
 Sewerage, Scavenage, etc 
 
 Outside the Metropolition Division, there are no sewers. Within it, 
 the City of Sydney (caiTying an estimated population of 125,850 people 
 in 22,385 houses, on an area of 4-29 square miles), has for many years 
 been served by imperfect sewers constructed at different times, in 
 various fashions, running in many instances on unrecorded and now 
 forgotten lines, without ventilation, and discharging into the tidal 
 waters of the Harbour. During recent years, all but 1538 of the houses 
 have been fitted with water-closets, which in most cases are of antique 
 patterns. The houses communicate with the sewers without disconnec- 
 tion ; but fortunately, a large proportion have no sewer connection within 
 their walls — a usual ari'angement being to place the closet in the yard, 
 where also is a gully for slop-waters ; baths often discharging on the 
 yard surface, or above the gully. 
 
 Outside the City proper again, there are no sewers, except such as 
 liave (juite recently been constructed ; these are mentioned below. 
 Slop-water is conducted from yard-gullies to street-gutters, which are 
 often unformed ; and if formed, are very often improperly graded. By 
 these it is led, or sooner or later finds its way to the natui'al surface 
 channels, which are thus converted into open sewers; and which 
 discharge either into the Harljour, or into that extension of it which 
 forms the mouth of the Parramatta River, or into Cook's River on the 
 south.
 
 THE PRESENT SANITARY STATE OF NEW SOUTH WALES. 443 
 
 Privies are either cess-pits, or pan-closets, the hitter being often 
 miscalled earth-closets. In most districts, these two forms are to he 
 found side Ijy side, for of late years there has been a \ery general 
 endeavour to abolish the cess-pits which, not long ago, were almost 
 universal. In a few districts, this effort has been completely success- 
 ful ; in others, the cess-pit still prevails. Pan-closets are emptied 
 by contractors with the Municipal Councils once or twice a week, 
 during the night, at a weekly charge of about 6d., which is paid by the 
 landlord ; but several districts are not effectually served, and in parts 
 of them tenants are not prevented from burying the soil on their 
 own premises, altliough that is contrary to a general by-law. The 
 construction of cess-pits is under control of the Councils, and another 
 by-law generally adopted reciuires that they shall be water-tight ; but 
 brick and cement are authorised materials to build them with, and 
 although such work doubtless can be made water-tight, as a matter of 
 fact, it very seldom is so. These also are emptied by the Councils, and 
 the charge falls on the landlords ; in consequence, emptying is often 
 delayed too long. 
 
 Garbage is regularly removed from houses within the city and in 
 some other districts, less regularly in remoter districts, and very 
 irregularly, or even not at all, in country districts. Everywhere 
 garbage is regarded apparently as a harmless material, and is put to 
 improper uses; that is to say, for converting into building sites land 
 otherwise useless for that purpose, for filling up hollows, and making 
 good the surface of places of public resort, and for spreading over foot- 
 ways, and over ai-id surfaces in public parks, to promote the growth of 
 herbage. 
 
 In 1880, a scheme of sewerage for pai'ts of the metropolitan district 
 was decided upon. It consists of a northern scheme designed to drain 
 an area of eight and a half square miles, and to serve a prospective 
 population thereon of 217,140 persons; and a southern, designed to 
 drain an area of one and a half square miles, and to serve a prospective 
 population of 50,500. It was arranged that the outfall and main 
 intercepting sewers, as well as some of the more difficult parts of the 
 subsidiary works, should be constructed by the Government; but 
 branch sewers, house sewers, and connections are to be left to the 
 Councils of the various municipalities to be sei'ved, who are to execute 
 the work under Government supervision and regulations. At the end 
 of 1887, the chief part of this design to be executed by the Government 
 itself was completed ; the northern outfall piercing a cliff, and discharg- 
 ing at a level four feet below high water mark into live fathoms or 
 more of the constantly agitated waters of the Pacific, where they flow 
 in an off-shore current; tlie southern discharging on a very large area 
 of pure sand at Botany Bay, the average level of whicli is nine feet 
 above high watei- mark, over which the crude sewage is distributed, and 
 crops grown. Tlie more diflicult part of the subsidiaiy works to 
 connect with the northern outfall, which involve tunnelling thi'oughout 
 their entire course, either through sandstoiie rock or tlu'ough shale, are 
 now approaching completion. These two outfall sewers, and the 
 systems they serve, will relieve nearly the whole of the areas mentixMied 
 by gravitation; a fringe at the shoi'es of the Harbour, which measures 
 in the aggregate about 1000 acres (but which does not carry a pro-
 
 444 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 portionately large population), will involve pumping. But that is but 
 a small part of the metropolitan district which urgently requii'es sewer- 
 ing ; and the rest of it is to be dealt with as follows : — A small scheme 
 for the district of Manley, calculated to relieve an area of 482 acres, 
 and a prospective population thereon of 18,316 persons (the present 
 population being 3000), with an outfall to the ocean; and a scheme for 
 North Shore, to serve an area of 888 acres, and a prospective population 
 of 30,225 (the present population being 15,000, to discharge at a level 
 of nineteen feet above high water mark into precipitating tanks, and a 
 filtration area on the shores of Middle Harbour, are sanctioned, and are 
 about to be begun. A third scheme, designed to sewer a suburban area 
 of thirty-two square miles, and a prospective population thereon of 
 482,000 persons, at present carrying 164,000, is now under consideration 
 of the Parliamentary Standing Committee on Public Works. This also 
 is in the main a gravitation scheme, but about twenty-nine per cent, of 
 the prospective flow will requii'e pumping. To these sewers it is pro- 
 posed to admit about fifteen per cent, of the rainfall only, or the 
 proportion calculated to fall on back yards and back roofs; and the 
 outfall will be at the sewage farm already mentioned, which at present 
 is laid out for irrigation. So that while the general description with 
 which this section began, at this moment liolds good with regard to the 
 metropolitan districts, carrying about 350,000 pei'sons on 111 square 
 miles taken as a whole; 125,000 persons, being the population of the 
 city proper, are served by old and defective sewers, with which the 
 houses are connected without pi'ecautions ; about 150 houses are 
 properly connected with the new northern outfall system, and about 
 1500 houses are properly connected with the new southern outfall 
 system, while the remainder are unsewered, and are exposed to all 
 those influences which promote a high death-rate from the filth 
 diseases. Those influences, however, are naturally modified by the 
 low rate of specific population which prevails over the greater part of 
 the area. 
 
 The sum expended by the Government on main sewerage woi'ks to 
 this date is ,£720,000, the sum authorised to be spent, either towards 
 completion, or on the new schemes mentioned, is about £180,000, and 
 the cost of the works now under consideration will doubtless amount to 
 £1,500,000, the total being £2,400,000. 
 
 Before proceeding to describe the steps taken to prevent spread of 
 the infectious diseases among the shore population, it is desirable to 
 describe the 
 
 Practice of Maritime Quarantine. 
 
 This is conducted on the principles which, in the States, are referred 
 to as Rational Quarantine. For my own pai^t, I prefer to use the term 
 Limited (Quarantine, because, within certain limits, the ancient plan is 
 followed. Sliips which arrive infected with such diseases as measles 
 or scarlet fever are not detained beyond the time necessaiy to 
 remove the sick to isolation, and to cleanse the vessel. But in the 
 case of some other diseases, as small-pox for example, all persons 
 are detained for a period of twenty-one days, in separate classified 
 enclosures, on shore, the vessel being held ready for release after 
 disinfection.
 
 THE PUESENT SANITARY STATE OF NEW SOUTH WALES. 445 
 
 The general rule thus indicated is subject to relaxation, and is best 
 illustrated by the ease of the U.S. Mail Steamer "Mariposa." A 
 considerable propoi't ion of hei'crew and passengers liad been successfully 
 vaccinated by the surgeon on l)oard, and tliese were either released 
 as soon as tlieir effects had been dealt with, or were only detained 
 until a period of fifteen days had elapsed since their successful re-vac- 
 cination. 
 
 But Quarantine is not imposed on vessels which arri^■e from otlier 
 provinces of Australasia, wlien the latter happen to be infected. 
 Conmiunication is so rapid and frequent, that the infection of one 
 province is taken to imply the infection of all. Xoi- against foreign 
 \essels arri^•ing from infected ports, China passenger ships alone 
 excepted, and tliat merely on account of practical difficulties, which 
 render any other course imprudent. In sliort, our practice is guided 
 l)y tlie facts of infectious disease taken in conjunction with tlie 
 circumstances in wliich we actually find ourselves placed. 
 
 Infectious Diseases. 
 
 Under the Statute, " An Act to Make Further Provision to Prevent 
 the Spread of the Disease Known as Small-pox, and for Other 
 Purposes " (See Boaixl of Health— Infectious Diseases Supervisio]i). 
 On the appearance of any case of small-pox, or eruptive fever, which 
 may reasonably be supposed to be small-pox, in any house or premises 
 in New South Wales, the householder or occupier of the said liouse or 
 ])remises, and also the medical practitioner attending the case, are 
 directed to immediately report it in writing to the proper authorities. 
 The penalty for neglect is a fine of not less than £10 nor more than 
 ,■£50, recoveralile by distress ; in default of sufficient distress, im^Drison- 
 inent, with or without hard labour, for any term not exceeding six 
 months, may be inflicted. 
 
 For the purposes of tlie Act, those powers which are conferred on 
 the Health Officer by the second Section of the Principal Quarantine 
 Act, are transferred to the Board of Health, and the latter, on that 
 authority, order the patient, the members of his household, any persons 
 who may be discovered to have been recently in communication with 
 the family, and the premises, to be isolated. Pei'sons are usually 
 isolated by removal to the Maritime Quarantine Station ; but, when the 
 number of cases is large (as happpened in 1881-2), or when tlie 
 household infected is very lai'ge, and the premises they occupy ai'e, liy 
 their position, sufficiently removed from neighbouring dwellings (as 
 happened once in 1886), the houses are barricaded, and, witli tlieir 
 occupants, placed under police sentries. In all cases, of course, 
 ]>remises are thus guarded until they liave been disinfected, and are 
 declared clean. 
 
 When an outbreak tln-eatens, an ambulance camp is establislied in 
 an isolated spot, and placed in connection wdth the Health Department 
 by telephone; and patients, with their families, are removed in 
 ambulances, which are driven by the staft' residing tliere, in Quarantine, 
 to one of the wharves. They are transferred tlience to the Quarantine 
 Station, in a launcli specially fitted to carry the sick. 
 
 Suspicious cases are reported from time to time all the year round, 
 but their number greatly increases as soon as it becomes known that
 
 446 IXTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 small-pox has made its appearance anywhere in Australasia. They arc 
 visited by the Chief Medical Inspector to the Board, who decides 
 Avliether they are cases of small-pox or not, and who at once takes the 
 necessary steps. He reports to the Board, who confirm the action 
 taken, obtains special executive authority for it, and give any further 
 directions wliich may seem necessary. 
 
 As the authority to administer " The Dairies Supervision Act," the 
 Board has power to declare what are infectious diseases for the purposes 
 of that Act. Cow -keepers, and also the medical attendant, must report 
 any case of the diseases named, which they meet with on dairy premises, 
 to the Board, in writing, under a penalty of £20. Prosecutions against 
 medical practitioners have been instituted under the first-mentioned 
 Act, and fines recovered from them, as well as, in one case, from an 
 unqualified practitioner who liad assumed the functions of medical 
 attendant; but, as in other places where dual notification is the law, no 
 prosecution has yet been undertaken against a lay householder, although 
 in one instance, at all events, there seemed to be sufficient ground to 
 proceed upon. 
 
 With exception, then (as to diseases) of small-pox, and (as to places) 
 of dairy premises, infectious illness among the resident population is 
 under no sort of supervision or restraint. No hospital regularly admits 
 such cases, or cases of erysipelas, except the Coast Hospital (see Hospital 
 Accommodation). There the Medical Adviser has improvised some 
 accommodation for them, but the total number admitted was, in 1887, 
 only 63. There is a Fraser's Disinfector at the Maritime Quarantine 
 Station, and anotlier at the Coast Hospital. Rarely requests for 
 disinfection are received from the public. They are attended to without 
 cliarge. (For prevalence of the zymotics, see Vital Statistics.) 
 
 The General Hospital Accommodation 
 
 foi' Sydney is furnished by 1003 beds, in six institutions; of these, one 
 is strictly self-supporting, one is exclusively supported by the Govern- 
 ment, while the remainder are suppoi'ted by voluntary contributions in 
 part, in part by payments made by the patients, in a further part by 
 subsidies of public monies, and lastly, by payments from the Vote for 
 the Maintenance of Sick Paupers, made at the rate of three shillings a 
 head a day for every destitute patient admitted by direction of tlie 
 Medical Adviser. There is also an institution, not included in the 
 above, which is partly supported by voluntary contributions, and partly 
 subsidised, called the Benevolent Asylum, where from 250 to 300 
 destitute women are received for lying-in annually. The 1003 beds are 
 assigned as follows : — 758 ar^ for medical and surgical cases in adults ; 
 there are 41 lock-beds (10 female, 34 male); 70 for children, 26 for 
 gy I uecological cases, 75 ophthalmic, 22 for infectious fev'ers (other than 
 tyi)hoid); and there ai-e 8 single bed wards. In the country, the last 
 re])ort of the Inspector of Public Charities (188G) shows that there ai'e 
 1029 beds distriliuted among sixty-seven small hospitals, and the latter 
 receive from tlie Consolidated Revenue either a grant in aid of their 
 building fund, or else a subsidy equal in amount to the public sub- 
 scriptions raised for building, and thereafter a subsidy equal in 
 amount to tlie sums raised by public subscription to meet current
 
 THE PRESENT SANITARY STATE OP NEW SOUTH WALES. 447 
 
 expenses. The inspection unci passing of plans for new liospitals is a 
 part of the duty of the jMedical Advisei', preliminary to a subsidy being 
 paid over. 
 
 f append a table, which shows some details of the Sydney hospitals, 
 including revenue and expenditure, as far as these can be gathered from 
 the ainiual reports for 1887. Admission to hospital is as follows: — The 
 tiualitication for admissiontothe Coast Hospital for the majority, is destitu- 
 tion, this being aGovernment institution for the relief of the destitute sick, 
 but eases of entei-ic and other infectious fevers are admitted from all 
 classes for the sake of isolating them. To St. Vincent's, admission is free, 
 and depends only on the suitability and urgency of the case, but capable 
 patients contribute to their support. To Prince Alfred and Sydney 
 Hospitals, a proportion are admitted free as being urgent cases ; a 
 majority either contribute something towards their cost, or ai'e referred 
 to the Medical Adviser for admission as being destitute, when he pays 
 for their treatment at the rate of three shillings a day. The last 
 mentioned class of patients, however, are expected to apply for 
 admission to the Government Medical Officer for Sydney, who sits daily 
 to give orders for their ti-eatment at the hospital which may seem most 
 suitable. In addition, a large number of chronic cases of illness among 
 the destitute are lodged in the hospital wards of the Asylums for the 
 Infirm and Destitute, which are situated (to the number of four, 
 containing about 2000 inmates), in several situations outside the 
 metropolitan division, and I have not thought it necessary to do more 
 liere than just mention the Lunatic Asylums. The proportion of strictly 
 hospital beds to the estimated population of the metropolitan division 
 is therefore 2-9 per 1000; and, as mentioned elsewhere, in 1887 about 
 15 '7 of all deaths occurred in them.
 
 448 
 
 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA 
 
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 W M w H
 
 THE PRESENT SAMTAHY STATE OF NEW SOUTH WALES. 449 
 
 In connection with the present subject, it seems necessary to say 
 sometliing respecting the 
 
 Practice of Medicine, 
 
 since tlie manner in which tliis is conducted, under the existing laws, 
 lias a direct l)earing on tlie value of the mortality returns. There is 
 nothing to prevent unciualitied practitioners from assuming titles likely 
 to cause the public to believe that tliey are educated medical men ; they 
 must not, llowe^'er, deceive the Medical Board {ii}fra) into granting 
 them a certiticate that they are legally qualified practitioners, nor 
 must they falsely advertise that they possess such a certificate. In 
 1886, the unqualified practitioners, not including pi^escrilnng druggists, 
 ))ut only faith-liealers, herbalists, clairvoyants, electroqDathists, and all 
 the like, were to legally (jualitied practitioners as one to three, in the 
 whole province. But, by the "Medical Witnesses Act" of 1838, Coroners 
 and Justices were empowered to summon legally qualified medical 
 practitioners to give evidence at inquests, and to pay tliem certain 
 fees ; and by the Act to define the qualifications of medical witnesses at 
 coroner's inquests, etc., of the same year, it was provided that no 
 practitioner should be deemed legally qualified, who liad not proved 
 to the satisfaction of the Medical Board, to be appointed, that he 
 possessed one or other of certain qualifications ; and the Board, appointed 
 by the same Act, to consist of not less than three members of the 
 medical profession, was empowered to examine the papers of any person 
 desiring to be declared legally c[ualified, and to issue to him a certificate. 
 Further, by an Act to provide for the registration of legally qualified 
 practitioners, passed in 1855, it was oi'dered that any person who shall 
 prove to the satisfaction of the Board, that he has passed through a 
 regular course of medical study of not less than thi-ee year's duration in 
 a school of medicine, and that he has received, after due examination, 
 from the University of Sydney, or from some other University, College 
 or other body duly recognised for that purpose in the country to which 
 sucli University, &c., may lielong, a degree, &c., entitling him to practise 
 medicine in that country, shall he deemed to be a legally qualified 
 pi'actitionei' within the meaning of the Acts first mentioned. This 
 }>oard has no power to remove from the register any name once placed 
 upon it, either in case of death, or for any other reason. 
 
 Speaking generally, medical men performing public duties are required 
 to be registered in New South Wales ; cases occur, however, in which 
 Coroner's summon unqualified persons to give evidence even when 
 legally qualified practitioners are accessible, and seek to pay the former 
 the statutory fees. Some further remarks on this topic are made in the 
 section on Vital Statistics. 
 
 The law which regulates the 
 
 Registration op Births and Deaths 
 
 was placed on the Statute Book in 1855 ; it has never been amended. 
 Under it, parents (subject to interpretation) are required to give District 
 Registrars information of births within sixty days ; and thereafter, the 
 registration of a bii-th (within the Colony) is not lawful, unless some 
 person present at it, or the parent shall at some time within six inonth.s 
 
 iG
 
 450 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 next after it, make a solemn declaration regarding it. But in evexy 
 case of the arrival of a child within the Colony under the age of 
 eighteen months, born at sea, or in any place out of the Colony 
 whose parents are about to take up their residence in the Colony, 
 the birth may be registered on a solemn declaration being made by the 
 parent. It is not lawful to register a birth within the Colony after 
 the expiration of six month's, nor one without it after arrival of the 
 child within it. 
 
 In case of a death, the tenant of the house or place where it occurred 
 shall o-ive the Registrar information within thirty days ; the Registrar 
 must deliver to the undertaker or other person having charge of the 
 funeral, a certificate of registration, and this must be delivered by the 
 undertaker to the minister or ofticiating person who shall be required 
 to bury, &c., the body ; and if any body shall be buried without that 
 certificate, then the ofliciating person, who shall bury or otherwise 
 dispose of it, shall forthwith give notice to the Registrar. 
 
 In the case of any new-born child or dead body found exposed — in the 
 former case the Constable, in the latter the Coroner, shall give the 
 information to the Registrar. Under Section 6, the Registrar-General 
 may make regulations from time to time to be observed by the District 
 Registrars (see Vital Statistics.) 
 
 I now approach the last section of this paper — that which deals with 
 the 
 
 Vital Statistics. 
 
 of New South Wales. Although this subject naturally comes last, it 
 is by far the most important. Just as one way of testing the degree of 
 civilisation to which nations have attained, is to enquire into the value they 
 set on human life, as witnessed by tlieir laws. So, with some limitations, 
 it may be learned by examining the form of their mortality return.., in 
 what degree that legal or apparent value is based upon observation and 
 reason, and in what it is merely imitative. I have, therefore, devoted 
 a considerable space to describing the manner in which our retunis are 
 made. This is very much the same as in the other provinces, and, 
 perhaps I need not detain you to hear read details, of which the value 
 can only be arrived at after deliljerate study. With your permission, 
 therefore, I shall read only a few remarks on some of the more salient 
 pcjints ; first of all obserA'ing, tliat this matter is transacted quite 
 independently of the Health Department, and that the retui'ns are the 
 outcome of tlie joint laboui's of the Registrar-General and Government 
 Statist. 
 
 Registration Districts coincide throughout the country with electoi'al 
 districts; Ijut when the latter are very populous, or very large, they 
 are divided into registration sub-districts. In the metropolitan division, 
 sub-districts have, as far as possible, the same Ijoundaries as 
 municipalities; but, when tliinly populated areas lie adjacent to 
 municipalities, but outside them, such areas are sometimes included in 
 the registration sub-district, of wliich the said municipality forms the 
 main part. 
 
 As to Street Names and Numbers within the city of Sydney. Tlie 
 same name is not used more tlian once, and there are not many
 
 THB PHESRNT SANITAIJY STATK OP N'RW SOUTH WALES. 4ol 
 
 11 n nil ui be red liouses. Tlie foi-iner statement holds good of tlie otlier 
 metropolitan sub-districts, taken severally; but the same name is used 
 over and over again in diffeieiit distiicts. Houses in the more populous 
 districts are imperfectly numbered, and in the less populous, are 
 unnumbered as a rule. Long streets, which i"un through more 
 than one district, are often numbered in part only. No map or 
 index of streets and numbers within their districts are issued to the 
 Registrars. 
 
 StUl-hirths are unregistered, and it is well known that here, as in 
 other countries, children who Iiave lived even for several weeks have 
 been buried as still-ljoni. 
 
 The law as to the Registration of Births is defective, especially by 
 allowing an interval of sixty days. It prol^ably helps to swell the 
 numbers who escape registration. 
 
 The "Registration Act" contains no mention of the Cause of Death. 
 The Registrar-Greneral has power under it to make regulations, which, 
 when gazetted, have the force of the Act itself. In this way, the form 
 of register has been prescribed, and one of its columns is headed 
 " Name of the medical attendant by whom certified," and " When he 
 last saw the deceased." The Registrars are therefore bound to enquire 
 the name of the medical attendant, but are not bound to ascertain 
 wliether the iiame given is that of a legally qualified practitioner, 
 ^ilthough, no doubt, some of them do so. 
 
 In 1886, according to " Bruck's Medical Directory," there were in 
 the whole province 526 legally qualified, and 18-3 unqualified, 
 practitioners; 83 of the latter resided in Sydney. 
 
 Certijied and Uncertified Deaths are not distinguished in the regis- 
 ters. 
 
 Deaths in Public Institutions are not distributed. In the country, 
 there is no reason to suppose that they are in large proportion, and as 
 districts are large, and Hospitals few, error could l)e caused by them 
 only if abstracts for the larger towns were separately published, and 
 this is not done; but the case is veiy different with the metropolitan 
 district. There, in 1887, no less than 15"7 per cent, of all deaths 
 occurred in public institutions. 
 
 Abstracts of the returns oj' Births and Deatlis aie published monthly 
 for the metropolitan districts only, pursuant on a departmental order 
 of the Registrar-General. Outside this area, aijstracts are published 
 annually only, and the larger towns are not separately reported on. The 
 population which is dealt with in them, under the general heading 
 "countiy districts," is in unknown [)roportions strictly urban and 
 strictly rural (see sections 1 and 2). 
 
 I now give a detailed account of the important particulars furnished 
 in the monthly abstracts for the Metropolitan disti-icts, and iii the 
 annual abstracts for the whole province. The former are published 
 to the current date, but the latter only to 1885. 
 
 The Montldy Abstracts for the Metropolitan District (or, the City and 
 Suburbs of Sydney) then, give the following pai'ticulars and calculations 
 (the estimated population at the middle of the cui-rent year is used): — 
 The absolute number- of deaths under each of the eight classes, dis- 
 tinguishing those below five years of age, and the percentage of deaths 
 
 1« 2
 
 452 INTEKCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 ill each class to total deaths, are given for the city and for the suburbs 
 separately. Under each class are mentioned the orders most largely 
 represented by the observed causes of death ; and under each order are 
 nientioned the more fatal diseases, number of the deaths due to each 
 being given. 
 
 Another table enumerates the se^■en districts which form the metro- 
 politan division, and the twenty-four su])-districts comprised in them ; 
 it gives the estimated population of the several districts, and shows the 
 number of births and deaths, distributed under sex, which occurred in 
 the city district and in each of the sub-districts, and gives the per- 
 centage of deaths struck on the estimated population of each of the 
 districts. Deaths in public institutions ai-e here entered separately, 
 and are not used in the calculation just mentioned ; they are included 
 and used in the total for the metropolitan division. 
 
 A third table gi"\'es similar information for each of the eight wards 
 of the city, but the population of each ward is not estimated. 
 
 A fourth table, intended for comjiarison, gives the number of births 
 and deaths for the city and suburbs respectively, in the corresponding 
 montli of each of nine previous years and in the current month, and on 
 these ten strikes an average. To tliis table the mean temperature and 
 height of the barometer, and the rainfall in inches and on days, is 
 added. 
 
 A fifth table gives the deaths under one yeai-, under five years, and 
 at all ages, in the corresponding montli of eacli of five preceding years 
 and in the current montli, for the city and suburbs resj)ectively. 
 
 These reports open with some general remarks. In the course 
 of them, the percentage of deaths under five, to total deaths, and the 
 monthly millesimal proportion of deaths to the living, are given. 
 
 The Annual Abst7xicts furnish in several tables the following informa- 
 tion : — Table A, births and deaths in the whole pi'ovince, distributed 
 under sex, for each quarter of the current year. Table D, births in 
 tlie whole pi-ovince in each quarter of nine preceding years and of 
 tlie current year, and the millesimal propoi'tion of births to the 
 population estimated at the middle of each year. Table G is 
 constructed as Tal)le I), but relates to deatlis. Table H is entitled 
 " Infantile Mortality," it gives the total deatlis in the whole province, 
 distinguishing those under five, and the percentage of the latter to 
 th(; former, in each of nine pi-evious and the current years. Talile 
 Ha gives the deaths at all ages (1, 2, 3, 4. 5, and quinquennially up to 
 100) in the City of 8ydney, in its suburbs, and in the country districts 
 separately. Table Ub contains the births, the deaths (distinguishing 
 those under five), distributed under sex, in each ward of the city ; 
 the enumerated population (18(S1) is added. Table He is the same as 
 H />, l)ut for the whole city and foi- each sub-district in the metropolitan 
 di^ ision ; the enumerated populations are added. Table I shows 
 the centesimal proportion of deatlis under five to total deaths, of 
 deaths under live to births, of tot;il deaths to births, and of total 
 deatlis to the enumei-attnl population in each ward of the city during 
 the current and each of tlie nine previous years. Table J, is con- 
 structed as Table 1, but deals with tlie city as a whole, and each of the 
 sub-districts of the metropolitan division. Table K gives the per-
 
 THE PftESEXT SANITAKY STATE OF NEW SOUTH AVALES. 4o3 
 
 ceiitage of deatlis under each of the classes and orders of tlie older 
 classification, to the total deaths in the whole province in each of nine 
 previous and the current years. Table L shows the births and deaths in 
 Sydney and in the rest of the metropolitan division, the mean tem- 
 perature and the mean heiglit of the barometer, with the rainfall in 
 depth and on days, for each month of the current year. In an 
 appendix are shown the obsei-ved deaths from all causes, distributed 
 under ages (1, 2, 3, 4-, o, and (juinquennially up to 100), and set 
 against classes and orders of iiiales, of females, and of persons, which 
 occurred during the year in Sydney, in the suburbs, in the country 
 districts, and in the whole pi'ovince during the year (twelve tables). 
 Here there is also a summary table of deaths set against classes and 
 orders of disease, for each month of the year, distributed under sex, 
 and the percentage of deaths under each order to total deaths, for 
 the whole province. Lastly, there is a table which shows the deaths 
 that occurred in each ward of the city, set against classes and orders, 
 distinguishing those under live ; and to this is appended the total 
 deaths set against classes and oi'ders, which occurred in the city in 
 the current and in each of nine previous years. 
 
 It only remains now to sliowfrom tlie abstracts I have just described, 
 wliat the actual state of tlie public liealth was at the date of the last 
 published returns. No life table has ever been constructed for New 
 South Wales. I therefore give the two tables which follow, and which 
 I have made for tlie present purpose; I believe they contain all the 
 information that is necessary for the present purpose as far as the 
 returns furnish it. It is necessary to observe that they are uncorrected 
 for sex, that they give recorded rates only, and that the estimates of 
 population are rather above the truth in all probability. I do not till 
 up the column for density, for reasons which (in the absence of annual 
 enumeration) may be inferred fi-om what is said under Sections I. and 
 II. The means of making trustworthy comparisons between selected 
 districts do not, in my opinion, exist : —
 
 454 
 
 IXTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 
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 456 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 I may mention, in conclusion, that the following Bills and Select 
 Committees have been introduced or appointed by one or other House 
 during the past few years: — During the session of 1885-6, a Public 
 Health Bill was introduced in the Council by the late Mr. Dalley; it 
 was interrupted by Prorogation of Parliament, and not re-introduced. 
 During the same session, a Bill to regulate the practice of Cremation 
 was introduced in the Council by Dr. Creed, and passed ; it was sent 
 to the Assembly, interrupted by Prorogation, and re-introduced in tlie 
 Council ; it was then dropped. A Bill to amend the laws relating to 
 the Medical Profession was introdviced in the Assembly by Dr. Tarrant ; 
 it passed that House, was sent to the Council, and was interrupted by 
 Prorogation. A Government measure to proclaim a site on which 
 Noxious Trades might be carried on, passed the Assembly ; it was sent 
 up to the Council, M'as referred to a Select Committee of that House, 
 and was dropped. During 1887-8, a Factories and Workshops 
 Regulation Bill was introduced in the Council by Dr. Renwick, and 
 passed ; it was sent to the Assembly for concurrence, and was not 
 returned. Two Select Committees of the Council were appointed on 
 motion of Dr. Creed, one to enquire into the law relating to the 
 Registration of Births, Deaths, and Marriages, the other to enquire 
 into the laws relating to the Practice of Medicine ; and they repoi'ted. 
 A Bill to amend the Law relating to the Registration of Births, Deaths, 
 and Marriages, was introduced in the Council by Dr. Creed, and being- 
 ruled by the Pi'esident a money Bill, was dropped, and not re-introduced 
 elsewhere. Leave to introduce in the Assembly a measure to amend 
 the laws relating to the Practice of Medicine was granted to Dr. Cortis, 
 but the Bill being ruled by the Speaker to exceed the leave, was not 
 accepted ; it was re-introduced after amendment, and thrown out. The 
 Government introduced a short Bill to prohibit the Sale of Diseased 
 Animals for food, and to amend the law relating to the sale of Diseased 
 Meat, and was thrown out. A Bill to Regulate Common Lodging- 
 houses was introduced in the Assembly by Mr. Camei'on, and thrown 
 out. 
 
 STATE MEDICINE IN NEW SOUTH WALES, WITH SOME 
 REMARKS ON THE MEDICAL ACTS OF THE COLONY. 
 
 By C. W. Morgan, M.D. 
 
 Tlie thoughtful address of Dr. Whittell, the Chairman of the Section 
 of State Medicine at the First Intercolonial Medical Congress, dwelt on 
 the duty of the State, in providing for the removal and prevention of 
 disease, and indicated the objections to the principle of appointing 
 members of corporations, or of shires, oi- of district councils, to be 
 local boards of health, which his experience of the working of tlie 
 Health Act of South Australia suggested. Dr. Whittell contended 
 tliat the public health was too sacrcid a subject to be committed to tlie 
 care of gentlemen who, not being impressed with its importance, placed
 
 STATK MKDTCIXE T\ XKW SOUTH WALES. 457 
 
 it in a secondary poi^ition; and, while adAOcatiiig the principle of a 
 central authority, armed with the fullest powers to control and direct 
 local l)oards, he insisted upon the importance of the latter bein<f 
 composed of persons ha\ing a knowledge of sanitary laws, who would 
 act independently of local consideration. Tn the few remarks I have 
 to otlei- to the 8ection, I wish to pursue the lines which Di". Whittell 
 opened on the occasion referred to, and to point out some particulars 
 illustrative of the eminently unsatisfactory condition of the adminis- 
 tration of public health in New South Wales, believing that a meeting of 
 representative membei's of the profession from all the Australian 
 colonies, affords a legitimate opportunity for discussion of any broad 
 question affecting the public health of each and eveiy one of them ; 
 and in the hope that suggestions may be made for the remedy of 
 defective conditions. 
 
 The laws relating to medicine, either as regards the profession or the 
 public, in New South Wales, are few and feeble. There is neither a 
 Public Health Act, such as obtains in Victoria, .South Australia, 
 Queensland, Tasmania and New Zealand; nor is there a Medical 
 Practitioners' Act, which detines the status of the medical profession, 
 or confers such privileges on the legally qualitied practitioner as are 
 enjoyed both in the United Kingdom, and in most of our sister 
 colonies. From some cause or other, an active antagonism to the 
 medical profession has arisen in Parliament, and there exists a strong 
 objection to place us on a footing which, we think, our education and 
 service to the State and the public deserve. The few Acts having 
 reference to medical practitioners are: — (1) "An Act to Define the 
 Qualifications of Medical Witnesses at Coroners Inquests and Magisterial 
 Inquiries' (1(S3.S) ; (2) a "Registration Act, under wdiich a Medical Board 
 was appointed in the same year; and (3) " An Act which Provides for 
 the Registration of Foreign Diplomas, and Imposes a Penalty for False 
 Declarations" (1855). A perusal of these Acts will show that they are 
 very imperfect, and neither afford a safeguard to the public, nor protect 
 the position of those who are registered under their provisions. 
 
 The "Medical Witnesses Act" provides that — "When it shall appear 
 to a coroner or justice that a deceased person was not attended 
 immediately before his death by any legally qualitied practitioner, such 
 coroner or justice may issue a summons for attendance, as witness at 
 such inquest or inquiry, of some legally (jualitied medical practitioner in 
 actual pi-actice, who shall reside near the place where such inquest or 
 inquiry is holden," and if such summons is disobeyed, the penalty for 
 non-attendance is from £3 to £20. This seems plain enough, but in 
 the teeth of such enactment, it frequently happens that unqualified 
 practitioners are called upon to attend coroners' inquests, and their 
 evidence is received as if they w^ere, in all respects, entitled by law to 
 be considered skilled witnesses. This course is adopted as an expedient 
 in remote places, where no registered practitioner can be procured ; but 
 even in such a contingency, it is improper that the evidence of an 
 unqualified man should be accepted as that of an expert, and this 
 .sometimes leads to a false issue. But another practice obtains, which 
 is .still more objectionable. Coroners frequently accept unqualified 
 a-ssistants as witnesses, on the ground of their having attended the 
 deceased on behalf of their principals, and this in direct contravention
 
 458 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA, 
 
 of the terms of the Act, as above quoted, and is mischievous in a 
 variety of ways. It happens, not unfrequently, that the e^•idence of 
 unqualified medical men is received at Quarter Sessions, in cases of 
 assault and minor offences ; and even at Courts of Assize, in trials for 
 capital crimes, and thus the life and liberty of the accused have, more 
 than once, dei:)ended on the testimony of a person without legal 
 authority to be considei'ed an expert or skilled witness. A case of this 
 kind fell under my personal knowledge at an Assize Court, held at 
 Bathurst, in 1871. A young naan was condemned to death for rape, 
 ehielly on the evidence of an unqualified medical witness, whose 
 testimony was so loose, and displayed so much ignorance, that the 
 medical profession memorialized the Governor of the day for a pardon, 
 on the ground of its unreliability; but, though every influence was used 
 by the public in supporting the action of the profession, it was, with 
 the greatest difficulty, that His Excellency was induced to commute the 
 death sentence to imprisonment for life, the first three years in irons. 
 This case will show how little the public is protected by the "Medical 
 Qualifications Act.'' I do not say that the evidence of an unqualified 
 practitioner is preferred, but in the absence of a legally qualified 
 medical witness, it is taken on the ground of expediency, and presented 
 to the jury irrespective of its intrinsic value, and until recently, has 
 been paid for out of the sum voted by Parliament annually for medical 
 services. 
 
 Nor does registration of diplomas under the second Act referred to, 
 confer exclusive privilege on the profession. It is certainly the custom 
 to require applicants for appointment to country hospitals, or for the 
 medical attendants of benefit societies, to be registered practitioners, 
 but I could cite several instances in which clubs, hospitals, and other 
 appointments have been held by persons who have no qualification at 
 all. Again, the Government frequently places the unqualified practi- 
 tioner in the Commission of the Peace, or appoints him coroner for a 
 country district, and this assures him, at once, position of authority, 
 and throws round him the ?egis of State recognition. 
 
 Tlie moral effect is to shake popvdar faith in the legitimate pro- 
 fession, and to underrate the value of registi'ation. The public, very 
 naturally, supposes that the untjualified practitioner would not be so 
 recognised by the State, if the Government had any consideration for 
 legal (jualifications; and, it is generally assumed, that persons so dis- 
 tinguished possess a natural aptitude for treating disease, which is 
 superior to the educational training of the registei'ed practitioner. 
 Such recognition on the part of the State of unqualified men in New 
 South Wales, is naturally humiliating to the profession, and various 
 efforts have been made, hitheito without success, to place the practice 
 of medicine on a satisfactory legal basis, by Legislati^•e enactment. 
 
 ()n the occasions of the introduction of Medical Bills into the 
 Parliament of New South Wales, the profes.sion has had to run the 
 gauntlet of unmitigated abuse, such as, perhaps, could emanate from 
 no other- body than a purely democratic House of Representatives. 
 Gld stories of pi'ofessional incompetence and misconduct of medical 
 men, dating from the times of long ago, when the colony was the refuge 
 of tlie destitute or reckless, are raked up, and invidious compai'isojis 
 are made between a class of men long passed aw^ay and the unqualified
 
 statp: medicixe i\ new south wales. 459 
 
 practitioner of the present time. Circuiust;inees, liowever, have changed 
 since the old days, and tlie professional men who recruit our ranks are 
 for the most part well educated, and of a superior class, eager to 
 advance the interests of the medical .science. It is high time that the 
 profession should urge upon the State its claims to l)e placed on the 
 .same footing as in other colonies, and that legislation should detei'mine 
 who are tit to be trusted with life and liberty of the subject, or 
 competent to perform the duties which the State imposes, or the 
 .services it requires, at the hands of the educated practitioner. The 
 absence of a Medical Act is a misfortune, not so much in the interests 
 oi the practitioner, as to the public, whom he endeavours to serve. We 
 are the legitimate ad\isers of the public in all matters of health, 
 whether in relation to the State, or in private life ; and to undervalue our 
 educational status, to ele^■ate pretenders and charlatans at our expense, 
 or to shake public confidence in us by viliticatioii, under the protection 
 of Parliamentary pri\ilege, is a grave wrong to a liody of men, the 
 majority of whom \ui\e never wavered in their devotion to the public, 
 or their duty to the State. 
 
 One of the best of the ^Medical Acts we possess, is the " Lunacy Act 
 of 1879." The organisation and administration of the Department for 
 the Treatment of the Insane in New South Wales are well known, and 
 I only refer to the Act in question to relate a rather amusing incident 
 which came under my notice lately, bearing on the appointment of 
 unqualitied practitioners to the Commission of the Peace. The 
 '• Lunacy Act " states, that a supposed lunatic may be sent to a receiving- 
 iiouse for the insane by order of a Bench of Magistrates, on the joint 
 certificate of two "medical practitioners," the interpretation clause 
 explaining that by sucli a term is meant " legally qualified " practitioners. 
 1 recently saw a man who had arrived at the police station, Newcastle, 
 under committal by a country Bench, to be forwarded to Sydney, on 
 the certificate of an untiualified practitioner. This per.son had received 
 no medical education whatever, beyond that of a chemist; yet, being a 
 Justice and Coroner for the district, he managed to persuade his 
 brother magistrates that, as the Act mentioned medical practitioners, 
 without reference to legal qualification, he had a perfect right to certify. 
 He, and the Bench also, had forgotten to look at the interpretation 
 clause. 
 
 While on the subject of medical certificates, I may mention that 
 there is nothing in the " Registration of Deaths Act " of New South 
 Wales (19 Vict., 34) that touches on medical certificates of cavi.se of 
 death. The medical attendant is always a.sked for one, and never 
 refuses to certify without good and sufficient reasons. If, however, he 
 does refuse, or no certificate is forthcoming, it is customaiy for an 
 inquiry to be made by the police as to the circumstances of the death, 
 and possibly an inquest may be held. In case of an unqualified practi- 
 tioner having attended, his certificate is received as of ecjual value with 
 that of the registered practitioner ; and in this laxity the State incurs 
 a great responsibility, as thei-e is no guarantee to the public that 
 deceased persons have died from the disease alleged. Further, the 
 statistics of disease cannot be correctly conq)iled if derived fi'om certifi- 
 cates of persons ignoi'ant very often of medical terms ; therefore, the 
 nosological tables of the Registrar-General huve to be re-cast, and are,
 
 460 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 consequently, unreliable. One direction in wliicli reform is needed, is 
 the passing of a " Registration of Diseases Act," of a uniform character, 
 in the various colonies represented by the Congress. 
 
 I have thus briefly reviewed the laws which refer to the duties of the 
 profession in New South Wales. I pass on to the consideration of 
 those which are allied to State medicine, as protecting the public. 
 These include the "Sale of Poisons Act" (1876), "Adulteration of 
 Food Act" (1879), "Infectious Diseases Supervision Act" (1881), and 
 the "Inspection of Dairies Act" (1886). We may add the various 
 " Quarantine Acts " from 1833 to the present time. Under the 
 " Infectious Diseases Supervision Act," a Board of Health is appointed, 
 presided over by the medical adviser to the Go^'ernment, but its func- 
 tions are widely dift'erent from those of centi'al boards under the 
 provisions of the "Public Health Acts" of the other colonies, and 
 operate chiefly in the direction of control of infectious diseases accident- 
 ally introduced to the ports, and of isolation of those affected ; it is, 
 however, an excellent board of advice, and affords a channel of com- 
 munication between the profession and the Government. Practically, 
 however, the action of the State, with reference to the prevention of 
 diseases, is directed to protection from without ; and the machinery for 
 the prevention or removal of causes which operate from within the 
 limits of the colony is of, for example, so primitive a character as to be 
 inoperative. Immense care has been taken, and large expense incurred, 
 in precautions against the introduction of small-pox, in spite of wliich, 
 the disease has gained admission to the colony on two or three occa- 
 sions ; and there is nothing to prevent its becomiiig a pestilence, if it 
 eluded the Board of Health's precautions, and obtained a firm foothold ; 
 but vaccination is so neglected in New South Wales, as to be virtually 
 a dead letter. I much question whether one-third of the infant popula- 
 tion of the last ten years have been vaccinated. There is no Act 
 compelling vaccination, and though there are vaccinators appointed by 
 the State in most country districts, tlie nece.ssity for the precaution 
 has never taken hold of the public mind. On the contrary, popular 
 opinion is divided between the benefits that vaccination may confer, 
 and the dangei- of accidental communication of other diseases, which, it 
 has been asserted, may arise from tlie operation. The ([uestion of 
 compulsory vaccination has been mooted more than once in Pailiament ; 
 but I do not think it has ever passed the stage of a special committee, 
 but has been abandoned as an interference with the liberty of the 
 sui)iect. It seems a singular fact that a practice, which statistics ha^ e 
 .shown to be a .safeguard against so virulent a disease as small-pox, 
 should be influenced by the factious opposition of a few persons 
 obstinately antagonistic to the .sy.stem, and that the opinions of medical 
 scientists, derived from the experience of a century, should be over- 
 I'idden oi- disregarded at their instance ; but it is only an evidence of 
 tlie aiiti-[)i'ogi-essive sjni'it of New South Wales in matters of sanitation. 
 Tlie wondei-ful advancement of State medicine in the mother country 
 during the last ten ycius ; the victories ovei- disease wliich centuries of 
 neglect and oNcicrowfUng had occasioned ; the removal of accumulated 
 filth, and adoption of niofh>ni system of dispo.sal of sewage ; the purifica- 
 tion of air, and su])j)ly of pure water ; the reform in the dwellings of 
 the poor, and tlie improvement in the in.spection of the food — all convey
 
 STATK MRDICIN'K I\ NEW SOUTH WALES. 461 
 
 lessons that should lun e iutliu'iiced our lulers and excited theif emula- 
 tion ; but it is reniackahle tliat, as refoi-niation in puljlic health has 
 progressed in the Ignited Kingdom, our sanitary condition is daily 
 degenerating, througli tlie niost culjiable neglect and mismanagement. 
 And in the absence of legislation to enforce sanitary rules, the very 
 diseases the home authorities are straining every nerve to combat and 
 stamp out, and which experience has proved to be controllable, are 
 gaining ground, and becoming more firmly rooted in the soil of oiir 
 young country. 
 
 T now proceed to detail the machinery by which the State exercises 
 its power for the preservation of public health in New South Wales. 
 The Colonial Secretaiy controls all the medical service, with the excep- 
 tion of the quarantine officers, who are in the Department of Finance 
 and Trade, under the Colonial Treasurer. Tn all cases of emergency 
 and danger, these Ministers take prompt action, and, being tlie chief 
 members of the Executive, no power in the land could be more efficient. 
 The responsibility of dii'ecting their actions rests with the Medical 
 Adviser to the Government, who is also, Pi-esident of the Board of 
 Health, to which reference has been made. This Board is composed of 
 the Secretary for Finance and Trade, the Inspector-General of Police, 
 and the Mayor of Sydney ex-officio, and of five members of the medical 
 pi'ofession, exclusive of the President, who are appointed by the Gover- 
 nor and Executive Council. Its functions are chiefly those of advice 
 and inspection. There are also a numbei- of Government Medical 
 Officers appointed to country districts. These gentlemen are required 
 to report tjuarterly to the Medical Adviser to the Government, on the 
 sanitary condition of the localities to which they are gazetted, and to 
 pen-form such services as the Government may require of them ; but I 
 do not think they have any connection, officially, with the Board of 
 Health, and their position and functions are defined by regulation, 
 rather than by Act of Parliament. 
 
 It will be seen that, in some respects, the organisation of the Health 
 Board, at head-quarters, and the Government Medical Officers in the 
 country, resembles the details of the Public Health Acts in the other 
 colonies; but there is this material difference, that there are no local 
 Health Boards, and the duties which such Boards would l>e called upon 
 to perfoun, under the provisions of the "Health Act," fall on the Muni- 
 cipal Councils of incorporated towns, under their special bye-laws. 
 These are framed under the "Municipalities Act," and relate to inspec- 
 tion, drainage, water supply, scavenging, disposal of nightsoil, »tc., 
 without any special reference to sanitary law ; therefore, the control of 
 the causes that lead to epidemics, and the exercise of pi"oper precautions 
 for prevention of disease, rest with bodies who are under no central 
 authority or skilled local advice. If a town is not incoi-por-ated, the 
 suppression of nuisances, or of the causes which lead to epidemics, rests 
 with the police. The officer in charge reports insanitary conditions to 
 the Inspector-General, himself a member of the Board of Health, and 
 active steps are taken; but the Municipal process is much more uncer- 
 tain and unsatisfactory. The routine of reports, reference to conanittee, 
 reception of more i-eports, delay and discussion on adoption, ha\e to be 
 undergone, and, in the me^intime, the opportunity of dealing with the 
 emergency is lost. From an intimate and personal knowledge of the
 
 462 INTERCOLONIAL MKDICAL CONGRESS OF AUSTRALASIA. 
 
 routine of a Borou<i;li Council, I have arrived at the conclusion, that the 
 importance of sanitation is a subject that the ordinary aldermanic mind 
 either cannot understand, or refuses to entei-tain; nor is it difficult 
 to explain the causes of this phenomenon, when we remember that 
 Municipal representatives are more frequently elected from the circum- 
 stances of their being either old residents or property-owners, than from 
 any special fitness for administration. The result of such a practice is 
 suicidal to sanitai-y reform, for the oldest inhal^itant is, invariably, non- 
 progressive, and the property-holder has a sti'ong objection to incurring 
 expense. The sanitary reformer is, therefore, in a hopeless minority at 
 most Council boards. Tt will readily be understood, that a Council 
 knowing nothing, and caring less, about sanitary laws, will pay moi'e 
 attention to street-making, reclamation of land, and improvement of the 
 value of 23i"operty, than to (questions of inspection of causes of disease, 
 imperfect drainage, pollution of soil, and removal of nuisances generally ; 
 and the disregard of sanitary pi'ecaution on the part of citizens, when 
 the exertion of Municipal authority is lax, may be taken for granted ; 
 but it happens, not unfrequently, that the Council offends against the 
 public health, not only by faults of omission, l)ut l)y those of actual 
 commission. 
 
 This may be illustrated by the case of the Attorney-General v. the 
 Borough Council of Newcastle, recently argued before the courts in 
 8ydney, to obtain an injunction to restrict the Council from using 
 recreation reserves as depots for the burial of nightsoil. I will ask the 
 indulgence of the Section if I give a short account of the circumstances 
 of the case, because the peculiar trade relations of Newcastle with 
 Melbourne, and almost eveiy other colonial port, makes its sanitary 
 condition an object of interest to every colony i*epresented to-day. For 
 the last two years, the Newcastle Council has had great difficulty in 
 tlie disposal of the contents of cesspits and other refuse matter. The 
 system which had always obtained was that of burial, and a nightsoil 
 depot at some distance from the city was used for tlie purpose. This 
 was on private land, rented from the Australian Agricultural Company, 
 but it ha\ing been alleged by the medical profession that a smart 
 outbreak of typhoid fever in an adjacent township, was caused by 
 ])ollution of wells l)y percolation, the Council received notice to quit. 
 It then became necessary to select a new site, or to dispose of 
 the obnoxious material by a different method. It was suggested 
 that the Council should discontinue the practice of burial, and 
 treat the nightsoil by chemical process, or remove it to sea ; 
 l)ut this advice was not received with favour, burial being 
 the only method which the Council understood or approved of. 
 There were, however, great difficulties in providing a new depot ; 
 the waste land at the disposal of the Council being very limited, and 
 the area of tlie borough confined between the sea and the harbour 
 on both sides, and met by two neighbouiing municipalities on the 
 the remaindei- of its l)Oundary. But the situation was urgent, and 
 the closets could not l)e allowed to ovei-tlow, so the expedient resorted 
 to was that of burying the nightsoil in a small paddock adjoining the 
 Hospital, which has been dedicated by the Covernment to the Borough 
 ('ouncil foi- public pui-i)oses. To this proceeding, the Medical Staff of 
 the Hospital strenuously objected, and the citizens joined in the protest
 
 STATE MEDICINE IN NEW SOUTH WALES. 463 
 
 against establishing a nightsoil depot in an inhabited portion of the 
 city, to the prejudice of the pul)lic health. These remonstrances being 
 disregarded, an appeal was made to the Board of Health, and the Chief 
 Medical Inspector, Dr. Ashburton Thompson, was despatched to 
 examine and report. The result of this action was a strong condemnation 
 of the system pursued, with some stringent remarks on the insanitary 
 condition of the city generally; and the Medical Adviser to the Govern- 
 ment, in a report thereupon to the Colonial Secretary, recommended 
 that the Council should be called upon to abate the nuisance complained 
 of within four months, and failing to do so, that the Governor should 
 be moved to exercise the powers entrusted to him under the " Nuisance 
 Prevention Act," which pro^'ides for the Executive taking the disposal 
 of the nightsoil out of the Council's hands. This course, however, the 
 Colonial Secretary did not see tit to adopt, J believe from a reluctance 
 to interfere with the administration of local authority. An appeal was 
 then made to the .Supreme Court for an ad iuteiiiii injunction, which 
 arrived just two days before the small paddock was completely filled 
 with the excrementitious tilth of the city. Being again in a dilennna, 
 the next proceeding of the Council was to cart the obnoxious matter 
 al)out four miles away, and to bury it in a large reserve, also dedicated 
 to the Borough Council of Newcastle for purposes of public recreation, 
 but situated in the heart of another municipality, a kind of iraperiuiii 
 ilk imperio. An appeal from the ratepayers of the incorporated district 
 so invaded, procui'ed an injunction to stop the deposit of foreign 
 nightsoil within the precincts of their territory ; and, driven to 
 extremities, the last resort of the Newcastle Councillors was to form a 
 depot within the ai-ea of the puljlic reserve or park at Newcastle, which 
 is situated on higher ground than the town, and in the immediate 
 A-icinity of the Hospital for the Insane and the I'esidences of many of 
 the wealthier citizens. The reserve is laid ovit as a j^ublic promenade 
 and planted with trees, and artbrds the only place of exercise for the 
 citizens, and recreation for the children. Here the system of burial 
 took a novel form. The Coi'poration used an old shaft of about eighty 
 feet deep, connected with the workings of an abandoned coal mine, as 
 the place of deposit. The contents of the night-carts were emptied 
 down the shaft at night ; cai'e was taken to keep the mouth of the shaft 
 closed and a high fence was erected round it. This conversion of the 
 public recreation grounds into a nightsoil depot, caused great indigna- 
 tion among the residents of the neighbourhood and the citizens 
 generally, and tlie Council was beset with remonstrances and protests, 
 which it met with the contention that, as the nightsoil was deodorised, 
 there could be no annoyance, and that the free use of disinfectants 
 removed any source of danger. An injunction was again applied foi', 
 but from some technical causes, was not granted until the third 
 application, and it w%"is not until after a year that the case was argued 
 before the Chief Judge in Equity, who decided that a nuisance existed ; 
 but as there were great ditficulties in the disposal of nightsoil, the 
 Council was not to blame; and in granting the prohibition, His Honor 
 allowed four months before it came into foi'ce, to allow the Council 
 time to perfect some other scheme. 
 
 During all the time that this litigation was proceeding, the Council 
 continued the process of storing up the nightsoil in the bowels of the
 
 464 INTKRCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 earth, which now contain between 2000 and 3000 tons of accumulated 
 faecal matter, tlie evil results of which, time and circumstances will 
 probably develop. 
 
 I cite this case, because it affords a very good example of the 
 imperfect system under which the public health is administered in 
 New South Wales, and a cogent argument in favour of reform. It 
 seems incredible that a Council should have persisted in ignoinng tlie 
 opinions of the medical profession, and continuing a practice by which 
 tlie public health was endangered for a period of two years, and that 
 the people could find no redress. The Government even declining 
 to interfere when the health of the inmates of a lunatic asylum, sup- 
 posed to be under the special care of the State, was jeopaixlised, and 
 the recovery of the patients at a general hospital prejudiced. Other 
 methods of disposing of the nightsoil were frequently brought under 
 the notice of the Council, and after all, their action resolved itself into 
 a question of expense, for proposals made for the erection of chemical 
 works, were rejected as too costly, as was also the offer of a local firm 
 of steamer proprietors to convey the nightsoil by steamer and deposit it 
 on a uninhabitable island at a distance where it could have done no 
 harm. Under the provisions of a Public Health Act, a vigorous 
 central authority would have exercised his powers, and so lamentable a 
 display of incompetency could not have been permitted. 
 
 The history of municipal shortcomings at Newcastle is not exceptional. 
 There are numerous instances familiar to most medical men in which 
 Municipal Councils in each and every of the colonies represented, have 
 committed grave errors in sanitary matters, for the simple reason that 
 they are unacquainted with the subject, and object to be dictated to. 
 From conversation with memljers from various parts of Australia and 
 New Zealand, I am convinced that the sister colonies stand equally in 
 need of sanitary reform as we of New South Wales. There is nothing 
 to prevent as perfect a condition of sanitation in the Australian 
 colonies as obtains in England at the present time. W^e have not the 
 overcrowding and poverty to contend with, our climate is one of the 
 most healthful in the world, and we have ample means at our disposal. 
 What we require is (1) special legislation, (2) organisation and co- 
 oi-dination of authoi'ity, and (3) what is most important, the sympathy 
 and assistance of the public, who, at the present time, display an 
 a]iathyin all matters of sanitation, from which they can only be aroused 
 by instruction in hygienic laws, and a realisation of the danger incui'red 
 by their neglect. It is unjust to blame local authorities for the careless 
 habits of individuals, yet it is by tlie want of cleanliness and care in 
 liousehold premises tliat epidemics generally are fostered. It is lament- 
 able to contrast the assertion of the English authorities, that no soil 
 exists in England favourable to the propagation of cholera, under the 
 sanitary precautions exercised under her laws governing State medicine, 
 witli the following extract from the report of Dr. MacLaurin, the 
 Medical Adxiser to the (Government of New South Wales, on the 
 sanitary condition of Newcastle :- — " From the position of Newcastle, as 
 a large seaport, it is eminently exposed to the introduction of epidemic 
 diseases, such as cholera, yellow fever, and the like. Should any such 
 disease takti root in the town in its present filthy condition, we may 
 leasonably expect an outbreak which would be fatal to the progress of
 
 HYGIENIC CONDITIONS IN VICTORIA. 465 
 
 Newcastle, and highly injui'iou.s to the whole of Australia." The 
 exceeding virulence of our constant epidemics, as enteric fever, 
 diphtheria, scarlatina, witli occasional outbreaks of erysipelas and 
 septicivniia, assure us that the case is not overstated. 
 
 In conclusion, I would remark, tliat the medical profession has now 
 an opportunity of impressing on the State the importance of legislation 
 on Public Healtii. 80 representative a meeting as this Congress, com- 
 prising the lughest rank of the medical confraternity in Australasia, 
 the most learned, the most able, and the most influential of so widely 
 spread a body, and under the patronage of Her Majesty's representa- 
 tives governing her several colonies, cannot be disregarded. In bringing 
 forward tlie subject of defectiAe Medical Acts, and imperfect adminis- 
 tration of Public Health, I am actuated by no other motive than the 
 public weal. I am sure there are good men and true men in the 
 Parliament of New South Wales, who will heartily enter into the 
 question of medical legislation, if they can be impressed with its 
 importance ; and I trust, before the conclusion of the Congress, special 
 committees will be formed, to consider the details of reform, with a 
 view to making representations to the various Governments of the 
 Australian colonies, so that some degree of uniformity may ])e arrived 
 at, in the Public Health laws of the whole, and that the position of the 
 medical profession, with relation to the State and to the public, may be 
 establislied on a basis at once just and honourable; that the State will 
 recognise the position and value of the practitioner, to whose services it 
 owes nnich, and that the public will learn to regard us, not simply as 
 servants, but as instructors and friends. 
 
 HYGIENIC CONDITIONS IN VICTORIA. 
 By J. W. Springthorpe, M.A., M.D., M.R.C.P. 
 
 Lecturer on Hygiene to the University of Melbourne. 
 
 It has been thought a fitting time, during this Congress, to place 
 upon record some reliable and fairly complete accounts of the state of 
 sanitary matters throughout Australasia, and, in the regretted absence 
 of worthier men, it has fallen to my lot to undertake this important 
 task, so far as the colony of Victoria is concerned. 
 
 The subject is treated under the three natural headings — of personal, 
 public, and legal hygiene; and the paper closes with a summary, em- 
 bodying the writer's views upon the points therein discussed. These, 
 of course, are matters of opinion; the rest of the paper deals with 
 matters of fact. 
 
 iH
 
 466 intercolonial medical congress op australasia. 
 
 Personal Hygiene. 
 (a) Inheritance. 
 
 The new race now springing up in Victoria is descended from a 
 healthy parentage. To quote the discriminating description of a recent 
 distinguished visitor, Dr. Dale — " The colony may be said to have been 
 created bv the great rush for gold, in 1851 and the following years. 
 In 1850, before the rush began, the population was a little over 76,000; 
 in 1854 it had risen to more than 312,000, of whom 205,000 were 
 males; the net immigration from 1850 to 1860 was nearly 400,000; the 
 immigrants remaining in the colony at the end of ten years were five 
 times as numerous as the whole population at the beginning of the 
 period. The men drawn to the diggings were, for the most part, men 
 of exceptional physical vigor, of courage and daring; indiffei'ent to 
 hardships, and careless of danger. They lived a rough, wild life. Only 
 those who were capable of great physical exertion, and of great physical 
 endurance, were able to stand it for long. Of the rest, some broke 
 down: some drifted into other employments; some ultimately settled in 
 other colonies; others returned to England. But the majority of the 
 strong remained, and they were numerous enough to impress their own 
 character on the colony. When they left tlie diggings for other 
 employments, they carried with them their boldness, their force, 
 tlieir confidence in themselves and their own resources, their vigorous 
 individualism." 
 
 The oifspring of such parents, naturally, inherited a sound bodily 
 constitution, noticeable illustrations of which are to be found in their 
 universal love of sport and excellence in athletic games. But equally 
 naturally, such ancestry meant also a predominance of the neurotic 
 temperament in its descendants, and the tendency thus inherited has 
 been accentu,ated by climate and environment. The " nervous tempera- 
 ment," indeed, characterises all strata of society — forming the basis of 
 the energy, the push, the restless activity of mind and body, the keen 
 receptivity of the Victorian people ; and pathologically evidenced in the 
 prevalence of lunacy, epilepsy, diabetes, and other nervous disorders. 
 Healthy, but neurotic, is thus the Victorian birthright. 
 
 (b) Hoiv the Inheritance is treated. 
 
 (1) Food. — There being an absence of abject poverty, and of profound 
 dietetic ignorance, rickets is practically unknown amongst our children. 
 All classes, however, alike commit the grievous error of consuming an 
 excessive amount of meat, as is shown by the following statistics : — 
 
 {a) Dr. Wilson, head-master of the Church of England Grammar 
 School, one of our largest public schools, reports that upon a " beef 
 basis," boys under sixteen years of age eat about 1 lb. of meat per day, 
 those over that age eating IJ lbs. On a "mutton basis," he would 
 deduct 12^ per cent., as the waste is less. These amounts do not 
 include fish, bacon, or fowl. 
 
 (6) Captain M'Callum writes from the recent cadet encampment : — 
 "There are 1850 cadets and 150 mounted rifles in camp. To the 
 former, six meat meals were served ; to the latter, eight. A calciilation
 
 HYGIENIC CONDITIONS IN VICTORIA. 
 
 467 
 
 shows that i^ lbs of meat were consuiiiecl per liead per meal, the meat 
 comprising corned beef, sausages, preserved meat, fi'esh beef and mutton 
 (including bone), and dried tish. The regulation allowance to militia 
 companies," he adds, " is 2 lbs of fresh meat per man per day." 
 
 (c) Mr. J. L. Currie, a well-known squatter, thus writes :— " My 
 sheep-shearers are twenty-four in number. They woi'k six or seven 
 weeks : their work is probably the most wearing that a man can engage 
 in. The average consumption of meat per man per day for the six 
 seasons 18S3-88, as weighed out to the men, was 2 lbs. 10.^ ozs. This 
 amount includes bone, and does not make any' allowance for waste." 
 The weekly allowance foi" ordinary station hands, as Mr. Inglis informs 
 me, used to be " 10 and 10 and no fat" (i.e., 10 lbs. of meat and 10 lbs. 
 of flour). 
 
 (d) As regards the community generally, the Government Statist, 
 Mr. Hayter, informs me that the daily rate for the past live years has 
 been -77 lbs. for all persons over two years of age, or over 1 lb. per day 
 for the adult population. 
 
 (e) As regards the consumption of foods generally, j\Ir. Coghlan, the 
 Government Statist of New South Wales, has forwarded me the follow- 
 ing suggestive table. I assume that Victoria may be placed alongside 
 New South Wales in the main conclusions : — 
 
 Consimiption of Foods. 
 
 Taking Mulhall's estimate, as given for America and Europe, tliis 
 table shows an excess of food beyond requirements, to the extent of f, 
 even though our population works for fewer hours, and our climate 
 necessitates less repair. 
 
 One noticeable outcome of this excessive consumption of meat and 
 other diet is, that a distinct hepatic tendency is being developed, and 
 hepatic vulnerability grafted upon our neurotic iiaheritance. To such 
 an extent, indeed, is this the case, that the type of the Victorian 
 individual may almost, at present, be classed as "bilio-nervous," with 
 all the functional disturbances and later structural changes which 
 characterise that combination. These, as being fully described in a 
 paper on "The Hepatic Element in Disease," in the Medical Section of 
 this Congress, need no further mention here. 
 
 iH 2
 
 468 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 (2) Sthmdants. — Mr. Hayter computes that the average annual con- 
 sumption per head of the Victorian population is, in gallons — beer, 
 16-41; wine, 1-01; spirits, 1-12 — equivalent to 32-88 gallons of beer. 
 That of the United Kingdom is given at 37-11 gallons; that of the 
 United States at 27-93 gallons. Mr. Coghlan gives the quantities for 
 those over eighteen years of age throughout the colonies as 22-6 of beer, 
 1-3 of wine, and 2-1 of spirits. No doubt, Victoria does not depart far 
 from the average. The quantities of tea and coffee have been already 
 given. It is difficult to draw fair conclusions upon these points. The 
 beers drunk, if English in name, are a specially fortified brew; if 
 colonial, they are frequently strong and injurious. The pernicious 
 habit of "nipping" between meals is less common than it was, but still 
 remains somewhat characteristic of the people. Climate and surround- 
 ings are so different from the English, that Anstie's safe limit might, 
 perhaps, be reduced amongst us to one-half. An increasingly large 
 proportion of the population is practically teetotal. Hence the 
 general conclusion seems to be, that the drinking population drink 
 more, take stronger intoxicants, and suffer more extensively from 
 the injurious effects than those in England. Tea is the main 
 beverage of a large proportion. In the country, the necessary boil- 
 ing of the water must have materially curtailed the spread of hydatids. 
 The fact that the tea is taken as soon as made, pi'obably explains 
 why the injurious effects on the digestion are practically confined to 
 a small class. 
 
 (3) Clothing. — In clothing, as with diet, Victorians have, unfor- 
 tunately, followed the fashion of colder and more equable climates. 
 The clothing generally adopted is, in several respects, ill-adapted to the 
 requirements. Black is, in the cities, the rule rather than the exception. 
 Too often the material is cotton, instead of woollen. In our climate, 
 and amongst our population, botli these fashions result in much injuiy 
 to health. Lastly, ill-ventilated hats, or non-ventilated hats, are very 
 largely worn. 
 
 (4) The Skill. — A very large proportion of Victorian houses contain 
 ))athrooms, but thei'e is a great dearth of washhouses and baths for the 
 poor. There is great need of free, or nominally free, fresh and salt 
 baths. With us, public baths are expensive monopolies. 
 
 (.5) Exercise. — Plenty of exercise in the open air is one of the greatest 
 characteristics of the people. By custom, nearly all trades work only 
 eight hours per diem. All business places close at noon on Saturday, 
 and public holidays are very numerous. By Act of Parliament, no 
 children can be put to work in shops or factories under thirteen years 
 of age; and all shops, except tliose for refreshment, or such as are 
 specially permitted, close each evening at an early hour. A larger pro- 
 portion of tlie population are tlius spending a longer period in the open 
 air, than can perhaps be found in any similar Anglo-Saxon community. 
 Generally, the time is healthily spent, and the result must be decidedly 
 l)eneficial. Perhaps the merchants, as a class, are too little given to 
 following the English custom of getting completely away from business 
 for some weeks each year. They have not yet learnt the lesson, that it 
 is an economy to do so.
 
 HYGIENIC CONDITIONS IN VICTORIA. 
 
 469 
 
 (6) Occupations and Population. — Tlie following tal)le is taken from 
 Mr. Hayter's "Year Book": — 
 
 Occupations of the People, about the Middle oj 1887 (Estimated ). 
 
 Occupations ok the Peoplk. 
 
 Mi:an Popur.AiioN. 
 
 
 
 
 
 Malos. 
 
 Females. 
 
 287 
 
 Total. 
 
 Ministering to Government 
 
 5,681 
 
 5,968 
 
 „ Eeligiou 
 
 1,299 
 
 239 
 
 1,538 
 
 Health .. 
 
 2,327 
 
 1,867 
 
 4,194 
 
 „ Law 
 
 1,515 
 
 
 1,515 
 
 ,, Education 
 
 3,192 
 
 4382 
 
 8,074 
 
 ,, Art, Science, and Literature 
 
 3,138 
 
 1,244 
 
 4,382 
 
 Traders 
 
 17,314 
 
 2,297 
 
 19,611 
 
 Assisting in exchange of money or commodities . . 
 
 8,008 
 
 766 
 
 8,774 
 
 Ministering to entertaining and clothing 
 
 17,717 
 
 31,637 
 
 49,381 
 
 Domestic servants 
 
 3,517 
 
 25,511 
 
 29,028 
 
 Contractors, artisans, and mechanics 
 
 55,514 
 
 1,244 
 
 56,758 
 
 Miners 
 
 26,000 
 
 
 26,000 
 
 Engaged in pursuits subsidiary to mining 
 
 1,028 
 
 
 1,028 
 
 ,, pastoral pursuits and agriculture 
 
 93,226 
 
 48,390 
 
 141,610 
 
 ,, pursuits subsidiary to grazing and 
 
 
 
 
 agriculture 
 
 4,004 
 
 1,197 
 
 5,201 
 
 ,, land carriage 
 
 17,423 
 
 383 
 
 17,806 
 
 ,, sea navigation 
 
 3,950 
 
 48 
 
 3,998 
 
 Dealing in food 
 
 16,773 
 
 2,058 
 
 18,831 
 
 Labourers 
 
 28,785 
 
 
 28,785 
 
 Engaged in miscellaneous pursuits 
 
 1,136 
 
 "96 
 
 1,232 
 
 Of independent means 
 
 2,868 
 
 1,340 
 
 4,208 
 
 Wives, widows, children, relatives, scholars 
 
 200,953 
 
 350,836 
 
 551,789 
 
 Public burthen 
 
 7,575 
 
 4,260 
 
 11,835 
 
 Of no occupation 
 
 1,461 
 
 48 
 
 1,-50.1 
 
 Uuspecitied . . 
 
 16,636 
 
 
 16,636 
 
 Total .. 
 
 541,070 
 
 478,630 
 
 1,019,700 
 
 The general hygienic results which follow from these data, need no 
 comment. The evils attendant upon unliealthy occupations must be 
 minimised by the outdoor life and limitation of the hours of labour, 
 and by the fact that up to tlie present time overcrowding exists only 
 in some metropolitan localities. Further, such ti*ades are under the 
 control of tlie sanitary authorities, and tliere is authorised inspection 
 of all factories and worksliops. 
 
 (7) Other Personal Conditio/is. — Education is free, secular, and 
 compulsory upon all. A scliool certiticate, as well as a health certifi- 
 cate, is required in all factories and worksliops. The State schools, 
 which are, generally, models of architecture, are provided with filters 
 for drinking purposes, but the closet and urinal arrangements are often 
 defective. In very few cases is education carried to the extent of 
 producing " brain fag." In the opinion of many, however, insufficient 
 prominence is given to tlie basement ideas of the moral sense — rever- 
 ence, self-control, and altruism — and in the opinion of the writer, the 
 unhealtliy results of neglecting these fundamental sanitary laws are 
 increasingly apparent.
 
 470 ixtercolonial medical congress of australasia. 
 
 Public Hygiene. 
 
 (a) The Sanitary Atmosphere. — In a new country, wliere the land 
 has to be opened up, and towns and cities Ijuilt upon a virgin soil, it is 
 but natural that sanitary matters should not be the first to be placed 
 upon a satisfactory basis. Still, in Victoria, such matters have com- 
 manded a large share of attention. Thus, the diffei'ent newspapers 
 tlu'oughout the colony continually devote a large quantity of their 
 space to the discussion of sanitary subjects. The State school programme 
 provides for instruction in the laws of health, to the scholars in its 
 2000 schools, and a course of i^hysiology for its pupil teachers. Tlie 
 Working Men's College makes similar provision for those more adv'anced 
 in years. An Australian Health Society has existed since 1875, with 
 some 500 subscribing members. Since its origin, this Society has 
 organised fifteen series of public health lectures, and seventy-eight 
 health meetings for wives and daughters ; has arranged a series of 
 cooking classes ; and published twenty -three original pamphlets, and 
 numerous wall-sheets and other sanitary diagrams, some of which have 
 been posted up on all i-ailway stations and in all State schools. The 
 St. John's Ambulance Association, also, have a Victorian centre, with 
 twenty-seven sub-centres. By its means, 2267 men and 1260 women 
 have been instructed in the principles of first aid, of whom 591 are 
 railway employes and 119 policemen. Questions affecting sanitation 
 and liygiene are thus brought well before the public mind, and the 
 public is being educated to take a rational interest therein. 
 
 [b) Climate. — The 56,000,000 acres, of which Victoria is composed, 
 may be divided into — (1) an extensive seaboard, open to polar currents 
 and ocean winds ; (2) an extensive and wooded mountain-range, 
 running across the whole breadth of the colony, its higher portions 
 often snow-clad ; and (3) the generally arid sub-tropical interior on the 
 northern and western boundary. The phenomena associated with the 
 cycle of the seasons may be grouped as follows : — Spring embraces 
 September, October, and November. The weather is usually mild, 
 genial, and pleasant. Strong northerly and westerly winds pi'evail. 
 (irenerally the rainfall is lar-ge. Summer embraces December, January, 
 and February. The temperature may rise above 100° in the sliade, 
 l)ut sudden and great changes are fi'equent, heavy rains and cold gales 
 replacing the hot, dry weatlier. The latter months ai-e often extremely 
 hot and dry, yet cooler and more pleasant weather frequently inter- 
 venes. Autumn — March, April, May — is the most genial part of the 
 year, though invaded by storms, gales, and large rainfall. It constitutes 
 a second spring, the trees often putting forth a growth exceeding that 
 of spring. Winter — .June, July, August — is usually cold and bracing, 
 with frequent I'ain and strong winds. Sometimes, however, it is remark- 
 ably dry. In Melbourne, tlie thermometei* is seldom below freezing- 
 point. 
 
 Coming to individual r-esorts, Melboui-ne has a mean average annual 
 temperature of 57 '6, placing it on the same isotherm as Lisbon, Florence, 
 itc. The average rainfall is 25-G inches. Northerly winds prevail, 
 especially in winter ; soutli and .south-west being next in frequency. 
 Both barometric pressure and temperature are exposed to great and 
 rapid changes, 20^ oi' .30" fall frequently occurring in as many minutes.
 
 HYGIENIC CONDITIONS IN VICTORIA. 471 
 
 and 80° linving been noted within twenty-four liours. Tlie drawbacks 
 are the great heat of siunnier, which, though generally dry, is depressant 
 when continued, and the great diurnal variations of temperature and 
 pressure. Spring and autumn are generally very pleasant, and the 
 winter bracing, if wet. Suitable changes are — to Adelaide or Sydney 
 during the winter, to Tasmania or New Zealand during the summer, 
 or to the Victorian resorts as indicated below: — Ballarat : 1438 feet 
 above the sea. Mean temperature, 53-6 ; generally moister than 
 Melbourne, though tlie rainfall is the same ; cold and bleak in winter ; 
 in summer not so hot in the daytime, and always cooler in the night. 
 Daylesford : 2000 feet above the sea. Partly sheltered on the south. 
 Mean temj^eratui'e, lower than Ballarat, and less bleak ; generally a 
 ^■e^y pleasant and salubrious climate. Beechworth : 1783 feet above 
 the sea. Mean temperature, 57"2 ; rainfall, 31 "6. Climate salubi-ious 
 and invigorating, with a characteristic subalpine flavour from the 
 neighbouring high ranges ; the mean winter temperature is 47 '8 — a small 
 difference from the annual, compared with other places of a similar 
 altitude, and a feature which adds much to the value of its climate. 
 Macedon, consisting of the village of Upper Macedon, 1900 feet high, 
 and Mount Macedon 2000 to 3000 feet in height. Taking the latter 
 tirst, the mean summer temperature is about 15° below that of 
 INIelbourne, and the liighest shade temperature seldom rises above 92°, 
 though, as is the case at all high altitudes, the direct heat of the sun's 
 rays is greater than at lower levels. The air is moister than on the 
 plains. Tlie southern slopes are exposed to the ocean winds, and 
 changes of temperature are often sudden and very great. The nights 
 are genei'ally quite cold. The cloud line frequently falls to the 2000 
 feet level, giving rise to dense mists, even when cool calm nights succeed 
 warm calm days. From May to October, the weather is bleak and 
 wintery. The village of Upper Macedon has the same characteristics, 
 modified by the difference in altitude and physiographical position. 
 Lying low, it is exposed to northerly and south-west winds, which are 
 too cutting for the most robust in winter. It is usually free from mist 
 and cloud. The mean temperature is 49°. 
 
 Riverina belongs, territorially, to New South "Wales, and is 
 generally hot and dry in summer, but subject to considerable extremes 
 of day and night temperature. It may be discussed here as a type of 
 the sub-tropical interior. The winters, as a rule, ai-e warm and pleasant, 
 and the general conditions very salubrious. Generally, as to others, 
 the most equable climates are near the coast, the least equable between 
 the coast and soutli face of the ranges, and on their southern slopes. 
 Fine climates ai-e found in the valleys and plateaux between the coastal 
 and northern faces of the ranges, such as Omeo, Harcourt, ttc. 
 
 Low level and sheltered valleys amongst the higher ranges are 
 objectionable; in summer the heat is great, and the air stagnant, whilst 
 in winter the winds are cutting; the frosts very severe. Sorrento, 
 Flinders, Phillip Island, Lome, the Lakes Entrance, Portland, and 
 Warrnambool, all possess the characters of the maritime climates. In 
 Portland, the seasons are latei', the summer much milder than in 
 Melbourne. 
 
 For the foregoing account, I am mainly indebted to the Government 
 Astronomer, Mr. Ellery, F.R.S.
 
 472 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Summarising some of the conclusions, we find that Melbourne proper 
 has a climate quite unsuited to phthisical cases. Of this fact, there is 
 urgent need that our brethren in England should be much more fully 
 apprised than they seem to have been hitherto. Again, its variability 
 is a fruitful source of bronchial, rheumatic, and hepatic attacks ; 
 whilst its trying summer often induces antemia, especially in young 
 girls, and causes a large mortality amongst infants. Next to the 
 summer, the autumn quarter is the most fatal. 
 
 (c) Surface Conservancy, Drainage, Hoiiseliold Construction, and 
 Removal of Excreta. — Here we meet with the great blot upon Victorian 
 sanitation, the reason why, in this new and healthy country, and 
 amidst surroundings which are mainly conducive to liealth, a young 
 and vigorous community continues to sufter under an excessive death- 
 rate. Surface conservancy is nowhere efficiently carried out. In many 
 of the townshij)s and boroughs, there is a great want of paved channels 
 of any kind, and no system of town cleansing is ever attempted. 
 Everywhere the maxim, "Own dirt, no dirt," is accepted as an axiom. 
 Individuals and authorities are alike to blame. Coming to the metro- 
 polis, we have, in Melbourne, a city far dirtier than there is any reason 
 for it to be. The streets are bi'oad and well planned; but as much 
 pulverised bluestone careers about wildly, in dust storms, as remains 
 quiet upon the roadway. Footpaths are generally untidy, the open 
 drains and gutters are almost always pervious ; rights-of-way dirty and 
 wet. The oftshoots of the main streets smell, at night, like badly kept 
 cesspools, such is the deplorable lack of public urinals and closet 
 accommodation. Round the corner of the imposing Town Hall meanders 
 a rivulet laden with foul odour — it has smelt just the same for some 
 years. In most of the suburbs, these evils exist in even greater degree 
 — many streets, roads, and rights-of-way are devoid of all sanitary 
 requirements. Tips and slop-sodden ground abound. Sweeping, flush- 
 ing, and cleansing are very inefficiently performed. It would be 
 interesting, indeed to know, in acres, the total area of filth in and 
 around Melbourne, in the shape of dirty rights-of-way, neglected dust- 
 bins, sodden manure heaps, made ground polluted in diverse ways; soil 
 pans in use or empty, but dirty; road sweepings, cinder and rubbish 
 heaps, stagnant foetid drains, and the like. And, to crown all, we have 
 converted our beautiful water-way, tlie Yarra, into a magnified, ob- 
 noxious, open sewer. 
 
 {d) Drainage. — An even greater sanitary misfortune is the total 
 absence of a properly-designed system of drainage alike in country, 
 towns, and cities. Originally, most towns are laid out without any 
 provision for drainage, and none may be made even when land is sold 
 and fresh houses erected. When, however, a higher grade in municipal 
 life is i-eached, open drains are constructed to convey li(iuid filth through 
 the city streets. In their construction, many of the canons of sanitary 
 science are disregarded, mainly because tliey were unknown. In all, 
 the final exit is not an intercepting sewer, but the nearest water-way. 
 As a rule, no wise foresight seems to be displayed ; each municipality 
 is content to free its own boundaries. Why sliould it care about others 1 
 They do not pay it rates. As an illustration of the waste of money 
 which such parochial views finally produce, it may be mentioned that
 
 HYGIENIC CONDITIONS IN VICTORIA. 473 
 
 the City of Riclimond Council have recently raised a loan of £50,000 
 to carry out a system of di-ainage, to terminate, as usual, in the hapless 
 Yarra, regardless of the fact that such pollution is a temporary 
 expedient, the doom of which is near at hand. The same pollution 
 awaits most of our country streams and watersheds, where it has not 
 already overtaken them. Even the Yan Yean reservoir is threatened. 
 For want of timely legislation, rights are obtained, and works under- 
 taken, at a subsequent cost of many thousands of pounds and much 
 injury to the public health. The kindred question of subsoil drainage 
 may be dismissed in one significant sentence — it is a thing unknown. 
 It must be admitted, however, that both these questions have entered 
 lately within the sphere of legislation, as will be seen when we come to 
 discuss State hygiene. 
 
 (e) House Construction. — Victoria presents two-thirds of its surface 
 occupied by strata of sand, clay, limestone, gravel, and conglomerate, 
 and the remaining third of lower Palaeozoic formations, or coal-bearing 
 Mezozoic strata — on the whole, a healthy site for habitations, and one 
 free from malarious influences. Sanitary house construction, however, 
 is a practice more honoured in the breach than in the observance. A 
 system of building has long been going on, which has lately reached its 
 culminating jjoint, in the phenomenal extension which Melbourne has 
 witnessed during the " land boom." Large areas of land have been 
 cut up into "pocket-handkerchief allotments," with streets to match. 
 In nearly all instances, no Building Act exists, and no Local Board or 
 other authority makes any inspection of the houses thereon constructed. 
 From plumbers, architects, and contractors no sanitary knowledge is 
 required. The site might be town rubbish, wet, undrained land, or 
 corporation tip — even ground into which manure had been trenched. 
 Regardless of Farr's law of density, that " the nearer men live to eacli 
 other, the shorter their lives," jerry -builders and building societies 
 crowd thereon hurriedly-erected tenements — in many instances little 
 better than dog-kennels — closely packed, without drainage, with insuffi- 
 cient ventilation, with damp continually rising, and the terraces abutting 
 upon streets or lanes neither paved nor drained. Interference, there is 
 none. Soon, occupants come; the rights-of-way become accumulations 
 of filth, the closets, disgusting and offensive nuisances — the whole a 
 state of affairs which should not be tolerated a day in an intelligent 
 and wealthy community. Now the more energetic of the local sanitary 
 authorities steps in — "Would further give you notice, and require you 
 within fourteen days from the service hereof, to form, pave, level, drain, 
 and make good, in the manner and according to the levels and specifica- 
 tions approved by the said Local Board of Health, kc. tfec, the street, 
 lane, yard, and passage of the house referred to." Some system of 
 removal of excreta is arranged, and more or less lazily carried out, and 
 the new terrace becomes merged in the ordinary rate-paying portion of 
 the borough. Such may be taken as a fair sketch of the construction 
 of a large proportion of our houses. The sanitary 2;)rospects of such 
 dwellings may be prophesied without much difficulty. AVe need look 
 no further for an explanation of much unnecessary sickness and mor- 
 tality. It is much to be regretted that Parliament, in passing the 
 Amending Health Bill, struck out the clauses giving the sanitary 
 authority a controlling power in these important matters.
 
 474 IXTERCOLOXIAL MEDICAL CvONGRESS OF AUSTRALASIA. 
 
 {f) Bemoval and Disposal of Nighisoil. — "With us, as elsewhere, thia 
 is the problem of the clay. In many large towns, and in most scattered 
 districts, cesspools are common, and the adjoining ground becomes the 
 final receptacle. In better instances, the pan system, or some modifica- 
 tion thereof, is adopted. In no part of the colony is the fiush system 
 in operation. No doubt, in many parts such a system will long remain 
 unnecessary and impracticable. The same apathy and neglect which 
 was noticed in respect to cleansing, drainage, and house construction, is 
 found in dealing with excreta. Few of the drawbacks to tlie pan 
 system are absent. The closets are, usually, too near the houses — the 
 undersoil polluted, the receptacle unventilated, improperly placed, and 
 frequently returned dirty. Removal, at best, is weekly, almost always 
 attended with unnecessary exposure, and the contents frequently strewn 
 along the main thoroughfares, as if the nightmen wished to show that 
 the corporation gutters were not to have the monopoly of filtli carriers. 
 Only in individual cases are deodorants or admixtures of any kind used. 
 True, the Corporation of the City of Melbourne has issued a bye-law, by 
 which closets ai-e to be ventilated and deodoi'ants to be used, but no 
 attempt is made to enforce it. The final disposal is equally uncertain 
 and insanitary. In almost all cases it is carted, as just mentioned, 
 and strewn upon the surface of market gardens. The Melbourne 
 Benevolent Asylum, however, with a daily average of nearly 700 
 inmates, and situated in the heart of the city, simply buries its nightsoil 
 in the asylum grounds, some eighteen inches below the surface, despite 
 continued protests.* 
 
 (17) Water Snpplij. — The sources of water supply throughout the colony 
 are veiy varied — natural springs, lander and over ground tanks, artesian 
 wells, rivers, ci'eeks, watei'holes, and lakes, are all made use of ; and in 
 tlie more settled parts, the waters are carried to more or less elaborately 
 constructed reservoirs, througli open races, pipes and culverts, and 
 distributed by water carts, pumping, or pressure, as the case may be. 
 Considerable attention has been paid to ensure purity, and almost the 
 whole of the colony is under the control of water trusts. In many of 
 the cities, boi'oughs, and shires, however, the water is not only scarce 
 at times, liut impure. Out of the 185, from which reports have been 
 furnished to tlie Central Board of Health, no less than twenty-five ai-e 
 declared to be polluted. In 1885 upwards of fifty samples of drinking 
 water were obtained from dams, reservoirs, tanks, rivers, and creeks, in 
 various parts of the colony, and examined by Mr. Newbery. In the 
 samples from unsettled districts, only the ordinary forms derived from 
 decaying matter were obtained; but in those obtained from the surface 
 drainage of tlie settled districts, micro-organisms and decaying excretal 
 matter were present, almost without exception. This pollution of the 
 creeks and rivers, by foul drainage, is increasing, and is one of the 
 questions which the sanitary authorities have to face without delay. 
 Its settlement is the more urgent, since in many instances, the drainage 
 areas are being sold, occupied, and polluted. In this connection it may 
 be mentioned, that in no part of the colony are the waters submitted to 
 any coarse filti-ation, and that the use of domestic filters is confined to 
 a few individuals. 
 
 * The practice has been stopped since this paper was read.
 
 HYGIENIC COXDITIOXS IN VICTORIA. 
 
 475 
 
 It is unnecessary" to enter into the details of the different water- 
 supply works constructed in ditierent pai-ts of the Colony. Brief 
 mention, however, may be made of the water-supply of the City of 
 ^lelbourne. The sources of the metropolitan water-supply are in the 
 Plenty Ranges, some thirty-three miles distant from Melbourne. The 
 actual water-shed area is 22,000 acres, with reservations, with an 
 aggregate area of 5-i,000 acres more, the whole being unalienated Crown 
 Lands, and the soil granite, over-laid with rich volcanic chocolate debris. 
 The waters are taken by a series of weirs and open aqueducts, of approved 
 composition and workmanship, to a reservoir some thii'ty-six acres in 
 extent, where, by a dam tliey are raised to a proper level and diverted 
 into an aqueduct, with a carrying capacity of 120,000,000 gallons per 
 day. This aqueduct, with a gradient of 7 "6 per mile, is 4^^ miles long, 
 is very solidly l:)uilt, and passes entirely through alienated and settled 
 lands. The Yan Yean Reservoir, which now receives the water, 
 impounds 6,400,000,000 gallons of water, 1,000,000,000 of which are 
 below "draw off" level. Its catchment basin of about 4500 acres, 
 however, is partly alienated, and in use as a settlement. Hence onward, 
 through the Pipe Head and Preston Reservoirs, the water is conveyed in 
 aqueduct and mains to the Metropolitan District. The aggregate 
 capacity is 43,000,000 gallons per day. The maximum consumption, 
 hitherto, has been 36,000,000 gallons. To meet the natural increment 
 required by the growth of the City, a fresh water-shed, the Watt's River, 
 is now ])eing diverted towards the Preston Reservoir, at an estimated cost 
 of £600,000. Here again, the water-shed area will consist entirely of 
 Crown Lands, and the fresh supply available, amount to 25,000 gallons 
 per diem. The cost to date, has been £2,480,000, and during 1888, the 
 avei"age daily coiasumption per head was 55 gallons, the maximum 
 >)eing 92 J gallons.* 
 
 ' As regards the composition of the Yan Yean water, the most recent analysis, 
 that of Professor Masson, is contained in the following table, taken from the Second 
 Progress Keport of the Eoyal Sanitary Commission, published since this paper was 
 read : — 
 
 Aiialffses of Fice Sa)ii2)les of Yan Yean Water from a Tup at the Unicersittj. 
 (Chemical const ituent>i estimated in part^ per million. j 
 
 Date of collection 
 
 
 13th Jan. 
 
 Uth Feb. 
 
 30th Mar. 
 
 23rd April 
 
 6th May 
 
 Teinperatme of the water C. . . 
 
 
 21°-22° 
 
 21-6' 
 
 21°-22° 
 
 17°-18° 
 
 not detir- 
 mined 
 
 Colour in 2-foot tube 
 
 
 All sample 
 
 s darkish ye 
 
 low. 
 
 
 
 Oilour at 40'" C 
 
 
 Slight in a 
 
 1 Ciises. 
 
 
 
 
 Reaction 
 
 
 Slightly all 
 
 laline iu all 
 
 case.s. 
 
 
 
 Total soliils 
 
 
 75 
 
 81.5 
 
 84 
 
 86-5 
 
 95-5 
 
 Total hardness 
 
 
 7-S 
 
 11 1 
 
 111 
 
 11^1 
 
 not deter 
 mined 
 
 Chlorine 
 
 
 ■2:i 
 
 21-5 
 
 22 
 
 24 
 
 25-5 
 
 Oxygen consumed at 27 -' '" 17""'"*"" 
 ■"' ( in 4 hours . . 
 
 1-0:5 
 1-90 
 
 1-07 
 2-05 
 
 109 
 
 2-u2 
 
 113 
 2^38 
 
 •84 
 2^CS 
 
 Free amiuonia * 
 
 
 tra:e 
 
 •006 
 
 trace 
 
 trace 
 
 •005 
 
 Alhnmeuoid ammonia 
 
 
 •218 
 
 •lao 
 
 •096 
 
 •132 
 
 •108 
 
 Nitrogen, iis nitrates 
 
 
 ■164 
 
 •137 
 
 •110 
 
 •113 
 
 not deter 
 mined 
 
 Nitrogen, as nitrites 
 
 
 AUsent in 
 
 ill cases. 
 
 
 
 
 Phosi>hates 
 
 
 Absent in 
 
 ill cases. 
 
 
 
 
 Microorganisms per j lifiuefying 
 
 'elatine 
 
 20 
 
 none 
 
 none 
 
 none 
 
 5 
 
 cubic centimetre "( not liquefj 
 
 ills ,, 
 
 5.0 
 
 45 
 
 none 
 
 1.-. 
 
 15 
 
 * Free ammonia less than •COS is stated as " trace."
 
 476 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 In connection with the question of water-supply, two questions arise 
 of great sanitary importance — the spread of typhoid fever, and the 
 prevalence of hydatids. 
 
 (1) Typhoid fever exists in Victoria to an alarming extent. The 
 figures of the President of this Section, Dr. MacLaurin, are sufficient 
 evidence upon this point. More recent statistics show that the disease 
 is rapidly increasing. Thus, during the six months ending May 31, 
 1889, no less than 5159 cases, 789 of which proved fatal, have been 
 repoi'ted to the Central Board of Health. No doubt, the main starting- 
 point lies in our insanitary surroundings, whilst our contaminated 
 surface and subsoil afford the germs a very prolific breeding-ground. 
 But here, as elsewhere, a polluted water-supply has much to do with 
 the extension of the disease. Already, numerous cases have been 
 traced to polluted tanks and water-holes, and several epidemics have 
 followed the contamination of creeks and rivers.* 
 
 (2) As to the prevalence of hydatid disease, Victoria still remains 
 the second most infected country in the world, despite the fact that the 
 danger must be materially diminished by the boiling of water in the 
 preparation of the general country drink, " tea." Some years ago, the 
 writer was successful in inducing the Central Board of Health to issue 
 and circulate some 30,000 circulars bearing upon the spread of hydatids, 
 but beyond that, little has been done preventatively. No investigation 
 has yet been made as to the proportionate number of dogs and other 
 animals infected, and no attempt has yet been made to attack the 
 echinococcus pi'ior to its entrance into water. 
 
 Legal Hygiene. 
 
 The earliest legislation afiiecting the Public Health in Victoria, was 
 the "Quarantine Act," of 1832, and the "Act for Regulating Buildings 
 and Party Walls, and for Preventing Mischief by Fire in the City of 
 Melbourne." Both these Acts were passed when Victoria was a portion 
 of New South Wales, and, with some amendments, remain in force to 
 the present time. 
 
 (1) "The Quarantine Act "of 1832, of course, was framed for the 
 exclusion of external disease. Power to take action, without waiting for 
 an order of the Governor-in-Council, has been added under Section 12 of 
 " The Public Health Act, 1888." For the j)ractical enforcement of its 
 regulations, a quarantine station, able to accommodate over 450 persons, 
 is maintained in a higli state of efficiency. There are three salaried 
 Officers of Healtli for tlie Port of Melbourne, and medical officers at 
 Geelong, Portland, Warrnambool, and Port Fairy, who are paid by 
 fees, and their inspection is very thorough. Considerable discussion 
 has, from time to time, taken ])lace as to the quarantine system adopted 
 by Victoria against external infection, the consensus of opinion being, 
 that the system is well suited to our requirements. On three occasions, 
 the passengers, ifec, of large steamers have been quarantined, and as 
 
 • More recently still, since this paper was read, similar contamination has been 
 shown to be only too probable in tlio case of the Yan Yean water-supply ; and 
 M. de Bavay, a pupil of the Pasteur school, has discovered in great abundance 
 germs, which he and the writer have every confidence, after isolation and cultivation, 
 in reporting as typical tyjihoid bacilli.
 
 HYGIENIC CONDITIOXS IN VICTORIA. 477 
 
 active measures in vaccination, isolation, and disinfection have followed 
 the few cases of small pox which have gained an entrance, that disease 
 has never yet obtained a jiermanent footing. A sanatorium, suitably 
 situated, and capable of holding some fifty patients, was built several 
 years ago, and is always ready for use. It is maintained by the eighteen 
 Metropolitan Local Boards, on a rateable basis of population, and is 
 under the immediate control of the Central Board of Health. 
 
 (2) The first Act relating to the internal health of the colony was 
 passed in 1854, but was applicable only to "populous places." This 
 was followed by an "Act to Prevent the Adulteration of Food." In 
 1865, Act 264 was passed. Part lY. of which, dealing with the 
 prevention of the pollution of the River Yarra, and Part YI., relating 
 to quarantine, are still in force. This was followed, in 1867, by Act 
 310, of which the portion, governing Cemeteries, is still in operation. 
 Then came Acts 436 and 524, both of which have been repealed. 
 
 (3) Some of the sections of the foregoing Acts, together with a 
 number of new provisions, and many sections based on the great 
 English "Public Health Act" of 1875, were incorporated in 1883 in 
 our " Public Health Amendment Act, 782." This measure was in foi'ce 
 in its entirety until the end of last year, when " The Public Health 
 Act, 1888," was passed. Now it is referred to as " The Principal Act." 
 
 The basis of this Act is, that a central authority composed of persons 
 not exceeding nine, appointed by the Governor-in-Council, shall exercise 
 a control somewhat similar to that vested in the Local Government 
 Board of England. The non-salaried members (except two, who are 
 Members of Parliament), draw fees of two guineas for attendance at 
 each ordinary meeting, the total paid to any member, not however to 
 exceed fifty guineas per annum. The Board is composed of three 
 practising medical men (one of them being the Government Medical 
 OfHcer), the two Professors respectively of Engineering and Chemistry 
 at the University of Melbourne ; the Director of the Technological 
 INIuseum, the Government Analyst, a Bank Director, and a practical 
 business man of long Colonial experience, with a Police Magistrate as 
 President. 
 
 The local and primary authority on sanitary matters, vests in Local 
 Boards, one for each Municipal District, and the members of the 
 ]\[unicipal Council for the time being, form such Local Boards ; every 
 City, Town, Borough and Shire, being a separate Municipality. With 
 the exception of some mountains in Gippsland, and the West Melbourne 
 Swamp, the whole of Yictoria is divided into Municipalities, there being 
 8 Cities, 9 Towns, 42 Boroughs and 128 Shires. Total 187. Local 
 Boards have the power of making sanitary By-laws, and must make 
 them, if required by the Central Board so to do. 
 
 At present, 170 Municipalities have By-laws more or less complete, 
 not including a series of By-laws passed by the City of Melbourne, 
 some of which are excellently framed. Nearly all the Cities and 
 Towns have well-drawn building regulations adopted under the " Local 
 Government Act." 
 
 The City of Melbourne and the Town of Geelong, were incorporated 
 and given special powers before the separation of Port Phillip and its 
 creation into a separate Colony.
 
 478 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 The Act requires each Local Board to appoint a Medical Officer of 
 Health, and also provides for the appointment of Analysts and 
 Inspectors of Nuisances. 
 
 The Town Clerk, or Shire Secretary, always acts also as Secretary to 
 the Local Board of Health. 
 
 Nuisances, adulteration of food, offensive trades, infant life protection, 
 unhealtliy dwellings, infectious diseases, control and regulation of 
 dairies, removal of excreta and liouse refuse, closing of polluted wells 
 -and tanks, and the inspection of certain public buildings, are the 
 principal subjects that daily come under the attention of Local Boards 
 and tlieir Officers. 
 
 As already stated, the Central Board has, to some extent, a controlling 
 power ; and in some cases of default on the part of a Local Board, can 
 enforce action, or may direct the Police to prosecute offenders against 
 the Act. In addition to this, the Central Board has the administration, 
 under the Chief Secretary, of all matters relating to quarantine, of 
 vaccinations throughout the Colony, and of cemeteries. No theatrical 
 licenses are issued witliout the Central Board's previous approval of the 
 building, and churches, concert rooms, stands on race courses, and 
 cricket grounds cannot be opened to the Public, without the previous 
 consent of the Board. 
 
 For the foregoing account, I am indebted to the kindness of Mr. 
 Akehurst, President of the Central Board of Health. 
 
 In pvirsuance of the powers thus vested in it, the Central Board has 
 continued to act with considerable vigour. In August 1884, it drafted 
 and forwarded to all the Local Boaixls, a pamphlet of instructions for 
 tlieir guidance ; and since then, it has issued model bye-laws upon the 
 questions of their duties, regulations for the prevention of the spread of 
 infectious disease, memoranda for the suppression of cesspools, the 
 suppression of nuisances, tlie methods of disinfection, and instructions 
 to officers of healtli. In addition to the annual report to the Govern- 
 ment, it has circulated valuable papers on the prevention of small pox, 
 the treatment of measles, diphtheria, croup, pertussis, and typhoid fever, 
 in the absence of medical aid. Recommendations, in view of cholera 
 outbreaks, on liydatid disease, closet and urinal construction, improved 
 stT'eet, gutter, and open drain construction, the building and manage- 
 ment of public structures. It has been specially energetic in pointing 
 out how to deal witli typhoid fever on railway and water work camps, 
 and in disposing of excreta; and in 1887, it issued a special report 
 to Parliament on the whole question, a report which was very favour- 
 ably reviewed in The Lancet. Its final annual report, for 1887-1888, is a 
 document of eighty-eiglit pages, which afibrds ample evidence as to the 
 time and attention which the Central Board has given to its important 
 duties. This report r-efers to the frequent failure of duty on the part 
 of Local Boards, to the fact that only fifteen boards had attempted to 
 carry out the law as to tlie adulteration of food. It deals with tlie 
 treatment of threatened small-pox, and supports tlie Victorian practice 
 of quarantine as, under oui' circumstances, safer and more efficient than 
 the Englisli system of medical inspection. Under the heading of 
 nuisances, it discusses the important questions of the Elwood Swamp, 
 the Port Melbourne Lagoon, the West Melbourne Swamp, and
 
 HYGIENIC CONDITIONS IN VICTORIA. 479 
 
 indiA'idual complaints, eighty-two in number. It lays special stress on 
 the want of public urinals and closets; and in view of the serious 
 danger to health from the conunon practice of speculators in land, 
 cutting up blocks without nudving sufficient pro^■ision for I'oads and 
 drainage, and submits a series of ckiuses, bearing ujjon these points, for 
 Parliamentary approval. Matters of vaccination, quarantine, water 
 pollution, abattoirs, polluted mattresses, drainage of stables and piggeries, 
 overcrowding in asylums, and buiial of nightsoil on Crown lands, also 
 receive intelligent and suggestive attention. Further, a general state- 
 ment is given of the sanitary state of the colony, and a synopsis is 
 presented of the reports from 185 of the Local Boaixls, containing a 
 detailed account of sanitary matters in their midst, and of the chief 
 facts observed upon offici;d inspection. A perusal of this report, there- 
 fore, wliicli is procurable on application to the Central Board, furnishes 
 a fair way of arriving at an intelligent conception of many of our 
 hygienic conditions, and tlie difficulties that stand in the way of their 
 amelioration. 
 
 (4) To improve the state of matters tlms shown to be very unsatis- 
 factory, the "Public Health Act 1888," was introduced. Most 
 unfortunately, this Act was not brought forward until the A^ery end of 
 Session, and to be passed at all, it liad to be passed without any 
 discussion, and in a mutilated form. i\Iany important Amendments, 
 liowever, were enacted. Thus, additional power is given to the Aarious 
 authorities to enforce sanitary regulations, especially against typhoid 
 fever. The jVlinister may define what are infectious diseases under the 
 Act, may order the enforcement of regulations, and in any emergency, 
 perform all or any of the functions of the Local Boards. Notification 
 of infectious disease is made compulsory upon medical practitioners, 
 X'egisti'ars, school teachers aiT,d members of the police force, as well as 
 householders, and provision is made to ensure the value of such 
 notification. A separate service in enjoined for the removal of typhoid 
 excreta, and their disposal by fire. The Health Officer is empowered 
 to question masters of ships, or passengers, as to infectious disease, and 
 the Central Board may act instanter. Penalties are provided against 
 over-crowding, and the continuance of nuisances. To prevent water 
 pollution, the sanitary authority is made a riparian proprietor, proofs 
 in court are simplified, and the penalties for food adulteration are 
 raised. 
 
 (5) Conflicts of opinion, however, were still permitted, and arose 
 between the Central and the Local Boards, and in the compromise 
 mentioned above, important clauses, such as those regulating the 
 powers of the Central Board, the disposal of nightsoil, the completion 
 of rights-of-way, and the subdivision and drainage of land devoted to 
 building purposes, had been sacrificed. Hence, there is at present 
 before the Legislature a Bill, the main objects of which are the 
 establishment of a Department of Health, with a responsible Minister, 
 and the enactment of clauses equivalent to those previously aban- 
 doned. 
 
 Such is an ab,stract of the general sanitary legislation of the Colony. 
 It may perhaps be claimed with justice, that it shows an appreciation 
 of the importance of the subject, and a desire, progressively, to grapple
 
 480 
 
 IXTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 with it. Apart from the general apathy and ignorance, howe^'er, to 
 which are due, here as elsewhere, most of its defects in construction 
 and scope, it must be admitted, that a great source of failure has 
 always been present in its inefiective execution. The great need of 
 both Local and Central Boards indeed has been, not so much increased 
 powers, as more inspection and better execution. 
 
 Special sanitary legislation, however, has not been forgotten. 
 
 (1) In 1874 a "Compulsory Vaccination Act "was passed. This 
 Act requires that every child be vaccinated within the first six month's 
 of life. All the necessary machinery, including an admirable Calf 
 Lymph Depot, has been provided. In 1887, the number of public 
 vaccinators was 180, the fees and travelling allowances amounted to 
 £5186 19s. 6d., and 85-85 per cent, of the children boi-n in the Colony, 
 are recorded as successfully vaccinated. 
 
 The quantities of calf and humanised lymph respectively, received 
 and issued at the offices of the Central Board during the year, are given 
 below : — 
 
 
 Received. 
 
 
 Issued. 
 
 
 
 
 
 Calf Lymph 
 from the depot, 
 and Humanised 
 
 from various 
 Public 
 
 Vaccinators. 
 
 To Public 
 Vaccinators. 
 
 To Private 
 Medical Prac- 
 titioners. 
 
 Sent to Qua- 
 rantine Sta- 
 tion. 
 
 |.| 
 
 Total sent out. 
 
 Calf lymph . . 
 Humanised lymph . . 
 
 15,690 points 
 3,425 tubes 
 
 11,861 
 1,395 
 
 1,966 
 654 
 
 182 
 170 
 
 592 
 429 
 
 14,601 pomts 
 2,648 tubes 
 
 The above is exclusive of the calf lymph used in direct vaccinations at 
 the Calf Lymph Depot. 
 
 It still remains possible for unqualified men to vaccinate, provided 
 qualified men sign the certificate, and there is no power to re-vaccinate 
 in cases of necessity. Clauses to remedy these defects were introduced 
 in the Amending Health Bill, but met the fate of all opposed 
 alterations. 
 
 (2) There is a " Pharmacy Act," regulating the sale of poisons, and 
 the registration and education of chemists and druggists. There is 
 also a " Dentists Act, 1887," placing the dental profession upon a 
 similar satisfactory footing. The number of registered chemists is over 
 600, and of registered dentists, 486. 
 
 (3) The insane and inebriate are also legally provided for. Until 
 last year, provision was made for their treatment by the " Lunacy 
 Statute," as amended by Act 342, and the " Inebriates Act, 1872," as 
 similarly amended. These are now repealed, and replaced by the 
 "Lunacy Amendment Act, 1888," and the "Inebriate Asylums Act, 
 1888." 
 
 J5y " The Lunacy Amendment Act," orders are made for conveyance 
 to a receiving house, which may be part of an asylum, or separate 
 therefrom. Tliere the superintendent may dischai'ge the patient, if not,
 
 HYGIENIC CONDITIONS IN VICTORIA. 481 
 
 in his opinion, insane; or, if in doubt, may take medical opinion, and 
 in case of disagreement, abide by the opinion of a second medical 
 practitioner. When, however, he considers the patient insane, two 
 medical men are to examine him, and if they agree, discharge or certify 
 him as insane, as the case may be; if they disagree, the patient is to be 
 examined before a police magistrate, upon fresh evidence, and his 
 decision is final. Not only is the course of procedure thus authorised, 
 both cumbersome and unnecessary, but, as the writer has pointed out, 
 the medical practitioner who signs the certilicate in the fii'st instance, 
 has to certify tlie patient as insane, though, within three days, his 
 certificate has to run the gauntlet of one, two, or three fresh opinions, 
 the result being, that he dare not certify a patient in an early stage for 
 fear of subsequent proceedings. Thus, the value of a receiving house is 
 reduced to the minimum. Other clauses deal with the yearly examina- 
 tion of all asylum patients, the boarding out of harmless patients, the 
 establishment of separate accommodation for paying patients (all private 
 asylums having been aliolislied), the separation of tlie criminal insane, 
 and the establishment of philanthropic hospitals, in which patients may 
 be maintained and cared for without charge. 
 
 By "The Inebriate Asylums Act, 1888," suitable places may )je 
 proclaimed as such asylums. To these, an inebriate may be committed 
 on his own application, or on the certificate of two medical men, to the 
 effect that he requires curative treatment. The term must not exceed 
 three months, without subsequent ordei's, made on similar grounds. 
 The expenses come from the inebriate himself, and penalties are pro- 
 vided against improper treatment. 
 
 (4) By "The Shops and Factories Act," provision is made for the 
 sanitary condition and inspection of all shops and factories, and for 
 limitation in the hours of labour. No childi-en under thirteen years of 
 age are allowed to work therein, and for all under sixteen years of age 
 a medical certificate must be obtained from a duly appointed officer, the 
 fee being Five shillings, payable by the applicant. 
 
 (5) The legal status of the profession is regulated by a " Medical 
 Practitioners Act, 1865." This provides a nominee board of registra- 
 tion, the requirements for registration being a three years' course of 
 study, "to the satisfaction of the board." Penalties are imposed for 
 the assumption of certain medical titles (from which, howevei", oculist 
 and aurist are absent), to be recovered by any person suing in the 
 County Court. Until recently, such prosecutions were undertaken by 
 the police, but a late remarkable order from the Chief Secretary has 
 forbidden such action. The unrepresentative character of the board, 
 the absence of power to erase names from the register, the scanty re- 
 quirements in the matter of medical education, and the want of defini- 
 tion as to power of prosecuting, on infringement of the Act, have proved 
 so damaging to the utility of tlie present Act, that the profession has 
 under consideration an amended bill, which it is hoped will be intro- 
 duced before Parliament during the present session. Meantime, though 
 quackery is very much on the increase, unqualified men have no legal 
 status ; and in only two instances do they hold office in institutions which 
 receive a Government grant towards their maintenance. As I'egards 
 the profession, numerically, Hayter's "Year Book" for 1887 states that, 
 
 li
 
 482 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA 
 
 at the last census, there was one practitioner for every 1 900 persons. The 
 proportion, however, is constantly being diminished, and at a somewhat 
 rapid rate. It would be unpardonable in this connection, to omit all 
 mention of the Medical School in connection with the University of 
 Melbourne, established in 1862. It has turned out more than 200 
 graduates in medicine, and has 236 students at present attending 
 lectures. The course prescribed is five years in duration, four of which 
 include hospital attendance. The range of lectures is comprehensive, 
 the examinations noted for their severity, and the clinical facilities 
 ample for all requirements. 
 
 (6) Lastly, Charitable Institutions are numerous, largely endowed by 
 the State, and under State supervision. The returns of the Inspector 
 for Charitable Institutions for the year ending 30th June, 1888, show 
 that there are 34 hospitals in the colony, with 1289 beds for male, and 
 681 for female patients, with a daily average of 1455; the total number 
 of 16,004 in-patients ti'eated, and 43,334 distinct out-patient cases 
 treated. There are also 10 institutions which are both hospitals and 
 benevolent asylums, with a daily average of 211 hospital and 267 
 benevolent cases. There are also 6 benevolent asylums, with a total 
 of 1974 patients; 7 orphan asylums, with 834 inmates — 331 boarded 
 out, and 148 in service. There is an infant asylum with 59 inmates ; 
 a blind asylum with 102 ; a deaf and dumb institution with 66 ; 4 
 female refuges ; 2 convalescent homes, with 10 male, and 17 female beds. 
 In addition, there are numerous benevolent disjDensaries, private chari- 
 ties, nursing and maternity societies ; Charity Organisation Society ; 
 and a Hospital Sunday Fund, which this year collected the large sum 
 of £14,691 14s. lid. 
 
 The actual results which follow from the hygienic conditions which 
 have thus been described can, perhaps, be best illustrated by the 
 presentment of the vital statistics, and expectancy of life, as compiled 
 by recognised authorities. 
 
 Vital Statistics. - 
 Book "for 1888:- 
 
 -The following table is taken from Hayter's " Year 
 
 Death-Rate at Various Ages in Different Countries. 
 
 ColTNTUIkS. 
 
 
 NuMBEK OF Deaths 
 
 PER 1000 LIVING AT 
 
 EACH AGK. 
 
 
 
 
 
 
 
 
 
 
 Under 5. 
 
 38-6 
 63-6 
 
 5 to 10. 
 
 10 to 25. 
 
 25 to 45. 
 
 45 to 55. 
 
 55 to 65. 
 
 65 to 75. 
 
 Victoria .. 
 
 3-5 
 6-6 
 
 3-9 
 5-5 
 
 10-2 
 10-2 
 
 16-2 
 17-4 
 
 29-1 
 31-8 
 
 59-4 
 
 Englaud . . 
 
 64-3 
 
 United States . . 
 
 58-8 
 
 10-1 
 
 5-4 
 
 10-8 
 
 17-6 
 
 27-2 
 
 51-4 
 
 France . . 
 
 75-6 
 
 9-2 
 
 8-8 
 
 12-7 
 
 16-6 
 
 28-3 
 
 66-3 
 
 Prussia . . 
 
 
 9-2 
 
 6-4 
 
 11-5 
 
 18-6 
 
 33-0 
 
 64-5 
 
 Austria . . 
 
 111-7 
 
 9-8 
 
 6-6 
 
 11-3 
 
 21-1 
 
 41-5 
 
 92-8 
 
 Switzerland 
 
 
 8.5 
 
 6-3 
 
 11-6 
 
 19-3 
 
 38-4 
 
 82-5 
 
 Italy 
 
 110-6 
 
 11-6 
 
 7-8 
 
 11-7 
 
 17-3 
 
 33-1 
 
 70-1 
 
 Spain 
 
 106-2 
 
 11-7 
 
 8-8 
 
 12-9 
 
 23-8 
 
 42-0 
 
 95-0 
 
 Belgium . . 
 
 68-1 
 
 12-7 
 
 8-1 
 
 12-9 
 
 19-0 
 
 32-3 
 
 74-5 
 
 Sweden . . 
 
 57-6 
 
 8-0 
 
 4-8 
 
 ^•2 
 
 14-7 
 
 27-4 
 
 62-6
 
 HYGIENIC CONDITIONS IN VICTORIA. 
 
 483 
 
 Expectancy of Life. — Tlie followin<^ table is taken from a work just 
 published by the Goveriuiieiit Statist of New South Wales, and entitled, 
 "Tlie Wealth and Progress of New South Wales" :— 
 
 Expectation of Life at Various Ages. 
 
 Birth 
 
 5 years 
 
 10 „ 
 
 15 „ 
 
 20 „ 
 
 25 „ 
 
 30 „ 
 
 35 „ 
 
 40 „ 
 
 45 „ 
 
 50 „ 
 
 55 „ 
 
 60 „ 
 
 65 „ 
 
 "0 „ 
 
 75 „ 
 
 80 „ 
 
 New South 
 
 Wales, 
 Victoria, 
 
 AND 
 
 Queensland s ^. 
 
 50-3 
 46-2 
 42-1 
 38-4 
 34-7 
 31-0 
 27-4 
 23 -S 
 20-3 
 17-0 
 13S 
 11-0 
 8-5 
 6-4 
 4-7 
 35 
 2-4 
 
 
 M. 
 
 F. 
 
 
 4()-5 
 
 49-6 
 
 
 53-0 
 
 55-4 
 
 
 49-2 
 
 51-7 
 
 
 44-9 
 
 47-4 
 
 
 40-S 
 
 43-3 
 
 
 37 
 
 39-4 
 
 
 33-3 
 
 35-7 
 
 
 29-7 
 
 32-3 
 
 
 26-2 
 
 28-9 
 
 
 22-9 
 
 25-6 
 
 
 19-8 
 
 22-3 
 
 
 16-7 
 
 18-S 
 
 
 13-8 
 
 15-5 
 
 
 11-2 
 
 12-5 
 
 
 8-9 
 
 9-7 
 
 
 6-9 
 
 7-2 
 
 
 5-4 
 
 5-7 
 
 
 4-,) 
 
 4-2 
 
 
 3-0 
 
 3-2 
 
 En(;laxi>. Holland. Belgium. Sweden. 
 
 M. 
 
 P. 
 
 41-9 
 51-5 
 
 48-2 
 
 45-2 
 53-6 
 50'3 
 
 39-9 
 
 42-1 
 
 33'2 
 
 34-1 
 
 26-5 
 
 27-5 
 
 19-9 
 
 20-8 
 
 13-6 
 
 14-5 
 
 se 
 
 9-1 
 
 5-2 
 
 5-6 
 
 2.S 
 
 31 
 
 31-4 
 
 48-7 
 45-9 
 
 38'3 
 
 3i'8 
 
 25-0 
 18-5 
 l^'-8 
 7'9 
 4-4 
 2'4 
 
 36-4 
 49-2 
 46-5 
 
 39-2 
 
 3'2'4 
 
 2(3-4 
 19-7 
 13-3 
 8-1 
 4-5 
 2-7 
 
 M. 
 
 43-8 
 
 44-8 
 
 41-3 
 49-4 
 46-5 
 
 45- 
 53- 
 50- 
 
 3(3-4 
 
 37-7 
 
 38-6 
 
 42- 
 
 30-5 
 
 31-9 
 
 3i'-2 
 
 34- 
 
 24-8 
 
 20-1 
 
 24-3 
 
 27- 
 
 18-9 
 
 20-3 
 
 18-0 
 
 20- 
 
 12-4 
 
 13-9 
 
 12-3 
 
 IS-. 
 
 8-1 
 
 8-3 
 
 7-4 
 
 s-( 
 
 5-2 
 
 5-4 
 
 3-9 
 
 i\ 
 
 2-9 
 
 3-1 
 
 2-4 
 
 2\ 
 
 47-0 
 393 
 32-1 
 25-0 
 18-0 
 li-7 
 6-9 
 3-0 
 
 48-7 
 42-2 
 35-3 
 28'2 
 20-9 
 14-1 
 %h 
 44 
 
 Vide A. F. Biirridge iu "Jounial of Institute of Actuaries," vol. xxiv. 
 
 Summary. 
 
 The following general statements will, in the opinion of the writer, 
 be found to give a fail- summary of the hygienic conditions of the 
 Victorian people : — 
 
 The typical Victorian individual is healthy, but neurotic. He eats 
 far too much meat, lives in a climate characterised by its variability, 
 and generally wears clothing ill adapted to his surroundings. The 
 result is that, upon his endowment, he is rapidly grafting a distinct 
 hepatic tendency. This is accentuated by the fact, that if a drinker, he 
 takes alcohol in greater quantity and more injurious form than the 
 average Englishman. In his favour, however, it must be said that his 
 hours of labour are light, and his social condition and general physical 
 and mental environment such as should conduce to health. In his 
 educational .system, however, sufficient prominence is not given to 
 certain fundamental moral elements. Taken as a member of a com- 
 munity, he would naturally enjoy an unusually long and healthy life, 
 did he not allow himself to be surrounded by numerous preventile 
 causes of disease. His water supply, in the country, is very frequently 
 contaminated by the germs of hydatid disease; and, in the settled 
 districts, it is becoming more and more liable to sewage pollution. It 
 is when we look, however, to his surroundings as a citizen that we meet 
 with the main factors of his corporate ill health. His household con- 
 struction is frequently bad, liis surface conservancy generally worse, 
 and his system of drainage and sewerage always worst of all. Regarded 
 
 li 2
 
 484 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 from .a medico-legal point of view, he is found enjoying the benefit 
 of more valuable legislation, perhaps, than is the case in any other 
 colony ; but, ineffective execution and municipal neglect, combine with 
 individual apathy to deprive him of most of its beneficial results. 
 After all, however, the fact remains, that the expectation of life and 
 death-rate of the community, compare favourably with those of most 
 other civilized countries, though they sink much below what might be 
 reasonably expected. 
 
 In conclusion, a brief resume of the main factors of Victorian disease 
 may not be out of place. In thus giving an individual opinion, the 
 usual terminology adopted on such occasions is discarded, partly because 
 such classifications are always full of errors, but mainly because results 
 and modes of death are therein discussed, rather than actual operative 
 causes. 
 
 I venture, therefore, to advance the statement, that the main factors 
 of Victorian disease are insanitary surroundings, hepatic vulnerability, 
 and climatic variability. The extent to which tliese are present, may be 
 gathered from the foregoing pages. The three are so interwoven in their 
 operations, that their separation is frequently impossible. Giving them, 
 however, a sejDarate existence, it may perhaps be said with justice, that 
 our insanitary surroundings are responsible for the wide extension 
 of typhoid fever and diphtheria amongst us — not to particularise other 
 less common forms of germ disorders — for the prevalence of hydatid 
 disease, and an indesci'ibable amount of general ill health, which 
 assumes many local forms, and upon which the seeds of future disease 
 of many kinds are found to flourish. Similarly, it may be said, that our 
 hepatic vulnerability is responsible for all our liver complaints, for 
 much of our circulatory, renal, and nervous disease, and for a large 
 percentage of our rheumatism. Finally, to the extreme variability of 
 our climate, we owe a vast quantity of respiratory disease, culminating 
 in phthisis; a large proportion of our infant moi^tality, many diarrhceal 
 and hepatic disorders, and the greater portion of our rheumatism. 
 For all further information, as to the extent to which each separate 
 foi'm of disease prevails in our midst, the reader is referred to the 
 reliable and exhaustive tables which formed the l:)asis of Dr. MacLaui'in's 
 most valuable presidential address. 
 
 I cannot conclude without thanking Mr. Ellery, the Government 
 Astronomer; Mr. Akehurst, the President of the Central Board of 
 Health; Mr. Hayter, the Government Statist; Mr. Coghlan, the 
 Government Statist of New South Wales; and Mr. Davidson, 
 tlie Engineer of the Water Supply Department, for the very great 
 assistance which they have afforded me in the collection of much 
 statistical and otlier matter.
 
 THE SANITARY CONDITION OF NEW ZEALAND. 485 
 
 THE SANITARY CONDITION OF NEW ZEALAND. 
 By Leger Erson, L.R.C.P. 
 
 Late Honorary Physician to the Auckland Hospital. 
 
 The health and well being of the GOO, 000 people who are scattered 
 over the wide area comprised under the general heading of New Zealand 
 is, legislatively, under the control of " The Public Health Act of New 
 Zealand, 1876." The machinery which is thus provided, comprises a 
 Central Board of Health, Local Boards of Health, and Road and High- 
 way Boards. The Centi'al Board of Health consists of His Excellency 
 the Governor, the Executive, a retired sea captain, and a medical man, 
 who is also othcial visitor to the various hospitals and asylums of the 
 colony. A Board so constituted, and so busied in many other import- 
 ant duties, cannot be expected to grapple, either energetically or 
 successfully, with the great questions of State medicine. Still, it is as 
 discreditable as it is surprising, to find how little work it has attempted. 
 It has not sent an official communication to the Local Boards of Health 
 for five years, and then only in the form of a few stereotyped questions 
 regarding local sanitation, and without taking any action thereon, 
 although incentives to such action were by no means lacking. The 
 whole burden of the care of the public thus falls upon the Local Boards 
 and Road Boards ; the latter have jurisdiction only in places situated 
 outside the corporate boundaries. Being unofficially advised, and largely 
 com})Osed of small farmers, elected from time to time to superintend 
 such useful work as road-making, etc., they rarely take any steps to 
 enforce sanitary ]n-ecautions; and the utility of their functions does not 
 deserve any serious discussion. 
 
 The health of the people is thus, practically, left in the hands of the 
 Local Boards of Health, or in other words, the various Municipal bodies 
 throughout the colony. The Auckland Borough Council, in its capacity 
 a,s a Local Board of Health, is taken, as giving a typical examjile of this 
 j\Iunici|)al Health administration in New Zealand. The Sanitary Staff 
 and Health Department, for this city of 00,000 people, comprises the 
 City Councillors, a Medical Officer of Health, a Sanitary Engineer, an 
 Inspector of Nuisances, scavengers, and a dog catcher. The drawbacks 
 to constituting a city council a health committee, are everywhere those 
 of connnitting health matters to those who are generally ignorant of the 
 suljject, without time to attend to its requirements, too easily removed 
 from their office, and too likely to be influenced by personal or ijetty 
 motives. These drawbacks, of course, are not absent in New Zealand. 
 Again, that the Medical Officer of Health should be without a si)ecial 
 <|ualification in State n)edicine, and allowed private jji-actice in addition 
 to his official duties, is a state of matters b}' no means confined to New 
 Zealand — however desirable the opj)Osite may be. But it is a gieat and 
 adilitional disadvantage when, as with us, he should receive ])ayment 
 only when his services are asked for, and that his remuneration should 
 be less tlian that enjoyed by a city scavenger. Further, as elsewhere 
 throughout the colonies generally, our Inspectors of Nuisances are 
 appointed rather for their general usefulness than foi- any approved
 
 446 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 knowledge, or experience in sanitary matters. But nowhere else^ 
 j)erhaps, has tliat officer snch an enormous amount of extraneons work 
 as with us. It may amuse readers to know, that he includes the follow- 
 ing amongst his duties : — Dog Registrar, Kerosene Inspector, Inspector 
 of Hackney and otlier Carriages, Inspector of Lodging Houses, of 
 Butchers' Shops, Prosecutor in cases of Breaches of the City Bye-laws, 
 and Issuer of Licenses to Ti'am Drivers and Conductors. He has, also, 
 to supervise the removal of nightsoil, the laying of dust, as well as 
 attend to all correspondence, receive all reports on infectious diseases, 
 and keep a return of the same. Can one wonder, if nuisances do 
 accumulate somewhat, even when the inspector is most anxious and 
 Avilling to remove them ; and can one wonder, if infectious and other 
 disease multiplies also, often to an alarming extent. 
 
 A striking example of how such a Health Committee may labour, in 
 the presence of an epidemic, was given during last season, when the 
 City Fathers, becoming alarmed at the results of sanitary neglect, 
 actually stopped the publication of the health retui'ns, under the pretext 
 of preventing alarm. The public, however, became both alarmed and 
 indignant, and the City Fathers fled to the local Medical Association, 
 confessed their shortcomings, and asked for guidance. 
 
 After due investigation, we found that the whole system of sanitary 
 administration was faulty, insufficient, and delusive ; while possible 
 sources of infection for the typhoid, then prevalent, were ^discovered in 
 almost every municij)al district. The main sewer was not properly 
 ventilated, and discharged itself, close by the frozen meat works, into 
 the harbour, almost adjoining the wharves. Abattoirs existed, full of 
 abominations, not far from the source of the water supply. Human 
 dwelling places were discovered, which only allowed for breathing 
 purposes :250 cubic feet of air for each of the unfortunate peojile who 
 occupied them; untrapped sewers; open side drains, with channels but 
 seldom flushed. Dairies were re[)orted reeking with poisonous exhala- 
 tions, from befouled surroundings of decomposing animal or vegetable 
 filth. Thus we have the eloquent fact, and I ask this Congress to note 
 it, that the Munici})ality of the largest city in New Zealand admittedly 
 confessed their inability to fulfil the duties assigned to them by the Act 
 of 1876, as a Local Board of Health, and had, in their difficulty, to 
 ol)tain the advice and guidance of a body of medical men. 
 
 The condition of aftairs just recapitulated, so far as relates to the 
 Northern c;i})ital, but reflects a similar unsatisfactory state in matters 
 appertaining to the public health throughout the colony. Towns are 
 laid out and Iniilt without due provision being made for sewerage and 
 water supply. Transitions are gradually taking place from the hamlet 
 to the village; the village to the town, and from the town to the city, 
 without a thought being given as to the disastrous eft'ects attendant 
 upon an increasing population, when associated with the steady accumu- 
 lation of insanitary surroundings. It, indeed, appears in many instances 
 as if history would repeat itself, and that no awakening would take 
 place until a succession of dire epidemics decimated and horrified a 
 repentant and alarmed people. From all sides come requests for water 
 supply, and waste ))ipes are placed in every direction, while the 
 petitioners remain ol)livious or careless of the fact, that if adequate 
 sewerage be not provided at the same time, it were far better and safer 
 
 1
 
 THE SANITARY STATE OP NEW ZEALAND. 487 
 
 that the water supply liad never been obtained; since the more sewerage 
 is dihited, the more will it penetrate the soil, and unless let off in proper 
 channels must increase decomposition, and ultimately poison the in- 
 habitants. This will account for the apparent anomaly of some 
 boroughs with no water supply, escaping typhoid; whilst others, who 
 are so supplied, become infected. Independently altogether of the loss 
 of valuable lives and of useful labour to the State, the aggregate cost to 
 New Zealand, which has been attendant upon the absence of proper 
 sanitary administration, must be enormous. One little epidemic cost an 
 already impoverished Town Council a trifle of over £5000 for the care 
 of typlioid victims within the borough. 
 
 The Seaclifie Asylum, which was built at a great cost to the country, 
 had to be almost re-erected, to remedy defects in drainage, which 
 threatened to make the building unlit for human habitation. In like 
 manner, public buildings have been erected and are even now being 
 erected, without proper sanitary inspection or supervision, with the 
 inevitable result, that in a little time they will also be condemned, and 
 upon an already burdened colony will fall the ultimate loss. I found 
 Wellington insanitary, and zymotic diseases prevalent, and that in 
 Dunedin no provision had been made for victims to infectious diseases, 
 although many were reported; whilst the general hospital was built on 
 what is known as made ground, and on principles now generally con- 
 demned for such institutions. I found, in Invercargill, the city laid out 
 on a flat, but three feet above the level of the sea, whilst the wards of 
 the local hospital were ill ventilated, and conveyed to the visitor a 
 sensation of stifling. I found, at Napier, a swamp, which for want of 
 pi'oper di'ainage, periodically injured and endangered the health of the 
 whole community. I found school-rooms so designed, that the rays of 
 light struck the eyes of the pupils obliquely, from windows on the 
 various sides of an octagon. I found public refuges, which upon 
 measurement, allowed but 385 cubic feet of air for the breathing space 
 of the unfortunate inmates, while everywhere, evidences were afforded of 
 the want of ])roper sanitary supervision, and of the truths contained in 
 the fact, that good drains and sewers vvill never be properly constructed 
 until regularly organised Boards of Health have competent sanitary 
 engineers and strict })lumbing laws. 
 
 Now to the conclusion of the matter. It is useless to blame this or 
 that for the spread of zymotic disease, when the whole system of 
 sanitary administration is faulty, inefficient, and honeycombed by 
 iucom])etency. Inflnitely better to go at once to the root of the evil, 
 and relieve Municipal Councils of duties they should never have under- 
 taken. At present, the whole business seems to have a premium laid 
 upon ignorance, since we know that these bodies are, with few excep- 
 tions, avoided by the best colonists as they would avoid leper- houses. 
 
 The sole IMunicipal control of the Public Health, as practically 
 adopted in New Zealand, is but a relic of the old English system, 
 which has long since been discarded in the mother country. It was 
 swept away at the instance of Sir Charles Dilke and the English Local 
 Government Board, with the happiest results; whilst the death-rate has 
 since been lowered to a figure hitherto unknown in the United Kingdom. 
 America also tried the .sole Municipal control system, but there also it 
 was attended with disastrous results, so it has been replaced by the
 
 488 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 establishment, over the length and breadth of that continent, of State 
 Boards of Health, which, being well organised and administered, have 
 already achieved grand results, to the lasting benefit of the great 
 American nation. Canada, in like manner, had a sole Municipal 
 control of health system, to be again rejilaced by the provincial Boards 
 of Health, which are now doing good work all over the Dominion. 
 
 It has been my privilege, Mr. President and Gentlemen, to have 
 travelled in recent years over America, Canada, and many parts of 
 Europe. T would, therefore, desire to bear testimony to the fact, that 
 in no part of the world have I found sanitaiy administration attain a 
 higher standard of efficiency, than in the Dominion of Canada. The 
 svstem, therefore, which commends itself most to my judgment as the 
 best for New Zealand, is a modification of the one adopted in Canada. 
 
 Since there are now engaged in the control of educational matters in 
 New Zealand a Minister of Education, with a large number of School 
 Boards, who are again furtlier assisted by a larger contingent still of 
 School Committees — and as the care of the Public Health is at least of 
 equal importance to any country or people, T would, in like manner, 
 suggest the establishing of a threefold cordon of sanitary administration 
 throughout the colony. 
 
 The first line of defence against the ravages of preventible disease 
 would be the ci-eation of a Minister of Public Health. To him should 
 be submitted, for final adjustment, any differences, when such may arise, 
 between local and provincial Boards ; and he would be held responsible 
 to the Parliament of the colony for the care of the Public Health. 
 
 The second (and, to my mind, the most important) line of defence 
 would be the establishing of a Provincial Board of Health, consist- 
 ing of seven members in each provincial district of the colony. 
 They should be elected triennially; and amongst the members of 
 the respective i)rovincial Boards, there ought to be at least one 
 medical man, a sanitary engineer, and one analytical chemist. Three 
 members of each Provincial Board to be elected by the Governor- 
 in-Council, and the remaining four by the Local Boards of Health, 
 to be hereafter described. The jiowers of the Provincial Boards of 
 Health to be analogous to those now exercised by the Central Boai'd of 
 Health of Victoria, and their relations to the Local Boards to be of a 
 similar character. 
 
 The last line of defence would be the Local Boards of Health, one of 
 which to be established in each town or district containing 4000 
 people and upwards. They should be elected solely for the })urpose of 
 attending to matters affecting the public health within their resjiective 
 districts, whether directly or indirectly, and be guided in all large 
 matters, such as water su})])ly and sewage, by the Board of Health of 
 their provincial district. 
 
 Such, briefly, is the scope and direction of these proposed measures of 
 sanitary reform; measures wliicli, I am convinced, are necessary and 
 essential, not only to the well being of the people, but to the good name 
 of the colony. Doubtless a minister may arise there, and declare as we 
 have already heard here, that public opinion is not ri|)e for the changes 
 indicated. Let the answer be to such political weaklings, that reform 
 should ever j)recede, and not follow, jjublic oi)inion. The cost attendant 
 ujton some of my ])roposals may also be objected to; but compared with
 
 STATE MEDICINE IX WESTERN AUSTRALIA. 4i59 
 
 the great good that would follow their adoption, the outlay bears but 
 little comi)arison, and would repay a hundred fold. New Zealand, once 
 purged from the consequences of sanitary mal-administration, would 
 shew a national longevity, hitherto nuattained by any nation in any 
 clime. Aided by her glorious climate and great natural advantages, 
 this lovely country would then take the ))roud place which a bounteous 
 Providence has apjiarently assigned to her lot, that of being the 
 sanatorium of the Southern Hemisphere, and one of the gardens of the 
 world. 
 
 In conclusion, let me add with Bryce, that if the voice of science 
 be unanimous as to the necessity for sanitary measures being taken 
 in the interests of the Public Health ; if the more thoughtful and 
 intelligent of the public are one in their opinion, as to the desirability of 
 sanitary laws being passed ; if foi-eign states press upon the country the 
 urgency of international quarantine and sanitary legislation, for mutual 
 benefit and j)x-otection ; if statistics from the most civilised states of 
 Europe and America incontestably prove the incalculable advantages to 
 the State, from the annual saving of many lives, and of the expenditure 
 of immense sums of unproductive capital in the treatment of disease and 
 the burial of the dead; if thousands of homes, desolated by the scourge 
 of epidemic diseases, and untold memories, sad and sorrowful at the 
 thought of what might have been, had not pale death cast a sable pall over 
 fair hopes blighted, and {)romises unfulfilled, are not to pass unheeded, 
 then can the wisdom be doubted, the urgency questioned, or the 
 necessity denied, of speedy, thorough, and extended measures being 
 taken by the firm, yet not harsh, hands of the men who guide the ship 
 of State in her appointed course towards the desired haven— the 
 people's good. Can there be any doubt that the people of New Zealand 
 are not only willing, but anxious, for reform in the direction indicated 1 
 
 STATE MEDICINE IN WESTERN AUSTRALIA. 
 
 By J. R. M. Thomson, M.B. Melb. 
 
 District Medical Officer, York, Western Australia. 
 
 In order to render a series complete, I have written the following 
 account of the legislative enactments in Western Austialia with regard 
 to medicine. The "Ordinance to Regulate the Registration of Medical 
 Practitioners " was passed by the Legislative Council in 1869. By this 
 act, provision is made for the registration of medical j)ractitioners on 
 production of diploma ; but there is also a })rovision for the registration 
 and licensing of persons who are not able to produce a dijiloma, if they 
 are able to prove to the satisfaction of the Licensing Board that 
 they are possessed of sufiicient skill in medicine and surgery. There 
 is also provision to punish ])ersons who falsely rejtresent themselves 
 to be qualified. By the provisions of this Act, no unqualified person 
 can recover fees for medical attendance in a court of law.
 
 490 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Other Acts relating to matters affecting the profession are those 
 concerning lunatics, quarantine, vaccination, and public health. I shall 
 treat of these seriatim. 
 
 The Lunacy Act is a copy, to all intents and purposes, of the 
 ordinary enactments on this subject ; it provides for the proper 
 examination of persons alleged to be lunatics, by two medical 
 practitioners, and the form of medical certificate is the same as in 
 England and the colonies. 
 
 Quarantine is also the same as in other British communities ; but 
 there is a " Land Quarantine Act," by which, on the outbreak of 
 infectious diseases, special regulations may be enforced to prevent 
 the spread of infection, by isolating the house in which the disease 
 occurs. 
 
 Vaccination at the age of three months is compulsory in Western 
 Australia ; and on account of the vast extent of the colony, provision is 
 made by the Vaccination Act for vaccination in the more remote 
 districts hy appointing vaccinators occasionally to make special journeys 
 into the country. Inoculation with small-pox virus is an offence 
 punishable by fine and imprisonment. 
 
 The Public Health Act is a recent one. It provides for the appoint- 
 ment of a Central Board of Health, and of Local Boards in the 
 ])rincipal towns of the colony, and such other places as may be 
 recommended by the Central Board. These Local Boards have ever}'- 
 thing to do with sanitation, and their officers are empowered to secure 
 the punishment of oflfenders. 
 
 SEWAGE DISPOSAL. 
 By W. F. Taylor, M.D. 
 
 Diplome iu Public Health, Koyal College of Physicians, Loudon. 
 Member of the Sanitary Institute of Great Britain. 
 
 Judging fi'om the present insanitary condition of many of the cities 
 and towns of these colonies, the subject of sewage disposal does not 
 ai)i)ear to have been fully understood by the various local sanitary 
 authorities. In the following i-emarks I shall endeavour to detail, as 
 briefly as possible, the result of my investigations with regard to this 
 very im])ortant matter: — 
 
 The removal of excreta by water is the cleane.st, most convenient, 
 quickest, and cheapest method in all cases where a public water supj)ly 
 exists. Sir Joseph Bazelgette says : — " There are few who will not now 
 recognise that the removal of the refuse of large towns by water, is so 
 vastly superior to any other known method, as to have caused it to be an 
 essential in these days of civilisation and refinement." 
 
 As channels must necessarily be made for the conveyance of the water 
 used for baths and other domestic purposes, such as washing, cooking, d'c, 
 some urine, and trade products, they can be used with little alteration
 
 SEWAGE DISPOSAL. 491 
 
 for tlie removal of excreta also. Tlii.s does not apply, however, to such 
 cities or towns where the system of surface sewerage pertains; where 
 the water tables of the streets are made to do the duty of sewers, and 
 house drains are not the rule, but the disposal of slop water, by 
 throwing it on the ground at the back of the kitchen, the almost general 
 l)ractice. In such places immediate sewering, with proper house drains, 
 is a crying necessity for the disposal of the slop water, whether the 
 excreta be intercepted or not. And as, in such places, provision is usually 
 made for the removal of the rainfall by means of these water tables and 
 underground conduits, the sewage could be dealt with on the separate 
 system, the advantages of which are fully recognised by all those who 
 have given the subject any consideration. 
 
 On the question of separating the sewage from the rainfall, the 
 evidence given before the Koyal Commission on Metropolitan Sewage 
 Discharge, which sat from July 1882, to October 1884, is pretty 
 conclusive. >Sir Robert Rawlinson says : — " If you had to begin at the 
 beginning and sewer London de novo, the Fleet Ditch should not be a 
 sewer; the Ranelagh River should not be a sewer; all the valley lines 
 should not be sewers. They should have been surface water channels 
 alone, and the sewage should have been intercepted on both sides, and 
 carried into the main outlets which are now provided." INIr. Bailey 
 Denton says, in his work of 1880: — "Experience has established the 
 fact, that no mode of cleansing sewage by tank treatment, or by 
 irrigation over, or filtration through, land, can be effective when the 
 sewage is diluted by rainfall beyond a certain amount. It is easy 
 enough to deal with an outflow from sewers, if the quantity be constant, 
 and is ascertained, but it is quite beyond the powers of any engineer to 
 devise a means of ti-eating liquids swollen by sudden and extraordinary 
 dilution." Colonel Jones also, very experienced in sewage treatment, 
 says: — "The Town Council of Wrexham have found it possible to meet 
 my views, by a very inexpensive diversion of surface water from its 
 former course (of admission into the sewers), direct into a river which 
 intersects the whole length of the town." 
 
 The Commissioners express the following opinion, in referring to the 
 sewage of liOndon : — "We consider, however, that this is a matter of 
 mucli importance as regards the future disposal of the sewage, in 
 whatever way this disposal may be ettected. If it is to be used on the 
 land, or treated chemically, its concentration and uniformity are highly 
 desirable ; and if it is to be carried further away by a long conduit, its 
 volume should, fiom motives of economy, be reduced to a minimum. 
 For these reasons, the separation ought to be effected as much as 
 possible in future extensions of tlie drainage. We are glad to see that 
 the Metropolitan Board are alive to the necessity of this measure." 
 
 Sir Joseph Bazelgette says: — "To carry out such a scheme as I am 
 suggesting, or uny scheme suitable for those districts (the valley of 
 the lower Thame.s), it would be necessary to separate the sewage from 
 the rainfall. The areas are .so large, and the quantity of sewage so 
 small, that it would be impossible to take them together ; they must 
 be taken separately." 
 
 Dr. Alfred Ludlow Carroll, formerly Secretary to the State Board of 
 Health of New York, wrote me as follows : — " We have had in 
 many parts of the countiy a very satisfactory experience of the
 
 492 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 " separate system " of sewerage, wherever it is possible (as it is in most 
 cases) to carry off surface water by surface grades. The modification in 
 construction upon which the success of these chiefly depends, consists 
 in the frequent and thorough flushing of them by means of automatic 
 flushing tanks (usually Field's syphon), discharging from 120 to 140 
 gallons at intervals of from eight to twelve hours. A 6-inch vitrified 
 earthenware pipe will carry the sewage of a considerable population 
 {over 400,000 gallons per diem, with a grade of fifty feet to the mile), 
 and is kept free from filth accumulations by the intermittent flushing." 
 
 This system has been in operation in Memphis (where it was first 
 tried), Keene, New Brighton, Rockaway, aiid other places, for some 
 years, and so far as I can learn, has answered remarkably well, being 
 comparatively cheap and easily worked. A complete description of the 
 practical working of it has been furnished by Mr. Horace Andrews, 
 C.E., in a report to the "Chairman of Committee on Drainage, Sewage, 
 and Topograpliy, Albany. It is the invention of Mr. G'eorge E. 
 Waring, C.E., who has recently written me to the effect that the 
 system has been much improved of late, and is being applied to many 
 different places in America. 
 
 The "separate system" appears to me to meet the requirements of 
 this country much more satisfactorily than any "combined system." For 
 in the case of the latter, the conduits must be made of large size, to carry 
 ofl" the sudden and great rainfall which so frequently occurs ; and these, 
 during periods of dry weather, would only have a small stream of sewage 
 flowing tlirough them, which, if undergoing decomposition, would fill 
 them with noxious gases ; whereas, in the case of the former system, 
 the pipes would never be less tlian half full of sewage, would be well 
 ventilated by the means which Mr. Waring has adopted, of carrying 
 the soil pipes above the roofs of the houses, and doing away with 
 any disconnection between house drain and street sewer, and would be 
 efficiently flushed as often as necessary by the automatic flusliing tanks. 
 
 The disadvantages of a separate system are — that separate channels and 
 pipes Jiave to be provided for the rain ; that the rain from all large 
 cities carries fiom roofs and streets much organic debris, which pollutes 
 the river or watercourse into which it may be discharged. But with a 
 single system the drains require to be much larger, and storm overflows 
 must be provided, sufficient to carry ofl' the storm water when the 
 drains get filled, and with this storm water the whole contents of the 
 sewers are discharged, so the stream would run greater risk of being 
 ])olluted in this way, than if the surface water only were allowed to flow 
 into it. However, the second objection to the separate system has been 
 done away witli by an ingenious contrivance of Mr. Horace Andrews, 
 by means of which the first portions of rain water (containing the 
 foulest parts of the street washings, tfcc), may be intercepted, and be 
 thus i)revented from polluting any watercourse into whicli they would 
 otherwise run. It consists in jJacing an intercepting drain at a lowe)- 
 level than the conduit for rainwater, and so ai'ranged that the contents 
 of the conduit will flow into it until they increase in volume and 
 rapidity sufliciently to shoot over the drain, by which time they are 
 comparatively jiure. 
 
 In a pajjer on "American Sanitation," by John B. Gass, A.R.I.Bd., 
 read at the Congress of the Sanitary Institute of Great Britain, held at
 
 SEWAGE DISPOSAL. 493 
 
 York in September 1886, he says :— "Memphis is the best known and 
 largest example of the application of the result of the investigations 
 in various cities, by order of the United States National Board of 
 Health. In these cities, the main sewers were gauged to determine 
 the actual size of pipes needed for the removal of the greatest 
 amount of foul sewage matter only, produced under various circum- 
 stances. These gaugings show conclusively that for foul sewage matter 
 for a large jiopulation, main di'ains of only small diameter ai'e necessary. 
 
 Colonel Waring, of Newport, R. I., the engineer who designed the 
 JMemphis sewage scheme, communicated a paper to the Sanitary 
 Institute, in September 1880, giving a full account of this work : — "It 
 has now been in use over four years, and the practical working appears 
 to have been very satisfactory. To recall the main features, 1 may 
 say that Memphis is a city on the Mississii)pi, of between forty and 
 lifty thousand inhabitants. The main drainage system is for foul 
 sewage only, and when complete, will have a total length of about 
 forty miles. There being very few cellar."., and the ground having a 
 good natural fall, the drains were laid about six feet deej). No outlet 
 drain from any house was allowed more than four inches in diameter, 
 the tributary mains being eight inches and six inches in diameter, 
 and the two mains commencing from eight inches diameter and 
 increasing to twelve inches and fifteen inches diameter, all being of 
 socketted glazed pipes. The two mains are joined together into a 
 twenty-inch brick sewer, which has swicches turning the drainage into a 
 three-foot iron pipe for the high water outlet, and into a twenty-inch 
 iron pipe for the low water outlet— the extreme variation in the river 
 being thirty-five feet. On the main lines, man-holes have been put in 
 at intervals. No house connection is trapped, but each has an 
 unobstructed ventilator reaching to top of roof ; this gives vent to 
 about thirty feet of sewer. Every slop stone, water-closet, sink, &c., 
 has an independent trap ; hopper closets are insisted on ; the sanitary 
 regulations are very strict ; and all plumbing work is inspected by 
 engineers. The whole system is flushed daily or half dail}- with about 
 one hundred and fifty Rogers Field's well-known automatic flush tanks, 
 supplied with town water, and placed at the dead end of every branch, 
 to thoroughly flush each length ; each flush tank discharging one 
 hundred gallons in forty seconds, thoroughly scours the pipes. The 
 subsoil drainage is by agricultural drain tiles one inch to three inches 
 in diameter, laid beside sewei-, and in the same trench ; these dischai'ge 
 into the nearest watercourse, or, on very level ground, into the main 
 sewer, with special precautions against sewer water backing up. Storm 
 water is removed by surface gutters, with outlets through shallow 
 conduits, easily accessible." 
 
 On this system, there have been ofiicial reports bv Mr. Gardiner, for 
 the Board of Health, New York State ; and Mr. W\ H. Baldwin, C.E., 
 the latter dated March 29, 1884. The following is a summary of these 
 reports, with regard to the working: — " In the mains, from ten inches and 
 over, a deposit is found of tine silt, supposed to be mud and paper pulp; 
 this is cleaned out about once a month, by rope and steel brush being 
 dragged through from man-hole to man-hole. In the lateral sewers, there 
 are very few stoppages; when stoppages occur, they are from schools 
 or shops only, and in pipes six inches in diameter and under, and are
 
 494 IXTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 caused by sticks or pieces of metal getting crosswise in the pipes. For 
 stable washings, catch pits have been found necessary. A few T clean- 
 ing pipes have been inserted, and hand holes are now put in all 
 extensions 100 feet apart. Some of the sewers are 2000 feet from the 
 mains, and the longest lines generally run about a quarter full. Over- 
 flows have had to be provided, for taking the water in winter, when the 
 water taps are left running in the houses to prevent them freezing. 
 Neither in removing obstructions, in cleansing the main sewers, nor in 
 connecting with house drains, is the odour of sewer gas ever observed. 
 This system was adopted at Keene, N.H., and executed in 1882-3. I 
 am informed that it is working well, though the greatest fall is only 
 four inches in 100 feet, and the lowest fall being -^-^ inches in 100 feet, 
 and that line nearly two miles long. It is also being used in parts of 
 Paris and other places, and may, I think, on a large scale, be considered 
 a success." 
 
 TJie "separate system" offers a very great advantage over the 
 single or combined system, in places where the sewage has to be 
 raised to a higher from a low level ; the quantity being nearly uniform, 
 the pumping machinery could be easily regulated to meet all require- 
 ments. Mr. Isaac Shone's system of pneumatic ejectors would, however, 
 in many cases answer this purpose better than pumping. It consists in 
 forcing the sewage, by means of compressed air from iron tanks, termed 
 ejectors. At a central station an engine is placed, which forces air 
 under a pressure of sixty five pounds to the square inch, into air 
 compressors, consisting of large vessels made of boiler plate iron. From 
 these, pipes lead to the ejectors, which may be placed at different points 
 of the town; the distance at which they are placed from the central 
 station being practically of no importance, as it is said, very little loss of 
 power ensues, no matter how long the pipe may be. The ejectors are 
 iron vessels of about 600 gallons capacity, having an inlet for the 
 sewage which flows into them by gravitation, and an outlet for the 
 discharge. When the ejector is full, the compressed air is admitted by 
 an automatic arrangement, which opens the valve of the air pipe, and 
 shuts it again when the ejector is emptied. A ball valve prevents the 
 sewage being foi'ced back into the sewer. The height to which sewage 
 or water can be lifted by this means is i)ractically unlimited. The town 
 can l)e completely sewered on this principle, ejectors being placed at 
 certain cross streets to receive the sewage of a number of houses, the 
 sewage being forced into and along air-tight main sewers to the outfall. 
 At Eastbourne there are seven pneumatic ejectors, which ai"e supplied 
 with compressed air from one station, one ejector being about two miles 
 from the station. The cost of working the system at Eastbourne, the 
 sewage of which is entirely managed by it, is £600 per annum ; the 
 total cost of plant, land, houses, tfcc, being .£8500. Eastbourne is, for 
 the most part, about twelve feet below the level of high water, yet the 
 low lying part is as well and efficiently drained by this system as the 
 higher parts are by gravitation, the sewage being lifted sufliciently high 
 to flow by gravitation into the sea. The mains being air-tight, there is 
 no danger of sewer gas escaping. 
 
 The disposal of sewage at the outfall is a matter of serious considera- 
 tion, and the method must differ with the position and other circum- 
 stances of the place. When possible, it should be discharged directly 
 
 I 
 
 t
 
 SEWAGE DISPOSAL. 495 
 
 into the sea, its manurial value being less than the cost of applying it 
 to land. Its value as a manure may be gathered from the fact that, in 
 100 tons of sewage of average quality, the susi)ended matters are worth 
 2s., and the matter in solution, 15s. = 17s. in all, or about 2d. per ton 
 theoretical value, or less than ^ of a penny actual value. Sir R. 
 Rawlinson says : — " Sewage, to have value, must have certain natural 
 facilities, such as cheap land and a free outlet to the sea. If the sewage 
 of London is to be valued (at what it is worth) all the year round, you 
 could not ])ut more than I a penny to a ton on it." Dr. Meymott Tidy 
 says: — " The local authorities always will get it into their heads that 
 they ought to make their sewage pay, whereas sewage is a great ugly 
 thing that one has to spend money on to prevent its being a trouble 
 and a cause of nuisance." Sir Frederick Abel, C.B., says : — "That it 
 is impossible to deal with sewage in reference to its manurial value. 
 The only real method of disposing of sewage is to carry it out to sea." 
 
 In considering the question of disposal of the sewage of any place, 
 that plan should be ado))ted which will be the least costly and most 
 efficient — i.e., efficiency and cheapness should be solely considered, and 
 all idea of utilisation for manui-ial purposes dismissed. 
 
 Storage in Tank with an Overflow. 
 
 The sewer water runs into a cemented tank with an overflow pipe ; 
 the solids subside, and are removed from time to time ; the liquid is 
 allowed to run away, either into a ditch or stream, or is conducted in 
 drain-pipes half to one foot under ground, and escapes into the subsoil, 
 where it will be readily absorbed by the roots of grasses. The fat, 
 grease, and coarser solids, may be intercepted by a strainer, and the 
 liquid portion may be discharged automatically by means of a flush 
 tank (Field's). The plan is only adapted for a small scale, and when 
 the .soil is light. It may be used for a single house, or a small village, 
 for the slop water, even where the excreta are removed by the dry 
 method. The tank should be ventilated by a shaft leading up a tree, 
 and there should be a well-ventilated disconnecting gully between the 
 house-pipe and sewer. 
 
 Discharge at once into Running Water. 
 
 All new works of this kind are ])roliibited in Great Britain, and the 
 tendency is to do away with the plan altogether. The injury to rivers 
 by turning sewage into them is of three kinds : — (1) Sediment whicli 
 forms banks of mud ; (2) destruction of fish (fish will live in fresh 
 sewage, but not in stale) ; and (3) emanations into the air of gases. 
 
 Precipitation. 
 
 The solid part of the sewage is precipitated before the liquid is 
 allowed to pass into the stream, or over the land. This is sometimes 
 done by subsidence, the sewage being made to pass through strainers 
 into a settling tank ; but usually, some chemical precipitant is also used. 
 A variety of substances have been employed as precipitants, such as 
 lime, salts, albuminous substances, charcoal, alum, blood, clay, charcoal, 
 manganese, &.c. ; the A. B.C. process — perchloride of iron, sulphate of 
 zinc, permanganate of soda, ikc, and the effluent is more or less
 
 496 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 satisfactory. Mr. Dibdin (consulting chemist to the Metropolitan Board 
 of Works), maintains however, that the dissolved organic matter is not 
 aiFected to any appreciable extent by chemical treatment, the sewage 
 being merely clarified, the clearness of the effluent, i.e., the degree of 
 removal of the suspended matter being dependent on the quantity of 
 of such chemicals used. 
 
 Chiswick offers an example of the chemical treatment of sewage, 
 without any subsequent filtration through land, the effluent being 
 rendered sufficiently pure to permit of its discharge direct from the 
 settling tanks into the River Thames, above London. Lime and alum 
 are the chemicals used, in the proportion of 11 grains of the former, to 
 7 grains of the latter per gallon. The lime is first mixed with the 
 sewage by means of a revolving mixer, and the sewage passes into the 
 pump-well, and then has a run of 300 feet before it is mixed with the 
 alum. It is then run into tanks and allowed to precipitate for three 
 hours, and the effluent run off into the river. The sludge is turned into 
 a small tank at the rear of the sludge-press shed, and is then passed 
 through a Tobinson's pneumatic sludge-press, which turns out 24 cakes, 
 of 5 libs, each at a time, a bag of slacked lime being added to eacli lot. 
 The sludge cakes are sold as a manure at Is. 6d. per ton. 
 
 '•' Broad irrigation means," says Mr. Edward Piitchard, " the applica- 
 tion of a minimum quantity of sewage upon a maximum area of land, 
 l)y which we obtain the greatest amount of utilisation combined with 
 purification, that enables the crops to be grown upon the land, at the 
 same time that the sewage is treated, and the land purified." The land 
 is cropped principally with Italian rye grass, but root crops, such as 
 mangolds, turnips, &c , are also grown. The sewage water passes over 
 and through the soil, and is thus brought under the influence of growing 
 plants, a very good clean effluent being the usual result in the case of 
 well-managed farms. 
 
 When the sewer water passes through the soil, there occurs — First, a 
 mechanical arrest of suspended matters; second, nitrification. — Dr. 
 Thomas Stevenson says: — "There is no agent which so efficiently 
 deodorises sewage as the soil, which acts not only as a checker of 
 ])utref action, but also absorbs the gases of sewage; and further, is the 
 nidus of the well nigh demonstrated nitrifying agents — i.e., the bacterial 
 organism by which ammonia and nitrogenous organic matter, imme- 
 diately, or through the intermediate stage of ammonia, are converted 
 into nitrates." Third, chemical interchanges. — The soil I'equii'es to be 
 deeply ploughed, or dug with a spade, and otherwise properly prepared. 
 In the case of a light soil, ploughing will probably be sufficient; but in 
 clay soil, underground drainage, and the a])plication of ashes or ballast 
 (l)urnt clay) may be necessary. The land should have a gradual slope, 
 and be levelled of all its irregularities. The sewage is allowed to flow 
 into main carriers constructed of concrete, earthenware, or trenches dug 
 into the ground, and from these it is carried by subsidiary carriers to 
 different parts of the land. By a simple arrangement, any carrier 
 may be blocked, and the sewage allowed to flow on to the ground below, 
 and thus its distribution may bo regulated. The heavier suspended 
 matters in the sewage are usually removed l)y passing it through strainers 
 and subsidence tanks, the sludge being removed, and dug into the 
 ground. By pro[)er attention to detail, a sewage farm may be managed
 
 SEWAGE DISPOSAL. 497 
 
 SO as to be free from disagreeable odours, and any danger to health. At 
 some farms, the sewage is chemically treated, to increase the precipitation 
 of the suspended matters. 
 
 Sir Robert Rawlinson, C.B., stated before the Royal Commission 
 referred to — "That in Doncaster 1,000,000 gallons of sewage per day 
 were put on the surface of the ground, and that no effluent could be 
 seen. And also in Bedford, the same quantity was put in sandy soil, 
 with a similar result. They have discountenanced the use of tanks 
 at Doncaster, the sewage being pumped directly into the carriers." 
 Examples of the treatment of sewage by " broad irrigation " are to be 
 found at Croydon — the Beddington Farm, consisting of between five and 
 six hundred acres, receives the sewage of a population of 60,000; South 
 Norwood, with an ai'ea of sixty acres, receives the sewage from 12,000 
 peo[)le ; and Tunbridge Wells, which has a population of 26,000, and 
 the sewage of which is disposed of by two farms of 205 and 125 acres 
 respectively. 
 
 On the subject of Broad Irrigation, the Commissioners alluded to, 
 state : — 
 
 (1) That generally speaking, it offers a satisfactory mode of disposal 
 of town sewage, when circumstances admit of its application. 
 
 (2) That it offers the mo.st likely means of realising some portion of 
 the value of the sewage. 
 
 (.3) That when properly arranged, and carefully conducted, the 
 effluent will be effectually purified ; but that under careless management, 
 the purification will be incomplete. 
 
 (4) That it need cause no danger to health. 
 
 (5) That with proper care, when applied on a moderate scale, it need 
 cause no serious nuisance to the surrounding neighbourhood; but that 
 if improperly managed, nuisance may arise, and may become considerable. 
 
 (6) That there may be a danger of the pollution of subsoil waters. 
 
 Intermittent Filtration. 
 
 The Croyden Rural Sanitary Authority dispose of the sewage from a 
 population of 21,000, by filtering it through a filter-bed consisting of 
 twenty -eight acres. The ground is underdrained to a depth of from four 
 to six feet. The drains are twenty feet apart, and consist of six-inch 
 socketed pipes. Grass is grown on the filter-bed. Irrigation may be 
 combined with filtration, and chemical precijntation may be combined 
 with either, or with both. 
 
 In a paper on the " Sheffield Corporation Sewage Works," read by 
 Mr. John Merrill, at the Congress of the Sanitary Institute of Great 
 Britain, in September 1886, he gives the following description of the 
 intermittent system of precipitation as in operation at Bradford and 
 Sheffield :— 
 
 " The works cover about seven and a half acres, and consist of a main 
 building and thirty tanks, each having a capacity of 50,000 gallons, 
 together with an oxidising weir and two filters to each tank. The 
 process may be said to consist of four parts or sub-processes — subsidence, 
 precipitation, oxidation, and filtration. 
 
 *' The sewage enters the works, and flows through four deep subsi- 
 ding tanks ; these act also as catch-pits, as well as separating the heavier 
 
 Ik
 
 498 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 solids contained in the sewage. The reasons for this separation of the 
 heavier solids are threefold : — Firstly, the heavier solids form a compost 
 •which can be readily and easily got rid of ; secondly, the quantity of 
 sludge from the precipitating tanks is thereby reduced; and thirdly, the 
 separation of the heavier from the lighter solids abolishes all nuisance 
 in the drying. 
 
 " From the subsiding tanks, the sewage flows forward under the 
 main building, and receives the milk of lime. It then flows through a 
 conveying channel, which serves also as a mixing chamber, where by a 
 beautifully simple and ingenious arrangement, the lime is most 
 thoroughly mixed with the sewage without the use of any machinery 
 whatever. So intimate is this mixture, that the quantity of lime has 
 been reduced from one ton per million gallons to fourteen cwt., a 
 saving of about one-third. The sewage is then admitted into the 
 precipitating tanks, which are the most important feature of this process 
 (first introduced by M. Alsing at Bradford), and from which it takes 
 its name of "intermittent precipitation." 
 
 " As soon as a tank is full, the flow is shut off", and the sewage allowed 
 to remain comjoletely at rest. The advantages of this method of treat- 
 ment are very great; by it, we are able to get rid of every trace of solid 
 matter, which cannot be done when a constant flow is maintained. 
 
 " In the Shefiield Works, twenty-five minutes after a tank is filled, 
 complete precipitation has taken ])lace, and the clarified sewage is as 
 bright, clear, and colourless as spring water, and contains not a trace of 
 solid matter." 
 
 The next feature of the works is one entirely novel, namely, the 
 oxidation of the eflEluent. Oxygen is the great purifier, and to quote 
 the Glasgow report — " If an efiluent is brought into contact with oxygen, 
 either by churning it up with air, or passing it over numerous falls, or 
 exposing it in a thin stratum to the air, it speedily becomes inodorous, 
 and no longer putrescable." 
 
 The problem, however, has been solved in the Shefiield works, by the 
 establishment of weii'S— one to each tank. The clarified sewage runs 
 from the tanks in a very thin stream over a weir, with a slight fall, 
 exposing a very large surface to the air. From the weirs, the sewage 
 runs through two filters, downward and upward. The filters are so 
 constructed that, after a tank is run off", the filters used can be com- 
 pletely emptied of liquid, and allowed a period of rest, so that the 
 filtering material becomes re-charged with oxygen. The sludge runs by 
 gravity from the tanks into a collector, from whence it is pumped into 
 open air drying ponds. These ponds ai-e placed at a higher level than 
 the tanks, consequently, the supernatant liquid can be run back into the 
 tanks, and treated over again. 
 
 Mr. Merrill sums up the advantages of the intermittent system to be 
 — " Simplicity, great efiiciency, small tank area required, economy of 
 both construction and in working — cost of Shefiield works £32,000, 
 and working expenses about £5000 a year." 
 
 The solid excreta appear to be a great bugbear to most local authori- 
 ties ; but their admission into the ordinary sewage does not chemically 
 affect it, as it is well ascertained that the sewage of a non-water-closeted 
 town does not differ chemically from that of a water-closeted one. Dr. 
 Thomas Stevenson has stated that the composition of sewage varied 
 
 I
 
 LEPROSY. i99 
 
 much less tlian luight be ex})ected, and the difference was one vatlier of 
 degree than of kind ; that there was little difference between the sewage 
 of a water-closeted town and a non-water-closeted town (see Lancet, 
 May 9, 1885). 
 
 The average amount per head per diem of moist excreta is, in Europe, 
 2^ ounces, equal to 1 ounce dry ; which, if added to 30 gallons of water 
 — the average water-su{)ply per head per diem of London — Avould repre- 
 sent an addition of only 15 grains of solid matter to tlie gallon — i.e., 15 
 grains to 10 lbs. — a mere fraction. Home provision must be made for 
 carrying off the urine, which amounts to an average of 40 to 50 ounces 
 per head j)er diem ; and as we now know that the bacilli of typhoid 
 fever are to be found in the urine, it is not so innocuous as hitherto 
 supposed. 
 
 From the foregoing, it is apparent that no valid reasons exist for 
 intercepting the solid excreta from ordinary sewage. All intercepting 
 methods fail more or less in effecting their object. They are expensive, 
 and contribute, in a great measure, to engender those habits of constipa- 
 tion, which are so common among such a large section of the female 
 population of non- water-closeted towns. 
 
 LEPROSY : IN ITS RELATION TO THE EUROPEAN 
 POPULATION OF AUSTRALIA. 
 
 By John M. Creed, L.R.C.P., M.R.C.S. 
 
 Member of the Legislative Council of New South Wales. 
 
 It is not my intention, nor do I think it will be the desire of the 
 Members of the Congress, that I should enter very deeply in this j)aper 
 into the pathology and symptoms of leprosy, my object being to point 
 out in a concise mode, the amount of danger to which a community such 
 as that of these Colonies is exposed, by the presence in it of the few 
 lepers which are now here. I think that only good can follow an 
 attempt to point out how comparatively ungrounded is the unreasoning 
 terror in which this disease is held by most non-professional persons, 
 and to show that the danger of infection is comparatively trifling. 
 
 I do not, however, for a moment wish it to be understood, that I do 
 not think the disease a terrible one for its unhappy victims when once 
 infected. Leprosy may affect any portion of the body. It is essentially 
 a constitutional disorder, indicative of a cachexia, or depressed condition 
 of the general system. Its outward manifestation occurs in three forms 
 — the tuberculated, the maculated, and the ansesthetic. One, or all, may 
 be present in the same subject at the same time. In lepra maculosa, 
 the first symptoms are the appearance on the skin of spots varying in 
 size, having an area of from half a squai-e inch, to five square inches or 
 more. At first the colour is light red, disappearing on pressure. This 
 by degrees gets darker, gradually increasing in intensity until it becomes 
 
 Ik ?
 
 500 INTEKCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 a dark brown. The surface of the spot is shining and .smooth, and the 
 skin feels like fine velvet. The latter characteristic, Hebra considered 
 absolutely diagnostic. The affected part is not much elevated, but 
 between the fingers the skin feels hardened and thickened, and is 
 sometimes very sensitive. The spots are generally situated on the trunk 
 and limbs. They grow peripherically, the centie turning into yellow 
 brown, while the fresh outer jjortion is red and slightly swollen. They 
 never perspire. The whole spot may disappear. 
 
 In lepra tuberculosa, the nodules may grow out of the spots of the 
 last form, or they may appear independently, they may vary in size 
 from a shot to a walnut, they generally first appear on the face, and are 
 almost always in the gieatest proportion on this part. The face is 
 broadened, puffed, and brown or red in colour. On the tubercles, the 
 hair is thin or completely lost. The nose is genei-ally thickened, and as 
 well as the lips, covered with knots. The lobes of the ears are converted 
 into thick, rugged masses. The tubercles may appear on all parts of 
 the body and limbs. Next to the face, however, the hands and feet 
 show the most striking appearance ; they become deformed ; the digits 
 are enlarged, especially at the tips, and are frequently ke})t apart by 
 their thickened extremities ; the joints become stiff and often immovable. 
 The knots may atrophy, be re-absorbed, or turn into abscesses and 
 ulcerations. Destnxction of the tissues sets in, and portions of the 
 hands or feet may be spontaneously amputated, and death ensue after 
 some years, according to Drs. Danielssen and Boeck, on an average in 
 about nine or ten, though many })atients live for many years, and 
 occasionally life is jirolonged to old age. Lepers, however, do not 
 usually die directly of leprosy, but of diarrhoea or dysentery, of inflamma- 
 tion of the lungs or air passages, or of disease of the kidneys. In these 
 varieties of leprosy, neuralgia is said to be a special symptom ; but 
 leprous neuralgia seems to be limited to the ulnar nerve, a little above 
 the inner condyle of the humerus ; to the auricularis magnus nerve on 
 the sterno-mastoid muscle, and to the posterior tibial nerve along its 
 course ; but the ulnar nerve is attacked by this neuralgia most frequently 
 and most severely. These nerves may be felt even in the early stages 
 of the disease, when there is no neuralgia, to have assumed a tense cord- 
 like character. Marked changes have been noted on post-mortem 
 examination in the nerves of lepers, by Drs. Danielssen and Boeck of 
 Norway, and Dr. Carter of Bombay, the latter's more exact observations 
 confirming those of the former. 
 
 The third form, lepra ansesthetica, is, as a rule, associated with one or 
 both of the others, but it may occur alone. When it is the original 
 form, large vesicles first appear on the skin, which will, probably, be 
 mistaken for pemphigus, and for a time the sensibility of the skin 
 remains normal, but subsequently, the seats of the vesicles lose all 
 feeling. The anaesthetic spots may appear on an otherwise apparently 
 healthy skin, so that patients first gain a knowledge of it by medical 
 examination, or by the painless result of some accident, for they may 
 burn, scald, or cut themselves without being conscious of it, except from 
 seeing the thing happen. This insensibility is not confined to the skin, 
 but extends to the deeper tissues beneath the anaesthetic spots. 
 
 The disease may make its a])pearance at any period of life, even in 
 early childhood, but from the age of puberty to that of maturity is the
 
 LEPROSY. 501 
 
 more general time of its incidence. Until the discovery of the bacillus 
 of leprosy, those observers who had the best means of judging, with few 
 exceptions, were of opinion that the disease was non-contagious ; and the 
 numerous examples given, of continued intimate association for years, 
 even as husband and wife, by healthy persons witii lepers, without the 
 transmission of the disease, gave such support to this view that it was 
 practically incontestable. The ])resence of this specific germ, however, 
 gives such support to the opinions of those who believe that it is 
 contagious, that I think ])robability is in accordance with this view. 
 At the same time, the difficulty of transmission is so great, excepting 
 under circumstances extremely favourable to the development of the 
 disease, that there is but little danger of infection to the white popula- 
 tion of these colonies. The long period of incubation, often many years, 
 renders it the more difficult to decide this question positively. A case 
 is (juoted from Borneo, in which a boy, having thrust a knife into an 
 anaesthetic spot of a leprous child, afterwards incised with it his own 
 thigh. He had no further dealings with lepers, but nineteen years 
 afterwards developed the disease. Dr. Massanao Goto, a Japanese 
 physician educated in European medicine, stated in his graduation 
 thesis at the Cooper Medical College in San Francisco, that, by the 
 permission of the Hawaian Government, an attem])t was made to 
 reproduce leprosy in a convict, by inoculation with leprous matter, but 
 that two years afterwards lie had developed no signs of the disease. 
 According to the same gentleman, who was practising in the Sandwich 
 Islands, and ))aid great attention to leprosy, the disease was unknown 
 there until 1859, when it first occun-ed in the persons of two Chinese 
 coolies; but in 1884 there were upwards of 1200 lepers, about IS per 
 cent, of the ])opulation in this grou]) of islands; 721 of whom were, in 
 that year, confined in the leper settlement of Molokai, and 186 in a 
 branch hospital in the suburbs of Honolulu. About 300 more were met 
 with by him in his private practice, who were not under Government 
 su))ervision. 
 
 In view of the fact that, in twenty-five 3'ears, the disease manifested 
 itself in 1-5 per cent, of the population, it is impossible to deny that it 
 must be communicable by contagion or infection ; but when this is 
 considered, it must be borne in mind how extremely favourable for the 
 development of the disease are the conditions of life of these people. In 
 the Report of the Committee on Leprosy, of the Koyal College of 
 Physicians, are given a numljer of instances, by various observers in all 
 ])arts of the world, of the most intimate relations having existed 
 for years between healthy ])ersons and others suffering from the disease, 
 without its being conununicated. Dr. Goto made careful inquiry as to 
 hereditary transmission in leprosy, and succeeded in collecting sufficient 
 data in Japan to show that the disease occurs from hereditary trans- 
 mission in about fifty per cent, of cases. Leprosy, when inherited from 
 the mother, is more severe than when inherited from the father ; and is 
 more severe when inherited fi-om both ))arents, than from one alone. 
 The disease may skip a generation or more, to re-appear in later 
 descendants, who have it in a milder form. This physician, as well as 
 otlier observers, are of opinion that the presence of constitutional 
 syphilis increases the susceptibility to leprosy, and that in those cases in 
 ■which hereditary leprosy is latent in an individual, the infection of
 
 502 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 syphilis will bring it into activity. He claims considerable success in 
 the treatment of the disease, and is said to have cured several cases. 
 The Japanese Mail says — " Dr. Arai Saku, a Japanese practitioner, who 
 has charge of the Shusai Hospital, has been most successful in treating 
 cases of leprosy amongst his countrymen. It is said that this was made 
 known to the Indian Government, and resulted in their writing to Dr. 
 Arai Saku, to invite him to go over to India, and there try his hand on 
 confirmed cases." It must not be forgotten, that the practice of 
 medicine in Japan is of the most advanced European type, and that its 
 conduct is regulated by Im])erial decree as to study and qualification for 
 practice, far in advance of the regulations in these colonies. 
 
 The disease is found in all parts of the world, and under the most 
 diverse circumstances of climate, latitude, and mode of life but in every 
 place where it is present, the conditions of life of the people are such 
 as to lower vitality. It is found so far from the equator as 70° north, 
 and in such cold countries as Iceland, . Norway, the Baltic provinces of 
 Russia, and New Brunswick ; but it is perhaps more pi-evalent in 
 the warmer climates, and in damp, low-lying situations. In the middle 
 ages it was common in all the countries of Europe, including Great 
 Britain and Ii-eland, in which latter country it was prevalent until 
 the close of the seventeenth century. The disappearance of the disease 
 in the countries of a higher civilisation, is accounted for by the vast 
 improvement which has taken place in the food and dwellings of the 
 people during the last two or thi-ee centuries. Prior to this, for at 
 least six months of the year, the entire animal food of the population 
 consisted of salt meat or fish, often in a semi-putrid state ; whilst 
 wheaten bread was an unknown luxury to the majority, and fresh 
 vegetables were unprocurable, except in the summer months. The 
 dwellings were unventilated and often filthy in the extreme, the I'ushes 
 or straw with which the floors were strewed being frequently left until 
 they were rotten before removal — this insanitary condition being added 
 to by the debris of food dropped or thrown down by persons eating. 
 Personal cleanliness was almost an unknown thing in those days, no 
 greater proof of which can be advanced than the curious fact brought 
 into prominence by " Saint Beuve," in a review of the diaries of 
 the physicians of Louis XIV. of France. Of this monarch it is recorded, 
 that after childhood he took but one bath, which he found so distasteful, 
 that he vowed he would never take another ; and it is believed he 
 kept his word. When such a thing is recorded of so great a personage 
 — the head of the most refined court of Europe at a comparatively late 
 period — what must have been the condition of the lower classes during 
 the time in which leprosy was prevalent on that continent. Even in 
 the great houses, men slept on straw in the large hall, often with a 
 common covering ; whilst clothes were made of such lasting material, 
 and were so passed from one to another, as must have greatly aided the 
 transmission of disease of all kinds. These clothes it must be remem- 
 bered were worn, by at all events the lower classes, without body-linen. 
 
 As to the conditions under which le[)rosy exists in these times, we 
 have the fullest information in the answers to the interrogatories put 
 by the Committee of the College of Physicians, of London, who made 
 inquiry some twenty-five years since. Almost without exception, the 
 answers show that the disease rarely attacked any but persons living
 
 LEPROSY. 503 
 
 under conditions of the most insanitary kind; and that in the majority 
 of instances, it showed the greatest activity where the diet consisted 
 principally of salt tish, often semi-putrescent, with dry vegetable food, 
 mainly consisting of inferior and damaged gi'ain ; and that in those places 
 where the patients had had a fair supply of fresh meat, there had been 
 a complete absence of fresh vegetables. 
 
 In Hawaia, where the spread of the disease has been more rapid than 
 anywhere else, the staple diet is chiefly vegetable, with fish ; the former 
 is generally prepared so as to be in a fermented or even partially putrid 
 state before being eaten. Dr. Thomson^ surgeon to the 58th Regiment 
 in 1853, accounted for the presence of leprosy amongst the Maories by 
 their neglect of personal cleanliness, and their fondness for putrid 
 vegetable food. He says that the disease was more common just in 
 proportion to the fondness of the people for this kind of diet. He 
 remarks that " since the improvement in the condition of the New 
 Zealanders by intercourse with Europeans, the disease is becoming 
 rare." 
 
 In Australia, in 186-5, there were no known lepers, except in Victoria, 
 which at that time had thirteen. To the present time, there have been 
 none known in South Australia or Tasmania, and the number has 
 decreased in Victoria to five, but there are now ten in New South 
 Wales, and several in Queensland — the exact number I have been 
 unable to ascertain from the health authorities of that colony. The 
 lepers in the older colonies are all Chinese immigrants, with two excep- 
 tions — one of whom is a Malay, a native of Java ; the other a young 
 European, aged twenty-seven, born in Sydney. The latter is, as far as 
 I can ascertain, the only instance of a white leper known in Australasia, 
 except the young daughter of a British oflicial in a South Sea island. 
 His is a well-marked case of the tuberculated variety, but little informa- 
 tion can be obtained from him as to the probable source of his disease. 
 He, however, denies all intimate association with the Chinese. 
 
 To summarise, I submit we may fairly assume : — 
 
 (1) That the disease is contagious, but only under circumstances 
 (extremely favourable to its propagation) which lower the vital powers 
 of the persons exposed to it ; and that there is no real danger to persons 
 who live with good sanitary surroundings, have a fitting, wholesome 
 diet, and are personally cleanly, however intimate their association with 
 the lejjer is. 
 
 (2) That the disease may be hereditary, but frequently skips genera- 
 tions, and becomes less severe as the descent becomes remote. 
 
 (3) That the presence of constitutional syphilis increases the liability 
 to the disease. 
 
 (4) That though very intractable, it is not incurable, and that cases 
 improve under treatment ; and there are occasionally instances of 
 spontaneous cure. 
 
 (5) That there are other diseases much more dangerous to life and 
 health rife in these colonies, and that there is no just reason for the 
 unrea.soning dread and horror in which leprosy is held by the majority 
 of the people.
 
 504 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 SHORT ACCOUNT OF THE CLIMATOLOGY OF NELSON, 
 NEW ZEALAND; AND THE DISEASES FOR WHICH 
 IT IS MOST SUITED. 
 
 By J AS. Hudson, M.B. Lend. 
 
 The town of Nelson is situated at the head of Blind Bay, in about 
 41 J parellel of south latitude, almost exactly the same latitude as the 
 City of Wellington, and right in tlie course of the westerly winds ; yet, 
 while Wellington is so windy, that it is often spoken of as the " City 
 of Blow," Nelson is comparatively free from wind. 
 
 The reason for this is seen in the disposition of the Mountains. The 
 main range of the Southern Alps, the backbone of the Middle Island, 
 about eighty miles south of Nelson, splits, roughly speaking, into an 
 eastern and western range. The former is continued thi-ough the Spencer, 
 St. Arnaud, and Raglan Ranges, Gordon's Knot, Ben Nevis, ikc, into 
 those lower ranges which tei'minate about the Pelorus and Queen 
 Charlotte Sounds. The latter (i.e., western) is continued through the 
 Brunner, Lyell and Owen Mountains, and the Mount Arthur Range, to 
 the gradually lessening declivities, which terminate at Separation Point 
 and the Farewell Spit. Between these ranges, lie Nelson and the shores 
 of Blind Bay. The effect of this is, that easterly, westerly, or southerly 
 gales are to a great extent deflected, and blown over the town, leaving the 
 lower atmosphere comparatively still. A striking demonstration of this 
 fact may be frequently observed on moonlight evenings, when the clouds 
 may be seen travelling o^'er the moon at a consideral)le rate, while the 
 lower atmospliere is absolutely still. The nights of Nelson are usually 
 still ; spring is the most windy season, and winter the least so. 
 
 The most characteristic winds of Nelson are — tirst, the sea breeze ; 
 and second, the Waimea wind. The direction of the first is northerly, and 
 generally accompanies fine weather. la summer, it usually commences 
 at about 9.30 or 10 a.m., and blows strongly until sunset, reaching its 
 maximum force at about 2 to 3 p.m. At niglit, and early morning, 
 there will be a slight land breeze from a S.S.E. direction. In winter, 
 the sea breeze is a very gentle zephyr, commencing about noon, and 
 blowing very gently until about 4 p.m., soon after which the sun sets 
 behind the we.stern hills; and the consequent sudden fall of temperature, 
 say between 4 and 6 p.m., is one of the most trying features in the 
 Nelson climate. Invalids with delicate chests should beware of that 
 period (4 to 6 p.m. in winter), and always arrange to be in the house. 
 After 7 or 8 o'clock, there is much less danger of exposure, for then the 
 atmosphere has in great part deposited its moisture, and is consequently 
 much dryer, and less irritating to the bronchial mucous membrane.
 
 ACCOUNT OP THE CLIMATOLOGY OP NELSON, NEW ZEALAND. 505 
 
 The Wainiea wind is S.W. in direction. It is a cold wind in winter, 
 for it blows ort' the then snowy mountains ; but a hot, dry, dusty wind in 
 summer, for then it comes from over the parched-up hill.s. It usually 
 does not commence until about 9 a.m., tlien blows hard all day, winter 
 or summer, and usually dies away about .sunset, though occasionally it 
 will continue titfuUy blowing all night. It is produced by a combination 
 of the general westerly wnnd (all over New Zealand) ; and locally, by the 
 sun heating the low lands round the shores of the bay, and so raising the 
 atniosphere — and the colder air from the mountains rushing in to supi)ly 
 its i)lace — in fact, a sort of reversed sea breeze, only it will not occur 
 except there be a westerly wind blowing over this part of New Zealand. 
 It is the driest wind we have, and is always indicated by the hygrometer 
 showing a large ditterence between the wet and dry bulbs. To give an 
 instance — on January 2, 1888, aWaimea wind was blowing; at 10 a.m. 
 the dry bulb stood at 81, the wet at 62, indicating a dew point of 40'6, 
 and a relative humidity of 23, taking 100 as saturation. That was the 
 hottest and driest day we have had this year. 
 
 Our coldest wind, and at the same time most bracing, is the S.E., this 
 is generally squally, and not unfrequently showery ; and if ever we get 
 snow in Nelson (which is extremely rare, only once did a few flakes fall 
 within the last eight years), it comes with S.E. weather. S.E. winds 
 are most prevalent in the early spring. Our rainy wind is the N.E. A 
 typical Nelson rain comes on something like this — you may notice a 
 bank of cloud along the northern horizon, and clouds more or less 
 piled up over the eastern and western ranges ; a damp northerly breeze 
 begins to blow, this increases in force, at the same time getting warmer, 
 and then down comes the rain, accompanied with much wind at first. 
 Gradually tlie wind lessens, the rain comes down straight, and then, if 
 you notice the sky beginning to get lighter over the N.W., you may 
 pretty certainly pio})hesy the rain will soon cease. 
 
 Our rainfall avei'ages from 30 to 40 inches per annum ; in 1887, it 
 was 29'04 ; and in 1888, up to the present time (December 11), it 
 has amounted to 26'38 inches. Comparatively little rain falls during 
 January, February and March, the rest is ])retty equally distributed 
 throughout the remaining nine months. North westerly winds are 
 damp and warm, they often blow with great violence and cause high 
 tides ; tli^y pile up a tremendous quantit}^ of mist on the south back 
 hills, and give the appearance of a heavy downpour, but we never get 
 more than a .shower with N.W. weather. After a short time the 
 wind usually changes to S.W., and all the mist on the hills rapidly 
 disaj)pears.
 
 506 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
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 ACCOUNT OF THE CLIMATOLOGY OF NELSON, NEW ZEALAND. 507 
 
 The chief characteristics of the Nelson climate are: — 
 
 (1) Stillness of atmosphere. 
 
 (2) Dryness of atmosphere. 
 
 (3) Equality of temperature throughout the year. 
 
 (4) Large proportion of bright sunshine. 
 The first point I have already touched upon. 
 
 The second is strikingly shown by the almost entire absence of fogs 
 at the sea level, and for almost 500 feet above it. During the eight 
 and a half years I have been I'esident in Nelson, there has only been 
 one foggy day (of course I mean white mist, not yellow London fog) ; 
 this occurred in July 1885, and cleared up towards evening. I think 
 this is the more remarkable, as in certain interior districts of Australia, 
 which are at the same time much hotter and drier than Nelson, are 
 subject to fogs, at any rate, in the winter months. For instance, I 
 liappened to be staying at Goulburn, N.S.W., for a few days in July 
 1886, and although it was tine weather, the fog was very dense until 
 about 10 or 11 a.m. This is a most important factor in the suitability 
 of Nelson for consumptives. Of course I am speaking of the lower strata 
 of atmosphere ; mist on the hills is of almost daily occurrence. The 
 average relative humidity of Nelson is about 70, taking 100 as 
 saturation ; and as might be expected, the summer months, January 
 and February, are the driest ; and the winter months, June and July, 
 the dampest. 
 
 Third — Equality of temperature throughout the year. — This is a 
 striking feature in the Nelson climate. The average day temperature, 
 taken at 10 a.m., varies from about 45*^ in July to a little over 70° in 
 January. I have taken the temperature carefully for the last three 
 years (at 10 a.m.), and the highest of which I have any record is 81° 
 on January 2, 1888, and the lowest is 37°, in June. These are day 
 temperatures. On winter nights, the thermometer will sometimes fall 
 to 25°, when fully exposed on the grass ; and even in summer the nights 
 are always cool. The temperature usually rises slightly after 10 a.m., 
 but not much, for the sea breeze usually sets in about that time, and 
 the warmer the day the harder it blows, and so keeps the temperature 
 from rising much. My thermometer is placed under a verandah, 
 facing the south, and I have never known it reach 90° at any time. 
 The summer minimums range from 40° to 55°. 
 
 Fourth — Amount of sunshine. — Bishop Selwyn, long ago, drew 
 attention to the sunny skies of Blind Bay ; and, although very many 
 parts of Australia and Africa can show a larger record in this respect, 
 still, taking into consideration that Nelson is excellently supplied with 
 water for all household purposes, and that there is plenty of rainfall for 
 agriculture, it is perfectly wonderful the amount of sunshine we get. I 
 find, from my observations, that out of thirty-two months, containing in 
 the aggregate 973 days, there were 550 days of continuous, or nearly 
 continuous (i.e., days on which the total obscuration did not amount to 
 an hour), sunshine. During the same period there were 283 days (i.e., 
 24-hour periods) on which rain fell. These must not be considered 
 rainy days, as in many instances the rain fell in the night, and even if 
 it only fell for ten minutes, it would be recorded in my observations as 
 rain having fallen on that day. The nights in Nelson are never very
 
 508 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 hot ; no matter liow oppressive the day may have been, the nights and 
 early mornings are always cool, and feel like a pick-me-up. 
 
 We now come to the considei'ation, most interesting to our profession, 
 of the diseases this climate is suited for. Foremost in the list stands 
 consumption. My eight and a half years' experience enables me to sj^eak 
 very confidently on that point; and I can assert without any fear of 
 contradiction, that almost every case of consumption, contracted in a 
 cold damp climate like England, will be considerably benefited, and life 
 much prolonged, by a residence in Nelson. This has been observed 
 time upon time, and I will now give a few details of individuals known 
 to me personally : — 
 
 J. G., a young man, came from England two years ago, with con- 
 siderable disease in both apices, pyrexia, quick small pulse, &c. He 
 rapidly improved in every way, and now rides and walks just like any 
 other man, attends meetings at night and in all weathers. I have not 
 examined him lately, but see him constantly about the town. 
 
 W. S., a medical man, came from home with phthisis considerably 
 advanced. He was able to follow a large general practice for over ten 
 years, including plenty of night work. During this time the disease 
 never advanced, and he became quite stout; but unfortunately, while 
 in liis usual health, he was seized with an attack of htemoptysis, due to 
 the old disease, and he expired within a fortnight. 
 
 W. B. G. contracted apical pneumonia in India, in the early part of 
 1880. This was followed by plithisis, for which he went to England, 
 and spent the winter of 1880-1 at Davos Platz, where he derived very 
 much benefit, so much so that he ventured back to India ; but finding 
 that he rapidly relapsed, he returned to England, and came out to 
 Australia about October 1881. He now lived for some months on a 
 sheep station in the interior of N.S.W., but finding the lieat too great 
 for him, he came to New Zealand in the early part of 1882, and lived 
 for some months at Tauranga, in the Bay of Plenty. Not feeling 
 satisfied with his progress, he removed to Nelson in August 1882, where 
 he remained under my care for three years. During this time he was 
 a valetudinarian, but kept tolerable health ; however, he was not 
 satisfied with remaining about the same, he wished to get well, and 
 remembering how very much benefit he derived from residence at Davos 
 Platz, lie decided to try the mountain climate of Colorado. There, 
 however, lie was very unfortunate; he broke his arm, he had an attack 
 of luemoptysis (this latter symptom he never suffered from in Nelson), 
 and about a twelvemonth ago, I heard of his death at Colorado Springs. 
 
 "W. T. sliowed symptoms of incipient phthisis about twenty-five years 
 ago; since his ai-rival liere he has married, bi'ought up a family, and 
 lives just like any otlier man. 
 
 Of course we get cases of consumption develop here in people born 
 in the district, and occasionally in those who have come out from Great 
 Britain, free from the disease ; for these, of course, continued residence 
 in the climate is useless, and I always recommend such cases to either 
 try the dry interior of Australia or South Afi-ica, and better still, the 
 mountain climate of Colorado. 
 
 Cases of clironic bronchitis, contracted in Great Britain or any 
 similar climate, derive great benefit in Nelson. We have here, among 
 us now, an eldeily F.H.C.S., who four or five years ago was brought
 
 THE COLONIES AS A IIEALTII RESORT FOR CONSUMPTIVES. 509 
 
 very low indeed with tliis iiialaily, combined with a weak heart. He 
 was ordered to Nelson, and since his arri^"al here has enjoyed unin- 
 terrupted fair health ; attends evening meetings, itc, and goes about 
 just as any other individual. 
 
 Asthma is such an erratic disease, that it is impossible to say whetlier 
 it will be benefited or not by a i-esidence in Nelson. 
 
 The Nelson climate also appears to be suitable for people more or less 
 broken in health by residence in the tropics. AVe have now, and always 
 have had, several old Indians living amongst us; one I can think of 
 now, who has been a victim to gout and rheumatism for several years, 
 tinds this climate suit him better than any he has tried yet. 
 
 The weak point in Nelson, as in so many colonial towns, is its drainage; 
 this is gradually impro^■ing year by year, but is far from perfect at pre- 
 sent — not that the town presents any insuperable difficulties in the way 
 of drainage, and we have enough available water to flush a sewer ten feet ' 
 in diameter, continuously all the year round — but the sewers have been 
 constructed by difterent men, having different ideas, and none of whom 
 have been qualified to write C.E. after their name. To this flaw, in an 
 otherwise almost perfect climate, may be attributed the fact, that we 
 are more subject to epidemics than we ought to be. The principal ones 
 that have occurred since I arrived in May 1880, have been : — An 
 epidemic of pneumonia, in September and October 1880; of measles, in 
 1882; whooping cough, in 1882; dysentery, in 1885; influenza, in the 
 spring of 1887; and diphtheria, in the winter of 1888. With regard 
 to this last, the majority of the cases were traceable to direct contagion. 
 Occasional cases of typhoid fever occur, but I think, leather less 
 frequently than I observed when practising in a rural district of 
 Norfolk, England. Our comparative freedom from typhoid fever I 
 attribute to our excellent water supply, of which every Nelsonian is 
 justly proud. The water supplied is perfectly pure, and practically 
 unlimited. Our food supjily is, in common with the rest of New 
 Zealand, good, varied, and abundant. 
 
 THE COLONIES AS A HEALTH RESORT FOR 
 CONSUMPTIVES. 
 
 By J. Carnegie MacMullen, L.R.C.S.T., l^c. 
 
 Late Honorary Surgeon, Auckland Hospital, New Zealand. 
 
 The subject of consumptives travelling to, and sojourning in, these 
 colonies, is of such great importance, that I wish to make some remarks 
 upon it, from the time such sufferers leave Great Britain, until they 
 recover, return, or die. 
 
 In the flrst place, it would appear that medical men in the old 
 country, having exhausted the usual remedies, advised change of air, 
 regulated diet, etc., and finding no improvement in their patients, at 
 last come to the stereotyped " sea voyage," with or without i-esidence 
 in the colonies " somewhere." They do not, as a rule, seem to have 
 any special knowledge as to the suitability or otherwise of any
 
 510 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 particular locality ; and so little do tliey seem to know of the colonies 
 generally, that a patient is frequently told to go to Australia or New 
 Zealand, no advice being given as to what part of either will be likely 
 to suit him. He may be roasted in Queensland, or frozen in Tasmania ; 
 be exposed to the intense cold and inclemency of Southland, or 
 enei'vated by the moist warmth of the north of New Zealand. He is 
 not told to go inland, or to the sea ; to remain in a town, or seek the 
 country. If he can only be got away, he may crane over an office desk, 
 idle about town, going to hot theatres and crowded balls ; or, if he be 
 fortunate enough to receive competent advice, he can live a wholesome 
 life in a suitable place, provided he can alford to do so, in which 
 case, if his lungs are not seriously damaged, he has a good chance 
 of getting well. 
 
 With regard to the sea voyage, if a patient has advanced phthisis, I 
 • do not think he should be sent upon a long sea voyage with a view 
 of re-establishing his health, for the vast majority of cases show that 
 death is the usual result ; and I would here quote a few passages from 
 the valuable work by Dr. Wm. S. "Wilson, of Sandown, Isle of Wight, 
 on " The Ocean as a Health Resort"' (J. and A. Churchill, 1881). He 
 says, at page 14 : — "Consumption is the illness of all others for which 
 it is now customary to prescribe a sea voyage, although it is only 
 compai'atively of late years that this has been the case. There can be 
 no doubt that, in the first stages of consumption, a judiciously selected 
 sea voyage is often of incalculable value — the one great point is to take the 
 disease sufficienthj early, if possible when the first threatenings only 
 have manifested themselves. Every physician is familiar with cases 
 where, while the patient is still young and the constitution otherwise 
 sound, symptoms arise which, though they might be regarded as trivial 
 by the patient himself, will be at once recognised by the medical 
 man as of grave import, especially if there should be any family 
 predisposition to lung disease. These are, in fact, the premonitory 
 symptoms of what may prove serious pulmonary mischief. It is in just 
 such cases as these that a sea voyage acts most beneficially. It will 
 often eradicate the tendency to consumjDtion, and establish the con- 
 stitution for life. Even in those cases w-here the first stage of the 
 disease is more fully established, a few months at sea will frequently 
 arrest the mischief, and sometimes effect a permanent cure. It is when 
 tlie disease has passed into its later stages, that the advisability of 
 sending a consumptive patient to sea becomes more doubtful. Even 
 then great benefit will sometimes be obtained; but the question whether 
 the possible good which may result, will weigh against the certain 
 loss of home comforts, and the many inconveniences of ship life, is one 
 that can only be decided by the physician in attendance on the case." 
 
 Even for those sliglitly affected, it is not good to travel in a noisy ship, 
 for it is anytliing but beneficial for a consumptive person to make one 
 of three or four in a small ill-ventilated cabin, putting aside the danger, 
 which is far more tlian a mere possibility, of his imparting the disease 
 to one or more of his companions, especially should any predisposition 
 exist amongst them. 
 
 A sailing ship, or auxiliary screw steamer, should be chosen, large 
 and well provisioned, liaving plenty of accommodation, good ventilation, 
 and properly warmed in cold weather. Tliere should be on board a
 
 THE COLONIES AS A HEALTH RESORT FOR CONSUMPTIVES. 511 
 
 large airy and well-appointed liospital ward, to which patients suffering 
 severely from any form of disease might be removed, both for their 
 own sakes, and for the comfort and well-being of their fellow passengers. 
 (Valuable information on the subject of ventilating ships' cabins, &c., is 
 given at page 330 of Dr. Wilson's book.) 
 
 On arriving at any port in the colonies, if intending to remain for 
 any length of time, the patient should consult a physician (say the 
 Health Officer of the port, who should make it his duty to be well 
 infoi'med as to the various localities and climates likely to suit his case) 
 as to where and how he should live; and should he have arrived at any 
 unsuitable place, be advised to seek some other moi'e likely to benefit 
 him. If the circumstances of a patient make it necessary for him 
 to engage, on arrival, in office-work, or other unsuitable employment 
 in a large town — placing himself more or less under similar conditions 
 to those he has just left — I do not think he can improve, and would 
 have been better advised to remain where he was. 
 
 As to the main question of the colonies as a health resoi't for 
 consumptives, I do not wish to extol one place as being better than 
 another, although certain parts are, no doubt, to be avoided. There 
 are parts of each of the colonies which are eminently suited for those 
 suffering from pulmonary disease, but they must live in those places 
 under certain healthful conditions conducive to recovery. They should 
 live in a comfortable house, well ventilated, warm in winter, and cool 
 as possible in summer. Their food should at all times be varied, and of 
 the best quality. There should be ample supplies of fresh milk, butter, 
 eggs, and vegetables. The question of stimulants should be decided in 
 each case by the medical attendant, both as to kind and quantity 
 allowed. Smoking should be limited, and clothing carefully selected to 
 suit the climate. The patient should live in the open air as much as 
 possible, but never over-fatigue himself. Riding, dinving, shooting, 
 fishing, and any other healthful occupation or amusement, will greatly 
 benefit him; but excesses of any kind must carefully be avoided. 
 Under such circumstances, I feel confident that many would recover who 
 otherwise would go from bad to worse; but the difficulty lies in placing 
 such conditions within reach of those requiring them. Many are 
 fortunate in having friends on home stations and farms, where all the 
 necessaries I have mentioned can be had. But there are so many who 
 must work to live, that the question is rendered very difficult of 
 solution, and it is mainly with tlie object of raising discussion on this 
 point that I have brought the subject forward, and in order that, if 
 possible, the question should he represented in such a light, that more 
 care and discrimination may be exercised in the selection of patients 
 sent to Australia and New Zealand for their health, thus also avoiding 
 discredit being thrown upon our colonies as a health resort. 
 
 We frequently see patients far advanced in phthisis, who have been 
 sent from home l3y their doctors, having been told that there was a 
 good chance of recovery. Huch a case came into my hands quite 
 recently. A gentleman from Glasgow arrived by sailing ship at 
 Auckland ; he had been sent away without friend or servant to 
 accompany him, and assured that he had a good chance. He was one 
 of three in a cabin, and the ship was ill-provisioned. On arrival, he 
 was in a dying state, though not much worse than that in which he
 
 512 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 started. I managed to keep him alive for a few weeks, and then sent 
 him back, hoping he would see his wife and children again before he 
 died. Anyone could have seen that when he left home, his case must 
 have been a hopeless one, and yet he was sent away without a friend to 
 cheer, or servant to help him, in a comfortless ship, to spend the last 
 few weeks of his life in misery, a stranger in a strange land, and to die 
 without the sympathy and kindly offices of his family, none of whom he 
 was likely to see again. 
 
 Cases of this kind are of such frequent occurrence, that I think it our 
 duty to lift our voices in strong protest against the practice of medical 
 men at home sending such cases away at all, and to beg of them to use 
 all care in considering the circumstances, both physical and financial, 
 of any patients they may advise to seek for health in the colonies. 
 
 With regard to the difficulties to be met liere in giving patients the 
 best chance of recovery, T would suggest the possibility of selecting 
 suitable localities for health establishments, and there having large 
 farms with cottage dwellings, where patients would live as in their own 
 homes — two or three friends in one house, a family in another, &c., &c. 
 Servants could be procured as required through reliable agents. A 
 manager would supervise the working of the farm, and the general well- 
 being of those living on it. Horses and vehicles could be kept for hire, 
 and fruit, ikc, grown on the farm, could be purchased by the patients. 
 Sheep, cattle, pigs, poultry, etc., could all be raised on the farm. 
 
 In conclusion, I would again refer to the great danger to healthy 
 persons from sleeping in small apartments, and for lengthened periods, 
 with those wlio are suffering from advanced phthisis. Recent scientific 
 research has shown conclusively that, under such circumstances, phthisis 
 is undoubtedly communicable. It is therefore our duty to warn the 
 public who are unaware of the fact, which I do not think is sufficiently 
 recognised even by the profession. My hope is that discussion on this 
 subject will lead to some practical steps being taken for the benefit of 
 the healthy public, for consumptive travellers, and the phthisical 
 portion of our population, which is not by any means inconsiderable. 
 
 SOME OBSERVATIONS ON THE WESTERLY WINDS OF 
 WINTER IN THEIR INFLUENCE ON DISEASE. 
 
 By F. MiLFORD, Sydney, N.S.W. 
 
 In the winter of the year 1851, when a student at the Sydney 
 Infirmary, now the Sydney Hospital, the late Dr. Douglass, one of the 
 honorary physicians, drew the attention of the other pupils and myself 
 to the important fact that, "during the prevalence of tlie present strong 
 westerly winds, the tongues of patients suffering from inflammatoiy 
 disease have been dark -colovx red and dry." Since that period, when I 
 have liad an opportunity of obser\ing, and during tlie last thirty years 
 tliat T have Ijeen in practice in Sydney, I have found the epidemic 
 constitution of the year influenced considerably by the presence or
 
 WESTERLY WINTER WINDS IN THEIR INFLUENCE ON DISEASE. 513 
 
 absence of these sti-ong winds. As a rule, these produce a depressinir 
 influence on the nervous system of persons sufiering from disease, and 
 robust healthy persons are more subject to assume zymotic disease at 
 these times than at others. Intlanmiatory attacks of a sthenic 
 character, during the prevalence of these winds, in some cases 
 rapidly become asthenic, typhoid symptoms supervene, the tongue 
 becomes dry, hard and brown, tlie temperature elevated, the pulse rapid 
 and small, and the patient delirious. So much has my practice been 
 influenced by the presence of these winds, that I have been in the 
 iiabit of postponing any surgical procedure, not ab.solutely necessary, 
 until such period as the westerly has blown itself out — perhaps two or 
 three days, or even more. 
 
 As a rule, westerly weather prevails during the winter months, but 
 occasionally a whole winter may pass without strong gales from this 
 (quarter. The westerly wind is more prevalent during April, May, 
 June and July, than other winter months. It may blow directly from 
 the westward, or southward, or northward, varying sometimes three or 
 four points during the day. 
 
 ]Mr. Thorpe, of Brisbane, in the year 1880, read a paper before the 
 Queensland Philosophical Society on these westerly gales, which was 
 afterwards printed in pamphlet form. Through the courtesy of 
 Mr. Lenehan, Assistant Astronomer at the Sydney Observatory, I ha%'e 
 recently had the opportunity of perusing it. He ascribes the origin of 
 most of the westerly gales of our winter months to an inrush of cold air 
 from the Southern Pole, which at tirst blows directly from the south, 
 and gradually curves round so as to blow from the west. After arriving 
 at between 35° and 25°, the gale alters its direction to the westward, or 
 a few points to northward or southward of it. Shortly before the 
 westerly conmiences, the barometer falls considerably ; is seen to be often 
 as low as 29° 50', and I have seen it as low as 29°. The gale during the 
 first twelve or twenty-four hours frequently blows at a velocity of from 
 fifteen to twenty miles an hour, and sometimes assumes a rapidity of 
 from forty to fifty miles. This wind is usually very dry ; caused, 
 according to Mr. Thorpe, by the deposition of the moisture originally 
 contained in its atmosphere during its passage along the southern coast 
 of South Australia and Victoria, and the inland districts to the 
 .southward and westward of Sydney and Brisbane. During the 
 pre^■alence of the wind, the barometer gradually rises, the sky is per- 
 fectly cloudless, the temperature in Sydney varying from 48° to 62°. 
 We learn also from the Government Astronomer's report (Mr. H. C. 
 Russell), that the amount of ozone in the atmosphere is less than 
 during the prevalence of easterly, north-easterly, and south-easterly 
 weather. 
 
 From tables most kindly furnished me by the Government 
 Astronomer, I have been able to draw up a resume of the various 
 p^e^'ailing weather which has occurred in Sydney during the first eight 
 months of 1888:— 
 
 During January, the most prevalent direction of the wind was easterly 
 during thii*ty days. The greatest velocity was from north-east or 
 south-east. On thirteen days out of the month, there were some 
 periods during which westerly airs prevailed, but there was only one 
 day in the month when its greatest velocity was from a westerly 
 
 iL
 
 514 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 quarter; this was the 15th, and the wind was S.S.W. The mean' 
 temperature of the month was 70° 8' Fah. 
 
 In February, twenty-two days partook of westerly weather, although 
 in two days only was it the prevailing wind, i.e., on the 10th and 24th. 
 Mean temperature was 64" 9' Fah. 
 
 In March, there were no less than twenty-seven days which partook 
 more or less of westerly weather, and in thirteen it was the prevailing 
 wind. Mean temperature 67° 7' Fah. 
 
 In April, twenty-seven days partook of westerly weather, but only 
 eight in which it was the prevailing wind. Mean temperature 
 64° 9' Fah. 
 
 In May, the wind blew eveiy day from the westward more or less, 
 and there were thirteen days in which it was the prevailing wind. 
 Mean temperature 56° 1' Fah. 
 
 In June, the wind was more or less westerly during the whole of the 
 thirty days, and during twenty-three days was the prevailing wind. 
 Mean temperature, 55° 7' Fah. 
 
 In July, the whole thirty-one days showed w^esterly weather 
 prevalent, with the exception of a few hours during nine days and two 
 days (the 7th and the 11th), when it blew strongly from S.S.E. and 
 S.E. respectively. Temperature, 53° 5' Fah. 
 
 In August, there was more or less westerly weather during the 
 tliirty-one days, and sixteen days out of the thirty-one days it was 
 the prevailing wind. The mean temperatui'e at Sydney was 54° 5' Fah, 
 With the exception of the direction of the winds, their force, the 
 barometric pressure, and the temperature, the hygienic conditions of 
 Sydney did not alter, although we find from the Registrar-General's 
 returns that deaths from diphtheria increased from March to July, 
 The deaths recorded from this cause in Sydney and suburbs dui'ing 
 the first months of the present year are as under :— 
 
 Deaths in Sydney and Suburbs. 
 
 May 15 
 
 June . . . . . , 12 
 
 January , . . . . . 5 
 
 February . . . . . . 7 
 
 March , , . . . . 6 
 
 Amil 11 
 
 JiUy 17 
 
 August . . . . . , 10 
 
 It will thus be seen, that the deaths from diphtheria increased and 
 decreased in the same ratio with the duration and strength of the 
 westerly winds. 
 
 As a rule, catarrh and influenza are more or less epidemic during 
 the prevalence of these westerly winds. These are caused, not only by 
 the retardation of the circulation, occasioned by abstraction of heat 
 from the cuticular surface of the body, contraction of the capillaries, 
 and congestion of the vessels in tlie internal organs, but also by the 
 irritating natui'e of the cold dry air itself, brought into contact with 
 'tlie mucous membranes of the nose, mouth and throat, as well as 
 the lining membranes of the larynx, trachea, and bronchi. This is, in 
 my opinion, one of the most predisposing causes of diphtheria. 
 
 I have known at least three rapid deaths result from exposure to 
 westerly winds during the months of May and June in the tram 
 carriages, the persons thus dying being, in two cases, healthy nursing 
 mothers ; and in the third, a healthy old man of eighty. The cause of 
 death in these cases Avas congestion of the internal organs, especially
 
 THE MEDICAL PRACTITIOXER AX OFFICKH OF THE STATE. 515 
 
 the lungs and kidneys. The persons most likely to suffer are those who 
 have a tendency to chronic bronchitis, or are affected with incipient 
 or miliary tuberculosis of the lun<fs. Persons who meet with severe 
 accidents, or undergo capital operations, do not rally from the shock 
 during strong westerly weather, as well as they would during the 
 presence of calms or light breezes. 
 
 In selecting a site for a hospital or asylum for the abode of old or 
 sickly persons, T think it is important that it should be protected as 
 much- as possible, by Ijeing placed undei- the lee of some projection, 
 which might ward off from it the full foi'ce of the westerly gales. Those 
 suffering from illness during the winter in their own dwelling, should 
 occupy a I'oom with an easterly aspect. 
 
 T am afraid I h.ave encroached considerably on the time and patience 
 of the Members of the Section, in offering these observations for their 
 consideration, but my excuse must l)e that, although I advance nothing 
 new to the seniors, yet junior English and Foreign practitioners may 
 gain some hints which may be of advantage in their practice, both to 
 their patients and themselves. 
 
 SHOULD THE MEDICAL PRACTITIONER BE AN 
 OFFICER OF THE STATE? 
 
 By James T. Mitchell, M.D. 
 
 In introducing this question to the Section of State Medicine of the 
 Intercolonial Medical Congress, I do so with the object of initiating a 
 discussion upon the relation of medical practice to the great niasses of 
 the people, who form the bulk of the community. It is not claimed 
 that the scheme here sketched out is the best that could be devised, or 
 that it is perfect in its details ; but this is an endeavour to meet a felt 
 want, and one tliat will press itself more and moi'e upon the attention 
 of the community. "Within the limits of this paper, I cannot hope to 
 give an exhaustive analysis of the question, but I shall attempt, as 
 briefly and clearly as possible, to show the need of some improvement 
 upon existing arrangements, and to suggest some alterations that appear 
 to me to point towards a solution of the difficidty. 
 
 It can scarcely be gainsaid, that the relation of the medical profession 
 to the puVjlic is not at present all that can be desired. The constant 
 introduction of medical bills into our Colonial Parliaments, evidences 
 the dissatisfaction of the pi'ofession on the one hand, and of the public 
 upon the other. This age is essentially one of government by the 
 people. We socialise our education, our railways, waterworks, postal 
 and telegraph systems, &c., and we shall no doubt live to see a great 
 many other things put upon tlie same basis. Whether or not it would 
 be to the advantage of the public, or of the medical profession, or both, 
 that we as a profession should be part of a State institution, is a 
 question well wortliy of considei-ation from both points of view. 
 
 iL 2
 
 516 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 The system here advocated is ah-eady admitted in these colonies in 
 some most important branches of our work. Public health or 
 preventi\'e medicine is recognised as being an aspect of the question 
 that very largely concerns the public safety. Hence our costly 
 quarantine stations, examination of over-sea vessels, the Destitute 
 Medical Relief Department, and Boaixls of Health, botli Central and 
 Local, scattered over the colonies, each having competent officers and 
 advisers from among the medical profession, paid for out of the public 
 pui'se — either the general revenue, or local rates. No one doubts the 
 necessity of these arrangements, or of the still more costly vaccination 
 departments; and the intelligent public would view with alarm any 
 movement which would lessen tlie efficiency of either the Public Health 
 or the Vaccination Departments, as endangering the safety of tlie 
 inhabitants. 
 
 What we are here considering is, tlie question of the advisability of 
 extending these departments, to include public health in its widest 
 signitication. The public being made up of individuals, the health of 
 these individuals is the pul^lic health ; and what affects the units, affects 
 also the mass to a corresponding degree. Granted that the destitute 
 poor are faii'ly well provided for under present arrangements; still, 
 outside these is the great mass of the people, far and away outnumber- 
 ing the few who are so favourably circumstanced as to be easily able to 
 afford medical attendance without stint. Granted also, that the 
 existence of Friendly Societies covers a portion of the ground indicated ; 
 this latter, however, is perhaps the least necessitous portion. Able- 
 bodied men in good health only are admitted to these societies. The 
 weakly, and women struggling single-handed to bring up their families, 
 are inadmissible ; and these are really the needy ones. Here, then, is 
 the failure of existing arrangements. For the most part, those best 
 able to afford medical attendance in sickness are those for whom it is 
 easily provided ; while those least able to afford it are scarcely, if at all 
 provided for, except at the expense of genei"ous and philanthropic 
 individuals, who are already taxed equally with the rest of the 
 community. 
 
 It is to the advantage of the State that all its units be as healthy 
 and as strong as possible, so that they may have the greatest possible 
 working efficiency. The honest poor try their utmost to avoid a 
 doctor's bill, and do not send for a doctor until they are absolutely 
 obliged to do so. In very many cases, they do not send until the case 
 lias assumed such an aspect that it is beyond treatment, and their lives 
 are thus thrown away, wlien but a very little medical skill would have 
 saved them. The dishonest are not so chary of claiming attendance, 
 and the unwary doctor is victimised. When sickness occurs, there are 
 so many expenses, and probably at the same time, diminution or 
 ce.ssation of income, that a man is least able to pay for attendance. 
 It is nothing at all unusual for the man to get so far behindhand 
 during a tedious illness, that lie can never hope to overtake it again. 
 Whatever ready money he could obtain, has gone to the tradespeople, 
 for the doctor would be scouted if he applied for money under the 
 circumstances. When tlie man attempts to resume work, weakened by 
 his illness, he is often in utter despair about the debts, and goes through 
 the Insolvency Court, or otherwise gives it up. Public sentiment is
 
 THE MEDICAL PRACTITIONEK AN OFFICER OF THE STATE. 517 
 
 very exacting with vet;ard to the Medical Profession. No doubt, we 
 have to some extent induced this feeling, and very properly so too in 
 some cases, by ready and willing attendance, where there is not the 
 least prospect of payment. We liold ourseh^es up as a humane 
 profession, and humanity is ]iot slow to push its claims upon us. 
 
 Look, for instance, at street, railway, and river accidents. Public 
 sentiment demands that the doctor shall attend these promptly, no 
 matter at what inconvenience, and is highly incensed if there be any 
 apparent neglect. These cases require a considerable amount of time, 
 ready wit, and quick and skilful treatment, and yet it is notorious, that 
 they are seldom paid for. The victims either disappear, or disclaim 
 liability, and the company or other pei'son or persons causing the 
 accident also disclaim, while the doctor must either go without his fees 
 or recover them by law. V^ery frequently also, to these accidents half- 
 a-dozen doctors are fetched by the bystanders, and it is impossible to 
 demand fees for all. I venture to assert, that on no other profession 
 are such heavy demands made for gratuitous services, and perhaps so 
 little appreciated. Indeed, very much of the gTatuitous service seems 
 to be estimated at cost price, judging by the way it is often received, 
 and grumbled at. 
 
 Position of State Doctors. 
 
 Under a system of State medical practice, every doctor should be at 
 liberty to locate himself in any place he might choose, as he does now. 
 The demand must regulate the supply, and he would naturally go where 
 he could make the best living. Everyone would still be independent 
 of every other one, vinless he choose to enter into partnership, and he 
 would be answerable only to the State and to public opinion. No one 
 would be over-worked any more than now. When he had done as 
 much as he could, or as he cared to do, he would refuse further calls. 
 The more work lie did, of course the more pay. There would, therefore, 
 be the same incentive to the exercise of the best possible talent, attention 
 and skill, as now. Popular and successful pi-actitioners would be 
 ahvays busy, while the weaker men would be less sought after, as now. 
 
 But the public, relying on State medical attendance, might, and 
 probably would, demand to be looked after at any hour of the day or 
 night, upon showing reasonable cause. Nowadays, when a doctor is 
 thoroughly tired, he declines to go out till rested ; but it would, no 
 doul)t, be necessary for doctors in any district to take turn and turn 
 about Avith urgent work, eacli man being on special emergency (night) 
 duty for a week at a time. In these days of telephones, such arrange- 
 ment could be most easily woi'ked. 
 
 Therefore, the ditl'erence to the doctors themselves would be very 
 slight, except in tlie matter of certainty of payment, while the differ- 
 ence to the public would be very great indeed, ensuring best attendance 
 to those most i-equiring it in the early stages of disease. 
 
 If it were thought necessary or advisable for the State to supply 
 medicines, surgical appliances, Ac, also free of charge, that would be 
 done upon the prescription of the State Medical Officer ; but the 
 arrangements for carrying this out would come rather into the province 
 of the druggist than into ours, and therefore I need not further con- 
 sider it.
 
 518 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Vaccination and Public Healtli appointments could he included in 
 their duties at their option, and the appointments being made by a 
 central authority, there would be no chance of local jealousy or 
 favouritism electing an unsuitable candidate, the best man always 
 being selected. 
 
 There should be nothing in this scheme to prevent any doctor from 
 practising in a wholly private capacity, should he prefer so to do, rather 
 than be a State officei*. Oj^erating and consulting surgeons, consulting 
 physicians, and specialists, might desire to be independent in their 
 practice, and they should have this liberty. They would then have to 
 collect their own fees, and would probably be as well supported, in 
 comparison, as our private colleges and schools are, in spite of the 
 great public schools available, either free or at a nominal charge. 
 
 English and German Laws. 
 
 Foremost among the successful legislative experiments of modern 
 times is the English Poor Law, which, with little substantial alteration 
 of principle, has stood the test of fifty years' experience. It is too 
 well known to the Members of this Congress to require elaborate notice 
 hei^e. I would remind you that, upon proof of a man being unable to 
 procure medical attendance, through being out of work, the Poor Law 
 Surgeon attends, provides medicine and surgical appliances, and, if 
 needful, orders medical comforts at the expense of the Union, with 
 power, in some cases, to send the patient into the Union Infirmary. 
 The surgeon is paid a fixed annual salary, irrespective of the amount 
 of woi'k he may do in any one year, and is also given extra fees for 
 operations, accouchements, and the reduction of dislocations and frac- 
 tures. The appointment of the svirgeon is by tlie Board of Guardians 
 of the district, a local body liable to caprice, and his tenure is not the 
 most secure. Only the very poor are hereby provided with attendance ; 
 and a man in employment, with small wages and with a large family, 
 must employ a surgeon at his own expense, although practically unable 
 to pay the doctor anything for his services. 
 
 The German Laws, being very much more modemi, may not be quite 
 so well understood, and I therefore venture to draw your attention to 
 an article in the Oontemporar// Review, August 1888, dealing with them 
 in a very able manner. It says : — " The Emperor William's message 
 to his Parliament of 1881 admitted most completely the right to public 
 assistance ; it recognised that the modern State is bound to take 
 positive steps to secure tlie life of tlie great mass of the people against 
 the vicissitudes to which it is sul)ject ; and it initiated a series of legis- 
 lative expei'iments of great boldness and magnitude, which are well 
 worthy of the observation and study of other nations." 
 
 In 1883, the Act for Compulsory Sick Insurance was passed by the 
 German Parliament. In 1884, the Act for Compulsory Accident 
 Insurajuce passed ; while that for Insurance for Old Age and Invalid 
 Pensions was only introduced into the Reiclistng during the current 
 year 18S,s. 
 
 L'^nder the Sick Insurance Law, only those who are in regular 
 employment for wages are sul)ject to this compulsion, but others who 
 follow^ industrial employment h-Axa the i-ight of insurance by voluntaiy 
 entrance. Tlie assistance is not worked directly from a State depart-
 
 THE MEDICAL PRACTITIONEli AN OFFICER OF THE STATE. 519 
 
 laent, but by local clubs or unions amongst the various trades. Nothing 
 has to be done by the woi'kniaii himself ; the mere act of getting 
 employment insures him, as the onus is thrown upon the employer, who 
 must give his name to the club, and forward the moiiey regularly 
 deducted from the man's wages. 
 
 Some objections to the German sclieme are these : — The multitude of 
 small unions must of necessity be more expensive in management than 
 one central department, and the small funds could not be laid out to 
 the greatest possible advantage, And again, a more forcible objection 
 is, that a man in work is better able to pay his doctor's bill than a 
 man out of employment, while this latter is unprovided for under the 
 Uerman law, unless he be a pauper. 
 
 The advantages offered by the Sick Insurance Law are : — • 
 
 (1) Free medical advice and treatment, including dentistry, free 
 medicine, and minor surgical appliances such as spectacles, trusses, ttc. 
 
 (2) From the third day after the notification of the illness, a money 
 allowance amounting to fifty per cent, of the average wages upon which 
 the insured person's subscription is assessed. 
 
 (3) In case of death, an amount equal to twenty times the local 
 daily M-ages of an ordinary day labourer payable to the survivors. 
 
 Method op Paying the Doctor and of Raising Funds for It. 
 
 No suggestion of a scheme such as the one under discussion should 
 be entertained, unless the practical point of finances wei"e also included 
 in the suggestion. 
 
 It will be asked. How is the doctor to be paid, and how is the money 
 to be raised to pay him 1 To answer these questions exhaustively 
 would be very wearisome, but a few points may be briefly indicated : — ■ 
 
 (1) The doctor should keep his own accounts of visits, consultations, 
 accouchements, operations, &c., and charge them in his schedules 
 according to a scale of fees fixed by the central authority ; the country 
 mileage being also determined by tlie same authority. At certain 
 intervals — weekly, monthly, or quarterly — he should send them in to 
 the head of his department, precisely as he does his vaccination 
 schedules (South Australia), declaring that it is a just, correct, and 
 faithful account of his work, and that no private charges have been 
 made for any of the cases. These schedules might be audited and 
 checked in a variety of ways, and might be subject to revision as to 
 charges. When allowed as correct, cheques could be at once forwarded 
 to the doctor. In anything human there is liability to fraud, ])ut 
 there would be no more liability in this than in countless other 
 schedules sent in by Government officers ; and, considering that we are 
 dealing with an honourable profession, sucli liability would be small, 
 for any wilful mis-statement could be summarily met by removing the 
 practitioner's name from the State Roll, and thus depriving him of his 
 means of livelihood ; or, still more summarily, by taking the case into 
 the criminal coui'ts, to be treated like any other felony. 
 
 (2) How is the money to be raised? The answer should be given by 
 a politician, rather than by a doctor. It certainly should come from a 
 central, rather than from a local source ; and for this reason, that 
 the expense of regulating and working the .system from one centre
 
 520 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 ■would be very much less than if several smaller centres worked 
 independently of one another. And also, if local arrangements were 
 made, there would be glaring anomalies between the working of 
 different local centres, and also in different epochs of the same centres. 
 Two courses are open by which to raise the money : — 
 
 (rt) A special tax. This might, and probably would, become 
 
 obnoxious, and it would be liable to interference and to 
 
 constant modification. 
 (6) From the general revenue. This scheme of medical aid would 
 
 be for the general advantage and of universal application, 
 
 and therefore the cost should naturally be derived from the 
 
 general revenue. 
 If this revenue be collected by "customs" or "excise," then large 
 families pay more than small ones, and probably they are the ones 
 needing the most attendance. If the revenue be collected by property, 
 income, or land taxes, then those better able to afford pay more 
 than those less able, and the strong help the weak. So, in either case, 
 the incidence would be fair enough for all practical purposes. 
 
 An objection to this might be that we are heavily enough taxed 
 already, and it would only be burdensome to increase taxation. But 
 that is a fallacious manner of putting it. The cost to the community 
 would be no greater than it is now; only the incidence would be 
 different, and a small regular payment would have to be made always, 
 whether in sickness or in health, instead of the present heavy burden 
 in sickness. 
 
 Advantages of State Practice of Medicine. 
 
 This scheme would in reality be a great extension of the existing 
 club practice, and would do away with the same by being upon a more 
 satisfactory and permanent basis. In no way would it interfere with 
 the functions of Friendly Societies. Then, as now, these could, by 
 banding men together, make provision to supply a limited wage-money 
 when the man was incapacitated from work, and a funeral donation 
 when he died. But they would not be required to provide medical 
 attendance, as the doctors would be as free to tliem as to any others of 
 the public; and hence, their weekly contributions could be considerably 
 reduced. Also, the constant friction between the lodge members and 
 surgeon would be done away with, as would also the evils attendant 
 upon tendering for vacant positions, lodge elections, &c. Undoubtedly, 
 in order to obtain positions in tliese Friendly Societies, fees are at times 
 cut down below a i-emunerative price, and as a natural consequence, the 
 attendance must be less efficient than it would otherwise be. 
 
 This last view of the case is by no means confined to Friendly 
 Societies. Whenever there is any overcrowding of practitioners, there 
 is a tendency to i-educe fees in useless competition. Although we claim 
 that our profession is perhaps more free than any other from slovenly 
 work, one cannot but feel that sucli competition will not tend to raise 
 the standai-d of the work done, especially by tlie less able men. The 
 competition liere referred to is distinctly that resulting from over- 
 crowding, and is not to be confounded with healthy rivalry, which tends 
 to raise, and not to lower, the standard of work.
 
 THE MEDICAL PRACTITIONER AN OFFICER OF THE STATE. 521 
 
 The staiulard of fees could be lowered to some extent, were tliis 
 thought to be necessary. In South Australia they are possibly at the 
 minimum, and could not be further reduced; but, in the other colonies, 
 they range distinctly above the South Australian limit. When all 
 work was paid for, and there were no bad debts, this could be accom- 
 plished. For, not only would the fees be certain, but the trouble and 
 expense of complicated book-keeping would be saved, and money 
 promptly paid is worth more than if it had been long delayed, and 
 grudgingly paid by instalments. 
 
 All pauperism in medical relief would be done away with. The 
 degradation that many of the honest poor feel in receiving Government 
 attendance would be a thing of the past, as would also be the embar- 
 I'assment of those in poor circumstances who are compelled to seek out 
 a genei'ous doctor and, from time to time, make claims upon his 
 generosity. The poor man should be exactly as eligilile for treatment 
 as the rich, and the fee being the same in either case, liis treatment 
 should be equally painstaking and effective. 
 
 The generous doctor's free list would be doiie away with. Every 
 doctor has more or less of this sort of thing, some very much more than 
 others. Year by year adds new names to the fi'ee list, as widows, 
 orphans or helpless cripples come "within the circle of his practice. He 
 finds it almost impossible to di"op names, and so more and more valuable 
 time is occupied by this work. One cannot deny that this work is 
 essentially necessary and valuable, l)ut that is just the point insisted 
 on. It is necessary to the State and the public, and so the State should 
 be prepared to take the burden from the few, and share it among the 
 many. The difference between work expected of us and ordinary 
 philanthrophic work is, that what we do can only be done by a few 
 individuals possessing skilled knowledge, while ordinary philanthropy 
 can be practised by anybody who possesses a kind heart. 
 
 The public being well and easily supplied with medical attendance, 
 quackery would at once be at a discount. The act of registration of a 
 medical or surgical diploma, would place its possessor at the service of 
 the State, unless he expressly demanded to be free from such service ; 
 and the Registration Boards could have tlie power to use their discretion 
 as to the qualification of applicants, as well as to remove from the list 
 of State officers, such as proved themselves incapable of performing the 
 services i-equired of them. The standard of medical work would by 
 this means, be kept up to a high average of efficiency, and the public 
 ■would get the best possible value for their money. They would 
 certainly be very chary of paying unqualified practitioners, when they 
 could obtain the services of the well qualified free of cost. 
 
 It might be objected, that all really clever men would remain in 
 private practice, while only the less competent would go into the 
 Government Service. In reply, I mu.st say, that experience has not 
 shown this in the past, in other matters. 
 
 No one will deny that our public vaccinators, and the medical men 
 who are now engaged on active service on behalf of the State, such as 
 colonial surgeons, health officers and so on, are men highly esteemed 
 among their professional brethren ; and they willingly accept these 
 positions, partly no doubt for the honour, but also for the certainty of 
 income, without the worry of collecting it ; although they could, in
 
 522 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA 
 
 private practice, obtain larger incomes. And also, the Staff of the State 
 Education Depai-tment, does not consist of men who have taken up the 
 work, because they were fit for nothing else. Among these various 
 Government servants, there are men who could hold their own with any 
 of their class. And we can safely affinn, that even if some of the very 
 ablest of the medical profession were to remain in private practice, still, 
 a large proportion of talent would enrol itself in the Government Service, 
 from the obvious advantag-es connected therewith. 
 
 ANTHRAX IX AUSTRALIA, WITH SOME ACCOUNT OF 
 PASTEUR'S METHOD OF VACCINATION. 
 
 DEMONSTRATION AT JUNEE, N.S.W. 
 
 By William M. Hamlet, F.I.C, F.C.S. 
 
 Member of the Board appointed by the Governmeut to report on the Juuee 
 Demonstration. 
 
 The microbe, whose presence and functions are indissolubly connected 
 with the disease known as anthrax, is of greater antiquity than many 
 persons ask us to believe. It is not a creature of yesterday, nor did it 
 come into existence with the advent of either Davaine, Pasteur, or 
 Koch ; although, on the other hand, the opinion advanced by some, 
 that anthrax is none other than the murrain amongst the flocks and 
 herds of the Egyptians, mentioned in the Book of Exodus is, I think, 
 a matter of speculation. 
 
 It is sufficient here to note, that the historical record in Europe goes 
 back at least to 1782, when Chabert accurately descriljed the disease as 
 a fievre charbonneuse, from the black or charcoal colour of the blood 
 and spleen. His results were confirmed by Gilbert in 1795, and 
 subsequently, by Yerheyen; and by Hensinger, who published a valuable 
 monograph on the subject. These were followed by Fuchs, Bi'auell, 
 Raimbert, and Burgeois — observers who generally agreed as to the 
 parasitic origin of the disease; and by M. Hurtzel d'Arboval, who wrote 
 a complete account of the nature of anthrax. Barthelemy, in 1823, 
 mentions the fact first noticed by him, that the disease is. attended with 
 more fatal i-esults in the case of the herljivora, than with the carnivora, 
 proving this l)y direct inoculation of tlie animals witli diseased blood. 
 
 In 1826, the disease appears to have made great progress in Denmark, 
 in Dantzig, and in several of the Prussian States, the probability l)eing 
 that it was introduced there from what was then known as Russiiin 
 Poland. Gerlach confirmed much of the work of the previous observers 
 in 1845, and showed its identity in both sheep and cattle. 
 
 Coming to the year 1847, we find the disease had found its way to 
 Australia. Sheep had been introduced into the country sixty years 
 previously, and the first outbreak of what is clearly recoi'ded as being 
 that of anthiax, is known to have occurred on a farm belonging to Mrs.
 
 ANTHHAX IX AUSTRALIA. 523 
 
 Cordeaux, at Leppington, near LiAerpool, in the County of Cumber- 
 land; and from the county, the disease took its name as Cumberland 
 Disease; while in other pai-ts of Australia, particularly in that part 
 now known as Victoria, it was called the New Disease. 
 
 In the time of Governor Sir Charles Fitzroy, a Commission was 
 appointed in 1851, under the direction of Sir Edward Deas Thomson, 
 then Colonial Secretary, from which there seems to have been little 
 doubt as to its identity with anthrax; for the Commission agree in. 
 stating, as a fact, that the symptoms, course, and post-mortem appeai'- 
 ances of the disease were in all respects,* " similar to a disease long 
 known in France under various names, of which the most common is 
 the maladie du sang," so that it is a clearly established fact, that our 
 early Australian observers recognised the disease at a time when it was 
 only just beginning to be understood in Eui'ope. Indeed, they mention 
 that, so far as they knew, no other British writers had previously 
 described the disease. 
 
 In the month of August of 1850 a great step was made, when some 
 blood, taken from animals suffering from the disease, was examined 
 under the microscope by two French physicians, Messrs. Rayer and 
 Davaine. They noticed that, interspersed here and there amongst the 
 corpuscles, there were a number of non-motile rods or filaments, 
 measuring about tw^ce the diameter of a red corpuscle. Davaine was 
 the first to establish the fact, that the disease anthrax was due to a 
 parasite in the blood of the animal. He also proved that the blood, 
 after having been dried and preserved eleven months, still retained its 
 virulence, and was capable of producing fatal results. f 
 
 Five years after MM. Davaine and Rayer came Pollender, who 
 demonstrated, quite independently, that anthrax was always accom- 
 panied by the pi-esence of the rods or filaments in the blood of the 
 diseased animal; that, in eft'ect, the one was ah\ays linked in some 
 mysterious but essential way, with the other. 
 
 In 1857, Brauell discovered the rods in the blood of a diseased animal 
 before death. He, moreover, discovered them in the human subject 
 after death. 
 
 In 1861 and 1862, Pasteur made known his discovery of the butyric 
 ferment — the bacillus subtilis or amylobacter — and showed that this 
 wand- shaped microbe or bacillus was the sole and active agent in the 
 process of butyric fermentation. This truth was made known to the 
 world by one who little suspected the important results that were to 
 follow. Davaine read and heard of these results with the most lively 
 interest, and became so much impressed with the similarity of Pasteur's 
 l)acillus amylobacter with the rods he had found in diseased sheep's 
 blood, that with true scientific inspiration he believed that the clue 
 was now obtained l^y which the cause of charbon could be ascei'tained. 
 Davaine's experiments in this direction were the subject of communica- 
 tions made to the Academy in 1863-65-66. By inoculating some 
 sheep with a liquid containing the rods, he thereby produced the 
 disease with its accompanying fatal results, and then beheld the rods 
 or bacilli again in the blood taken from the dead animal. 
 
 * Government Gazette, No. 69, June 19, 1851, page 938. 
 
 t Fiom actual experiment, it has since been shown that the virus may be kept 
 dry, and still retain its virulence, after twelve years.
 
 524 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 In 1868, Dr. Burdon-Sanderson was attracted to the inquiry. Again 
 revei'ting to Australia, we find that in the same year Mr. Gordon, Chief 
 Inspector of Stock in Queenshmd, became satisfied as to the identity of 
 the anthrax of Europe with Cumberland Disease in Australia. A few- 
 months later, Dr. Morris, of Sydney, wrote a very able report on the 
 nature and origin of the disease for Mr. Gordon. In 1873-74, Burdon- 
 Sanderson, who had by this time thoroughly investigated the disease, 
 made a report to the Privy Council, not only embodying all that was 
 known on the subject up to that date, but arriving by experiment at 
 the conclusion, that the contagium existed in two distinct forms — the 
 one visible as ti"ansparent rods, the other latent and invisible, or at 
 least, beyond the power of the best microscopes. 
 
 The year 1876 proved a most remarkable one in the history of the 
 elucidation of this disease. Mr. Archibald Park, veterinary surgeon, 
 now in Tasmania, but who was then at Mount Gambler investigating 
 the subject, formed his opinion as to the cause of the disease, which 
 was expressed in a letter to one of the Melbourne papers, wherein 
 he attributed the disease to something in the blood, by which a kind of 
 blood-poisoning was set up. 
 
 Graham Mitchell was drawn to the subject at the same time, and in 
 a letter to the Melbourne Arc/us, pointed out veiy clearly that what 
 was known as "Cumberland Disease," or "the New Disease in Sheep," 
 was none other than anthrax, or the splenic fever of Europe. The 
 question attracted considerable notice in Victoria ; and Mr. Cosmo 
 Newbery and Mr. Emerson Maclvor were both engaged in analysing 
 the blood of sheep that died of the disease, in consequence of certain 
 statements that were maintained by some, to the effect that a 
 diminished supply or assimilation of the potash in the blood was the 
 vera causa of the disease. 
 
 In Scotland, Professor Tyndall was lecturing at Glasgow, and, 
 incidentally, not only mentioned the work that was going on in 
 France, but made known for the first time in Bi-itain, Koch's celebrated 
 discovery on the aetiology of anthrax. 
 
 Pasteur's brilliant reseai'ches on the subject were made about the 
 same time, but published a few months later (1877). The. research 
 proved that the bacilli are the dii^ect and active agents in producing 
 the disease. In the same year, Professor Cohn, of Breslau, carefully 
 repeated Koch's woi*k, and gave it his valuable support and con- 
 firmation. In 1881 came the discovery of a protective vaccine by 
 Pasteur, wlio, associated witli Chamberland and Roux, were the 
 originators of the method of pi'otective vaccination against anthrax. 
 
 At the same time, and during the two years that followed, Drs. Klein 
 and Greenfield investigated the subject very fully, and reported on the 
 method to the Local Government Board. 
 
 Historical Summary. 
 
 First outbreak in Australia ... ... ... ... ... 1847 
 
 Rayer and Davaine's discovery of the rods ... ... ... 1850 
 
 Commission appointed in Australia to investigate the disease 1851 
 
 Similar one in France (Conference Eure et Loire) ... ... 1852 
 
 Pasteur's discovery of the butyric ferment ... ... ... 1861 
 
 Davaine's renewed attack on the subject ... ... ... 1863
 
 ANTHRAX I\ AUSTRALIA. 525 
 
 Koch's discovery of the life-Iiistory of the bacillus ... ... 1876 
 
 Pa.steur and Joubert's independent discovery of the same ... 1877 
 
 Pasteur's discovery of the vaccine of anthrax ... ^ ... "j 
 
 Fir.st public demonstration in France ... ... ... ... ( 1001 
 
 Second do. do. do. ... ... ... ... i 
 
 Third do. do. in Germany ... ^ ... ... .../ 
 
 Fourth do. do. in Australia .. . ... ... ... 1888 
 
 There can be no doubt, that what was known o\'er forty years ago as 
 Cumberland Disease, and diagnosed at the time as the French maladie 
 du sang, is identical with the disease bearing that name, known 
 likewise as splenic apoplexy, or anthrax; so that, after all, the term 
 Cumberland Disease is but the Australian synonym for this disease. 
 The work of the Commission in Governor Fitzroy's time seems to have 
 remained forgotten and unheeded until Messrs. Archiljald Park and 
 Graham Mitchell* took the subject in hand. The latter had carefully 
 observed the disease, and pronounced it to l)e identical with European 
 anthi'ax. 
 
 Mr. Anthony Willows reported to the Go\ernment, in 1883, con- 
 firming the diagnosis, and gi^•ing full details of a particular outbreak on 
 the Lachlan.t Mr. Willows was the first to adAOcate vaccination as a 
 protection against the disease. This report was followed up by Mr. 
 W. E. Abbott, of Wingen, N.8.W., who, in a letter to the Si/dnei/ 
 Morning Herald, April 3, 1883, also recommended Pasteur's method of 
 protective vaccination. Two years afterwards, Mr. Edward Stanley, 
 Government Veterinarian, in reporting on an outbreak in the Narandera 
 district, became favourably impressed with Pasteur's vaccination method ; 
 l)ut Mr. Alexander Bruce, Chief Inspector of Stock, could not, in the 
 absence of full information on the subject, recommend any definite 
 action to be taken in the matter until April last, when the repre- 
 .sentatives of M. Pasteur arrived in Australia, to deal with the rabbit 
 plague. Those of us who were interested in the investigation and 
 suppression of Cumberland Disease, saw the favourable opportunity 
 uftbrded of satisfying the public as to the identity of Cumberland 
 Disease with European anthrax, as well as to test the efficacy of 
 vaccination as a preventive measure. 
 
 Accordingly, Dr. Germont, M. Loir, and Dr. Hinds, visited Uarah 
 Station, and saw a sheep that had just died of the disease. As the 
 result of their examination, they unhesitatingly pronounced the disease 
 to be the same as that known in France as maladie du sang, charbon, 
 .sang de rate, &c. — a valuable confirmation of the opinions of the most 
 acute observers ever .since the disease first made its appearance in 
 Australia. 
 
 Through the indefatigable energy of the Chief Inspector of Stock, 
 some attenuated virus of vaccine was obtained from M. Pasteur, and 
 arrangements were made to have it tested officially, and in as public a 
 manner as possible, upon a number of sheep. A Board was appointed 
 by the Government to watch and report upon tlie experiments to be 
 
 •"Cumberland Disease (the so-called 'New Disease') in Australian Sheep." 
 Melbourne. Published by Alexander M'Kinley and Co., 1877. 
 
 t Anthrax (Cumberland Disease). Report by Mr. Anthony Willows on the 
 Prevalence of Anthrax in the Lachlan District. Sydney, 1883.
 
 526 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 Blade by Dr. Gerniont and M. Loir, to demonstrate the efficacy of 
 Pasteur's vaccine. Tlie Board consisted of : — John de V. Lamb, Esq., 
 Chairman Board of Hheep Directors, Sydney ; Arthur A. Devlin, Esq., 
 Chairman Board of Sheep Directors, Narandera ; Alexander Bruce, 
 Esq., the Chief Inspector of Stock ; Edward Stanley, Esq., the 
 Government Veterinarian ; and the Government Analyst. 
 
 My connection and interest in the subject of this paper began in 
 1884, more particularly in regard to a popular theory as to the cause of 
 the disease, namely, the poison plant tlieory. The idea prevailed in 
 the minds of tlie majority of the stock-owners in the colony, that one or 
 more poisonous plants were tlie sole causes of the disease — an impres- 
 sion that still lingers in some parts of the country. Squatters and 
 stockmen alike agree in attributing the disease to tlie plants or herbage 
 tlie sheep may have eaten. Stock passed over a given country, and 
 became smitten by some insidious disease, and died in large numbers. 
 The readiest hypothesis, with many people, was to attribute it to 
 noxious weeds, and large numbers of specimens of all kinds of plants 
 Avere submitted both to the Government Botanist for identification, and 
 to the Govei'iiment Analyst for examination and analysis. But these 
 steps failed to clear up the mystery, whilst direct practical tests with 
 the plants on the sheep themselves gave no support whatever to the 
 theory. 
 
 Mr. Charles Mooi-e, in summing up his report on the question,''' says : — 
 " If the sheep and cattle disease, commonly called Cumberland Disease, 
 be caused by one or more plants, it is not as yet possible to determine 
 with accuracy what these plants are." 
 
 So many samples of plants having, moreover', been analysed by the 
 Government Analyst during the past seven or eight years, without 
 tracing any poisonous principle or alkaloid, my interest became aroused, 
 and I requested Mr. Stanley to provide me with large quantities of the 
 fresh ripe plants, both in flower and in seed, particularly of the plants 
 alleged to be poisonous. In this w^ay, such plants as Croton verrauxii, 
 OmalantJius lesche, Eupliorhia drammoQidii, various Swansonia (Darling 
 Pea), and many others were exhaustively dealt with, liut without dis- 
 covering any poison whatever by chemical analysis. 
 
 Although no actively poisonous principle could lie detected, yet I am 
 of opinion that certain classes of plants are indirectly associated with 
 the tt'tiology of the disease ; some probably acting as a suitable host in 
 the development of the parasite, while others, such as the different 
 varieties of thistle, or hard, librous, or spring species of plants, are apt 
 to set up sufficient ii-ritation in the mucous membrane of the intestinal 
 tract, as to afford the microbe a sure and ready means of ingress into 
 the system. Pasteur made some interesting experiments in this 
 direction. He found that food that had been infected with virulent 
 virus of anthrax was not always fatal to sheep, and that the majority 
 of the sheep so fed did not conti'act the disease. But on mixing 
 virulent virus with dry barbed ears of barley, oats, thistles and chaff', 
 the mortfdity rose at once to eighty and ninety per cent., proving 
 beyond all question that the abi-asion and irritation of the alimentary 
 organs, caused by the sharp points of the plants, at once gave the 
 
 * " Votes and Pioceedings," 1858-59, p. 8.
 
 ANTHRAX IN AUSTRALIA. 527 
 
 necessary conditions, and placed the animal in reach of the disease. 
 'Mr. Willows* said that "much of the grass of the Lachlan district 
 ] found to be very penetrating, hard, and fine in its fibre, and the 
 terminal extremities of the seeds of this grass were quite prickly in 
 many instances. I also observed that many of the sheep were in the 
 habit of feeding upon thistle seeds." 
 
 Again, other plants, like En.pJiorhia drummondli, spread their leaves 
 quite close to the gi'ound, so that a sheep could scarcely nibble it 
 without taking up some of the earth along with it, and in this way 
 a large amount of infected matter from an infected soil could be 
 introduced into the system. The milky Huid expressed from E. 
 drnnimondu in the fresh state contains no poisonous principle, but 
 would become a suitable medium for the growth of the bacillus, and 
 lience there may be some ground for the suspicion held by shepherds 
 against this plant — a suspicion very widespread, and dating back from 
 the time of the early days of the colony. 
 
 Of other possible sources of contagion, may be mentioned dingoes, 
 cx'ows, and fiies. 
 
 The rod-like microbe first descriljed Ijy Davaine, which is the cause 
 and origin of anthrax, is a minute thread or staff-shaped cell named 
 bacillus anthracis (baculus, a wand or staff, and uvOpu^, coal or charcoal). 
 It lives and propagates itself in contact with aii', or an equivalent 
 quantity of oxygen, in almost any albuminous or proteid-laden solution ; 
 but most i-eadily in the blood of a living animal, where it does great 
 mischief, living at the expense of the serum, and pi'oducing a chemical 
 change in the htemoglobin. This change is l^rought about by the 
 microbe appropriating the oxygen introduced during the respii'atory 
 process of the animal, and reducing the haemoglobin, giving at once the 
 black or purple-black tint common to venous blood. The lu^^moglobin 
 has its oxygen-carrying functions disturbed; the chemical change set 
 up being analogous to asphyxia. For this reason, the earlier French 
 observers named the disease charbon; while in Germany it is called 
 milzbrand — burnt spleen, hence the term anthrax. 
 
 A drop of such blood taken from a diseased sheep, and placed under 
 a cover glass, and an eighth Zeiss-immersion, or other good lens, will 
 reveal the presence of the transparent, non-motile glass-like rods 
 amongst the corpuscles. At the same time, the corpuscles will have 
 lost much of their sharply-rounded outline, some of them becoming 
 agglutinated together in masses or groups, dotted here and there over 
 the field of the microscope. The microbe grown in different animals 
 present slightly different sizes, sometimes being found somewhat thicker, 
 aiid with more rounded ends. 
 
 It is found in nature in the bacillus or stafl'-shape, and sometimes m 
 long hair-like filaments. These, under certain conditions, become filled 
 with spores, like a chaplet or a string of beads. The spores elongate, 
 and develope into the full grown bacilli. 
 
 Thus we have, in the life-cycle of the microbe — spores, bacilli, and 
 filaments, and so on. From measurements I ha^e made, the spores are 
 uniformly one and a half millimetres long and three-quarters to eight 
 millimeti-es thick, and appear as bright shining dots under the mici'o- 
 
 •Op. cit.
 
 528 IKTEKCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 scope. The bacilli vary from four to ten millimetres in length, and 
 from one to one and a quarter millimetres in thickness, being slightly 
 thicker at the extremities. Where Klein, Crookshank, and some others 
 give twenty millimetres as a maximum of length, I think it is probable 
 that two microbes have been measured while they were joined end 
 on to each other, or that the bacillis was measured in the incipient 
 filament stage. 
 
 The same remarks apply to B. suhtilis, which closely resembles 
 B. anthracis. Filaments grow in the most fantastic forms, to great 
 length, and are practically immeasurable, owing to their hair-like 
 appearance. 
 
 In working with this subject, spores are only observed at certain 
 stages of cultivation, and filaments are mostly found in cultures, but 
 rarely in the ciedema at the seat of inoculation in an infected animal ; 
 while the bacillus itself, in lengths of from four to ten, and even 
 eighteen millimetres, is generally met with in the blood, spleen, and 
 tissues of an animal that has succumbed to the disease. 
 
 The spore-form is the most stable and persistent stage in the existence 
 of this microbe, and owing to the enormous powers of endurance of the 
 spore, through a wide range of temperature, it is possible to account for 
 the appearance, disappearance, and re-appearance of the disease, at 
 times and in places otherwise quite unaccountable. 
 
 Spores may be dried up to an impalpable powder, and preserved for 
 many years, and even subjected to a comparatively high temperature, 
 without losing their vitality. They appear to survive (although remain- 
 ing, of course, quite inactive) a temperature below the freezing point of 
 water, and likewise resist a temperature of 220° Fahrenheit. To be 
 quite sure of their destruction, a temperature of at least 260° Fahren- 
 heit is to be recommended. 
 
 Note. — A temperature of the boiling point of water is sufficient to 
 destroy the bacilli recently obtained from an infected animal, and hence 
 the knives and instruments used in dissection may be completely 
 disinfected by plunging them into boiling water. Towels, Arc, may be 
 thus cleansed at a temperature of 212° Fahrenheit. The most con- 
 venient disinfectant is a hot three per cent, solution of sulphate of 
 copper. 
 
 To obtain a pure cultivation of the B. anthracis (i.e., a virulent virus), 
 take a piece of glass tubing eight inches long and three-sixteenths of an 
 inch in diameter ; draw it out in the blow-pipe flame to a capillary 
 tube ; divide into two by holding again in the flame, taking care to seal 
 both ends ; insert a tiift of cotton-wool in the wider end. The tubes 
 are then to be sterilised, by heating in an oven to 260° Fah., discontinu- 
 ously, for half an hour on three consecutive days (Tyndall's method). 
 
 On exposing the heart of an animal just dead from the disease, slit 
 open the pericardium, and apply a cautery to any part of the organ. 
 Insert the point of the tube, which must have been just drawn througli 
 u spirit-lamp flame ; break the point in situ, and aspirate some of the 
 blood ; close the point by fusion in the flame, and the tube is ready. A 
 drop of this blood, placed in about two ounces of neutral meat extract 
 (bouillon) sterilised previously by heat, kept in contact with air, but 
 protected l)y a tuft of cotton-wool, and then placed in an incubator and 
 maintained at a temperature of 95° Fah. for forty-eight hours, will
 
 ANTHRAX IN AUSTRALIA. 529 
 
 yield a good crop of the B. anfJiracis in a state of purity. This is, to all 
 intents and purposes, a cultivation of virulent virus. 
 
 It is not absolutely necessary to maintain it exactly at 95°, as the 
 bacillus developes very well between 85° and 104° Fah., the tempera- 
 ture of a sheep being 103° Fah. At 125° Fah., the bacillus is killed; 
 but then, as I have mentioned before, it is necessary to raise the 
 temperature to 260° to be sure of killing the spores. 
 
 A culture grown in this way will be found full of bacilli. Allowing 
 the culture to remain a day or two longer, the bacilli assume the fila- 
 ment stage, and in a few days more this becomes visible to the eye as a 
 cloud or cluster of very fine filaments, which at last falls to the bottom 
 in a compact mass. 
 
 The formation of spores goes on between 64° Fah. and 109° Fah. 
 Below and above these temperatures, their birth and evolution is 
 hindered or prevented. Spores, however, e.vist both below and above 
 these points — in fact, below freezing-point, and above the hottest 
 recorded Australian temperature. Bearing this in mind, it is not difti- 
 cult to cultivate the bacillus in a medium so that only adult bacilli shall 
 be present, the spore growth being prevented, and altogether kept in 
 check, 
 
 A cultivation of this kind, which has been maintained for some days 
 at the spore-j)reventing temperature (107° to 109°) will become, as it is 
 called, attenuated; that is to say, it gradually ceases to possess virulence, 
 and at one particular stage, possesses the property of protecting animals 
 against the virulent virus of anthrax. Its injection under the skin of a 
 sheej) will set up a mild form of the disease, and become a protection 
 against the worst form of the malady. As age increases, the virus 
 gradually loses even this property, and finally, becomes inert. Not so 
 with the spores, whose vitality, on tlie other hand, is maintained for 
 years, even when dried to a fine dust. 
 
 After a culture has been maintained in a liquid medium for several 
 weeks, and the microbes ha\e l)een deposited as a silky tuft at the 
 bottom of the flask, the upper layer of clear limpid liquid maybe filtered 
 off, and upon injecting a sheep with this clear liquid, the sheep will not 
 contract the disease ; whereas, if some of the filament or cloud be mixed 
 with water, and injected under the skin, then all the symptoms of 
 anthrax appear, showing that it is the microbe B. anthracis, and it alone, 
 that is the cause of the disease, the microbe and its spore being the 
 true contagium vivum. It is well known that an animal having once 
 survived an attack of the disease, becomes insusceptible to a second 
 attack ; for it has been observed over and over again, that some sheep do 
 not take the disease at all, even where numbers from the same mob die 
 around them. It is highly probable that such sheep are spontaneously 
 protected, having had the disease in a benign form ; they become, in fact, 
 inoculated, are are thus able to resist the introduction of the microbe. 
 This resistance has been noticed in France and in Algiers. However 
 we may account for this phenomenon, we may call it natural immunity 
 or resistance, in contra-distinction to artificial vaccination, which I am 
 about to describe. 
 
 To Pasteur belongs the honour of having discovered the means 
 whereby an animal, susceptible to anthrax, may be protected when 
 placed in contact with the disease, and under circumstances when 
 
 iM
 
 530 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 infection is certain to occur, or even when the animal is directly 
 inoculated with the deadly virus of the disease. The discoveiy of 
 immunity by artificial means was first discovered in the case of chicken 
 cholera, and the method became the basis or touchstone for general 
 methods of protection in the case of other infectious diseases. In 
 making known his process at the International Medical Congress, held 
 in London in August 1881, Pasteur said: — " J'ai donne a I'expression 
 de vaccination une extension que la science, je I'espere, consacrera comme 
 un hommage au merite et aux immenses services rendus par un des plus 
 grande hommes de I'Angleterre, votre Jenner. Quel bonheur pour moi 
 de glorifier ce nom immortel sur le sol menie de la noble et hospitaliere 
 cite de Londres ! " 
 
 Vaccination against anthrax is accom})lished by injecting, hypoder- 
 mically, four minims of an attenuated virus of a known strength, obtained 
 by cultivation from the blood of an animal suffering from the disease. 
 A mild attack of the disease is set up, not enough to produce any 
 discomfort to the animal, imperceptible indeed, except for the rise in 
 temperature observed in the animal. The increase being from 103° 
 normal sheep's temperature to 105°, or perhaps 106°. This constitutes 
 the first vaccination, and of itself, is not sufficient to ensure the certain 
 protection of the sheep or cattle. A second vaccination is found 
 necessary, which is performed some fifteen days after the first. This 
 time, the attenuated virus is of an increased strength (vaccine No. 2). 
 The same quantity of vaccine is used, and the inner part of the thigh 
 is selected for the purpose of vaccination. 
 
 The observed increase of temperature is less than in the case of the 
 first vaccine, except in those cases where there was no increase at first, 
 and then a greater rise is always observed. In practice, the rule is 
 found to be — increase of temperature with No. 1 vaccine, gives little rise 
 with No. 2 ; whereas, a little or no rise with No. 1, gives a greater rise 
 in the case of No. 2 vaccine. 
 
 After the second vaccination, the sheep are protected, and possess 
 extraordinary powers of resistance. They may be inoculated with the 
 most deadly virus ; they may be inoculated with the blood taken, still 
 warm, from a sheep just dead of the disease, with absolutely no eflfect. 
 They may be placed in a pen of sheep that are dying and dead from the 
 disease, without the slightest effect. They may also be fed with infected 
 food, and live in infected paddocks, without taking the disease, and 
 finally, they may be fed on infected food mixed with chaff, thistles and 
 hard fibrous plants, and never become infected. This immunity is 
 found to last for twelve or eighteen months — sufficient time to enable 
 a flock master to safely pass through a season. 
 
 The susceptibility in various animals has been ascertained. In man, 
 the disease is called wool-sorter's disease, or malignant pustule ; and 
 wool-sorters, shepherds, butchers, fellmongers, ham-workers and tanners, 
 a)'e the most likely to suffer from its eflfects. Horses frequently become 
 infected, but in varying degrees, and in different countries. Cattle take 
 the disease very readily, but it is not always fatal. Pigs and dogs are 
 not usually susceptible, but if the former be fed on the offal from the 
 carcases of diseased animals, they have been known to become infected. 
 Cats rarely take the disease, and birds never, except when inoculated, 
 and even then, but seldom. Eats do not become easily infected. Sheep,
 
 ANTHRAX IX AUSTRALIA. 531 
 
 mice, guinea pigs and rabhits, are all readily susceptible; the greatest 
 known mortality being amongst slieep. 
 
 When Pasteur, Chamberland and Roux made known to the world in 
 1881 that sheep and cattle could be protected against anthrax, agricul- 
 turalists, veterinary surgeons and stock-owners were incredulous, and 
 looked for a sign or proof — in short, nothing less than a practical 
 demonstration in the eyes of the public was deemed satisfactory. The 
 question asked was, would it stand the test of practical experience in 
 the lield ? 
 
 The tir.st public demonstration was made in France, near the town of 
 Melun, on a farm known as Pouilly-le-Fort, on Thursday, the 5th of 
 May, 1881. Fifty sheep were obtained for the experiment; twenty- 
 five of which were to be vaccinated by Pasteur, while the other 
 twenty-five were to remain unvaccinated. At the suggestion of one 
 of the committee, a goat took the place of one of the unvaccinated 
 sheep, making twenty-four sheep and a goat for the unprotected series. 
 The entire lot of fifty animals were afterwards equally infected, 
 vaccinated and unvaccinated, alternately one after the other, every 
 one of the forty-nine sheep and one goat being inoculated with a 
 virulent virus. On Thursday, the 2nd of June, a great crowd 
 assembled to witness the results. In from forty-nine to fifty hours 
 after the inoculation, the four and twenty sheep and one goat that had 
 not Ijeen vaccinated were all found to be dead — the post-mortem 
 examination showing that anthrax had been the cause of death ; whilst 
 the twenty-five vaccinated sheep remained alive, and were found in a 
 sound healthy condition. 
 
 Some members of the medical profession who witnessed the demon- 
 stration, took notice of the fact, that Pasteur used a virulent virus that 
 he had himself provided — a circumstance that left some degree of doubt 
 in their minds. Wishing to have the most vigorous proof that it was 
 possible to obtain, another commission was formed to request Pasteur 
 to repeat the demonstration, all of the conditions to remain the same, 
 except one, namely, that the virus to be used should be the blood 
 taken direct from a sheep recently dead from the disease, and forthwith 
 used for the inoculation. 
 
 This request was unhesitatingly complied with, and the second 
 demonstration took place at an estate known as Lambert's Farm, near 
 Chartres, in Normandy. Again fifty sheep were submitted to the same 
 routine — half of them were vaccinated, the other half remaining un- 
 vaccinated. On the day of the final results of the demonstration, and 
 in the presence of a large number of persons, everyone of the sheep 
 underwent the ordeal of inoculation, with blood from a sheep that had 
 just died from the disease. The results were an unqualified success, to 
 the satisfaction of all the spectators ; being in fact, identical with the 
 trial at Pouilly-le-Fort. Every one of the unprotected sheep died in 
 forty-eight hours, while those that had been protected, remained ali\e 
 and well. 
 
 When Koch heard of Pasteur's discovery of the vaccine, and of the 
 demonstrations in France, he said, "it was too good to be true," and 
 shared the scepticism, common amongst the German doctors, as to the 
 truth of the fact. Anthrax being common in Gei-many, as well as in 
 France, it was not long before Pasteur was asked to come and protect 
 
 iM 2
 
 532 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 the German sheep. His reply was, " seeing the discovery is so warmly 
 contested in Germany, let there be a demonstration, such as we have 
 had in France." Accordingly, Dr. Kolott", of the Royal Veterinary 
 School at Berlin, applied to the Minister for Agriculture, and a 
 Commission was appointed. Pasteur sent M. Thiullier to go and 
 undertake the vaccination and inoculation, in the manner adopted 
 at the French demonstrations. The trial came off in the presence of 
 the celebrated Professor Virchow, Herr Beyer lieing President of the 
 Commission. 
 
 The demonstration took place that same year, on the Packisch 
 E.state, in the Kreis Liebenwerda, Mei'seburg, in Saxony. The pro- 
 gramme was practically the same as that at Chai'ti'es — diseased blood 
 being used for the inoculations. The success of the demonstration was 
 beyond all question, the full report being puljlislied in the Archiv fur 
 WissenscliaftUclie und Fraktisclte, Thierheilkunde von Rolofi" Miiller and 
 Schiiltz, Berlin XIII., Band 3, Heft s, 230, under the title, " Milzbran- 
 dimpfung in Packisch." 
 
 In April 1886, another series of practical experiments were made on 
 the efficacy of Pasteur's vaccine, when the question as to the necessity 
 of the second vaccination was raised. This was tested at Reit Nord- 
 hausen and at Kelba, when it was found that if the vaccination be 
 properly carried out — first and second vaccination — the metliod is 
 successful in protecting stock from anthrax ; but in the case of cows 
 that had only received the first vaccination, and were not thus fully 
 protected, two died of the disease, showing, as Pasteur has pointed out, 
 that the two vaccinations are reall}- necessary (" Jahresbericht fiber die 
 Verbreitung von Thiersenehen im Deutsche Reiche," Berlin, 1887, 
 Milzbrand,"^}). 12). 
 
 After the Packisch demonstration, Koch admitted the success of the 
 method, and openly stated it to be an excellent thing. He subsequently 
 published his own researches confirming the fact, and announced his 
 own independent discovery of an attenuated virus or vaccine, giving 
 the method by which he arrived at his results (" Mittlieilungen aiTS dem 
 Kaiserlichen Gesundheitsampte," Band. III., Berlin, 1885). 
 
 The next demonstration, which has special interest for Australians^ 
 took place at Junee in New South Wales, the Board already mentioned 
 having been appointed to watch and report upon the eflficacy of the 
 vaccine, and to report thereon. The plan of the demonstration was the 
 same as the one made at Pouilly-le-Fort seven years ago, and by 
 permission of T. AV. Hammond, Esq., the experiments were made on 
 his run, distant about a mile from Junee Railwaj^ Station. Arrange- 
 ments were made so that one member, at least, of the Board should be 
 on the spot, and in constant attendance, during the whole of the time 
 the ex|)eriments were in hand. Watchmen were kept day and night to 
 look after the stock-yard and sheep-pens, until the demonstration should 
 be concluded. 
 
 On the 4th of September, twenty sheej* and four head of cattle were 
 submitted to the process of first vaccination by Dr. Germont. The part 
 of the animal selected was the inner side of the right thigh. The surface 
 was first waslied with water, containing a few drops of carbolic acid, and 
 aV)0ut two minims of the vaccine injected under the skin by means of a 
 .small sterilised Pravaz syringe. Temi)erature of the sheep registered
 
 ANTHRAX I\ AUSTRALIA. 533 
 
 103° and 104° Fall. In forty-eiglit liours the temperature rose about 3°, 
 gradually falling to the normal. 
 
 On the 18th of September, the same lot of twenty sheep, which had 
 been marked and kept under supervision during the interval, were again 
 vaccinated by Dr. Germont for the second time, the general rise in 
 temperature amounting on an average to 4°. The inoculation was 
 arranged to take place on the 2nd of October, the sheep being timed to 
 die during the afternoon of the 4th. To roughly distinguish the sheep, 
 the vaccinated ones were left with their wool on, while the inivaccinated 
 sheep were shorn. The l)lood used for inoculation was taken direct 
 from the heart of a sheej) that had died of Cumberland Disease, or 
 anthrax, its history being as follows : — In May last, a sheep died from 
 anthrax at Uarah Station, contracted in the usual way in an infected 
 country. Some of the blood of this sheep was removed by Mr. Stanley, 
 Government Veterinarian, and kept in the office of the Chief Inspector 
 of Stock until the 13th of September, when it was handed over to me to 
 test its condition and virulence. As showing that the virus had lost none 
 of its vitality, two sheep inoculated died on the following day, thirty-two 
 hours after inociilation. Blood from one of these sheep was still retained 
 in my possession under lock and key, and a pure cultivation of the same 
 made and taken to Junee on the 29th of September. With some of this 
 virus a sheep was inoculated, so as to die just about the time when 
 required for the inoculation of the total number of sheep intended to be 
 used for the demonstration. The sheep died on the 2nd, and the 
 inoculation of the thirty-nine sheep proceeded with ; the blood, therefore, 
 was not obtained from, nor manipulated by, Pasteur's agents in any way 
 whatever. Nineteen healthy sheep were let loose into the same ja,rd 
 with the twenty vaccinated sheep; the whole thirty-nine were then 
 inoculated alternately, with two minims of blood, obtained direct from 
 the sheep that had just died from anthrax. 
 
 The results were clear and unmistakable. In a period averaging forty- 
 eight hours (maximum 60, minimum 27) every one of the nineteen 
 unvaccinated ones died, while the twenty vaccinated sheep walked about 
 amongst the dead carcases, eating food that was contaminated with the 
 sanious discharge from the diseased animals, and standing amid the 
 effluvium of the dead and diseased, unhurt, and in perfect health. 
 
 Of the cattle, four were vaccinated on the 4th and 18th of September, 
 at the same time and place. Two additional unvaccinated ones were 
 obtained, and turned in the yard with the others, and all six were 
 inoculated just after the sheep. 
 
 Results. — One of the unprotected cattle died, and the other recovered, 
 after severe illness. The four vaccinated animals showed no sign of 
 inconvenience from the inoculation. 
 
 The Australian Commission, appointed in the year 18.51, in their 
 Report, in view of what appeared to be the hopelessness of any cure 
 for anthrax, recommend the following rules: — 
 
 (1) That sheep, cattle, or horses, which have travelled through, or 
 rested in places where others have died from this disease, be kept 
 separate from all others for a few days (say fourteen), in order to 
 discover whether anv have caught the contagion. 
 
 (2) That when any one die.s, its body should be consumed by fire on 
 the sjiot where it is found.
 
 534 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 (3) That if moved for the purpose of being more conveniently burnt, 
 the body should not be di-agged along the ground; and the spot on 
 which it has lain should be chopped up, and scorched, by making a fire 
 on it. 
 
 (4) That consuming the body by fire is better than burying it. 
 
 (5) That travelling stock should, if possible, avoid every resting 
 place where any animal has died of the disease. 
 
 (6) That some means should be devised to keep the highways clear 
 of dead bodies. 
 
 (7) That a place should be provided in the suburbs of Sydney, to 
 which animals dying in the city, of disease or accident, could be taken 
 and burnt. 
 
 One cannot but admire the thoroughly practical and eflicacious 
 methods suggested by these pioneers, for looking back at our progress, 
 one can safely say that (vaccination excepted), no better means of 
 prevention could have been adopted in cases of epizootic anthrax, even, 
 after thirty years of scientific advancement. 
 
 When an animal dies of antlirax, the carcass should be completely 
 destroyed by fire. If buried, the ground will ever afterwards be infected, 
 unless, perhaps in the case of a bush fire passing over it. Pasteur 
 proved, that the long continued state of infection of certain soils, was 
 due to earth worms, and although the idea was criticised and opposed 
 by Koch, yet the show of reason lay on Pasteur's side. The matter 
 yielded at last, to a practical experiment. The carcass of a sheep was 
 buried in a certain paddock, and the grave was fenced all round, after 
 some time, the grass having grown on the spot, some sheep were folded 
 upon it, and everyone of these sheep died ; whilst in the case of a 
 number of sheep placed in an adjoining paddock, not one were afi'ected 
 in any way. 
 
 There is little doubt that anthrax was imported into Australia from 
 France and Germany. In 1797, Captain John Macarthur introduced 
 the merino sheep, to cross with the hairy-woolled animals then existing 
 in the Colony. Dr. Lang, whose memory is still green amongst us, and 
 whose statue is now being erected in Sydney, speaking of the eflTorts of 
 Macarthur in improving the breed of sheep, said :— 
 
 " The obligation under which he has consequently laid the Colony in 
 all time to come, througli his unremitted perseverance, and unexampled 
 success, are great beyond all calculation." 
 
 Some of the sheep breeders since jNIacarthur's time do not appear to 
 have had the best interest of the country at heart, according to Robert 
 Mestou, who, in a report presented about that time to the Legislature 
 of New South Wales, says : — " The most energetic attempts have been 
 made in general to up.set the good work of Captain Macarthur, justly 
 called the first. Every petty state of Germany was hunted over for the 
 purpose of obtaining sheej) with fine wool and weakly constitutions, 
 further to corrupt the remaining true merino blood of this colony." 
 After describing some of the alleged causes of disease amongst the sheep 
 of the colony, and the tendency of some stockowners to sacrifice every- 
 thing to quality and texture of the wool, he reconmiends that a 
 Professorslii}) of Agriculture and Pastoral Pursuits should be established 
 in the colony, and he concludes by urging preventive, rather than
 
 A NOTE ON PASTEUR'S METHODS, 535 
 
 remedial measures against the diseases of sheep, a consummation towards 
 which the Junee Demonstration is, I think, the latest and most valuable 
 step hitherto made. Hence the introduction of the Rambouillet sheep, 
 and the heavy fleeces of Germany, have not been without their attendant 
 disadvantages and losses to the squatter and pastoralist, who have to 
 reckon with their insidious foe, charbon or milzbrand. 
 
 Losses sometimes occur through imperfect manipulation during the 
 process of vaccination ; for unless sanitary and efficient antiseptic 
 precautions ai'e observed, septicaemia may be set up, or the animal may 
 die from other causes. In practice, the loss attendant upon vaccination 
 amounts to one per cent, for sheep, and half per cent, in the case of cattle. 
 
 A Selection from the Bibliography on the Subject. 
 
 Branell — " Virchow's Archiv," xi, xiv, xxxvi, 1857, 1858. 
 
 Ueber Milzbrand, Bollinger — CentralUatt filr d. Med. Wissenschaften, 
 
 June 29, 1872. 
 Koch — " Die ^tiologie der Milzbrand-Krankheit, begiindet auf die 
 
 Entwick des Bacillus Anthracis. Beitrage zur Biologie der 
 
 Pflangen de Cohn, 1S76." Bd. 2, heft 2, p. 277. 
 Pasteur and Joubert — '' Comptes Ilendus." Tome 84, 1877. 
 Greentield — "Report Medical Officer Local Government Board, 1881." 
 "Ueber die Experimentelle Erzengung des Milzbrand Contagiums." 
 
 Dr. Hans Buchner, Mi;nchen, 1882. 
 Pasteur — " Sur la Vaccination Charbonneuse, C.R." Tome 92. 
 Pasteur— Reply to Koch — Revue Scientifique, June 20, 1883. 
 " La Vaccination Charbonneuse." Par A. Chamberland and Bernard 
 
 Tignol, Paris, 1883. 
 Gaffky und Lceffler — Mitteil. ausd. Kaiserlich. Gesundheitsampte, 1884, 
 " Zeitschrift fiir Hygiene." I. Band 3, 1887 and 1888. 
 " Der Bakterienkunde." Frankel, Berlin //iVsc/it^aW, 1887. 
 " Le Charbon des animaux et de I'Homme." T. Strauss, Paris, 1887. 
 Pasteur—" Annales de I'Institute." 1887 and 1888. 
 
 A NOTE ON PASTEUR'S METHODS. 
 By M. Crivelli, M.D. Paris. 
 
 In glancing at the programme of communications for the Congress, I 
 noticed that Dr. Wigg was going to read a note on Pasteur's methods. 
 
 Having had the ]>leasure of meeting Dr. Wigg, I heard he was going 
 to combat principally the remedy against rabbits, and the treatment of 
 hydrophobia. 
 
 I mark with pleasure, that Dr. Wigg does not intend to attack 
 Pasteur's work on Cumberland Disease, and its vaccination — a discovery 
 now universally adopted, which no one doubts, and the efficacy of which 
 Drs. Germont and Loir have shown in such a conclusive way a short time 
 ago in New South Wales.
 
 536 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Firstly, as regards Pasteur's remedy against the rabbit pest, I regret 
 that 1 have not time to complete any long and scientific work, or to look 
 up all the documents aboiit the microbe of chicken cholera, that I would 
 like to give you. Also, I cannot here undertake a technical discussion. 
 I cannot however accept, and I must protest, when I am told that the 
 experiments made in Australia are a failure, when they have succeeded a 
 number of times all over the world. 
 
 After waiting and talking for six or seven months, these experiments 
 were at last allowed to be made, and everyone has in mind the success 
 which The Argus recorded. All the rabbits on the small island on 
 which the experiments were made, were destroyed, whilst none of the 
 other animals contracted the least indisposition. 
 
 The disease produced is so little contagious, that Drs. Germont and 
 Loir offered to eat the flesh of some animals inoculated with this microbe. 
 The contagion affects rabbits, and in no way does it afiect other animals. 
 It was said that birds were liable to take it. This has not been proved, 
 at any rate in the case of fowls. Does it not remain a fact, that the 
 rabbits were destroyed, as was announced ? Why are complementary 
 experiments not undertaken? For more than eight months Pasteur's 
 delegates have been here, ready to perform all the experiments which 
 they may be asked for, and certainly quite willing to try and convince 
 all who have doubts. 
 
 Secondly, in reference to hydrophobia. — I have here sufficient proofs 
 to convert Dr. Wigg, and I hope he may be convinced. I do not argue, 
 but bring figures and facts. That recovery from hydrophobia does occur, 
 is everywhere admitted. The most incredulous have, after a careful 
 study, been convinced, and there are now branch establishments of 
 Pasteur's Institute in nearly all parts of the world. 
 
 There is only one celebrated detractor of Pasteur — Professor Peter. 
 Dr. Wigg has read Peter's criticisms, which are based, on I do not 
 know what statistics, which have been falsely given. I regret very 
 much that Dr. Wigg is not in possession of all the discussions which 
 took place at the Academy of Medicine of Paris on this subject, and at 
 which Peter's arguments were completely and surely destroyed, one after 
 the other, and himself reduced to silence. In one or other of the many 
 and keen scientific discussions that have taken place on this subject, every 
 argument has been employed for and against anti-liydro])hobic vaccination 
 — its adversaries declaring it useless or dangerous ; its partisans pro- 
 claiming it inoffensive and wonderfully useful. The battle, after being 
 stopped for some months, was resumed in Pasteur's presence, when 
 presenting the report of the English Commission to the Academy. This 
 official commission, composed of the first scientific men of England, 
 and of a young and clever physiologist, Mr. V. Horsley, as reporter, 
 went to Paris full of incredulity. After a careful inquiry into the facts, 
 this commission returned to England, and repeated Pasteur's experiences 
 for more than a year ; the conclusion being, to the great disappointment 
 of his adversaries, that " M. Pasteur had discovered a ])reventive method 
 for hydrophobia, comparable to that of vaccination against small-pox." 
 This is a quotation from their report ! 
 
 There are now in the world more than twenty anti-hydrophobic 
 institutes. Besides those in Paris, there are seven in Russia: — Odessa, 
 St. Petersburg, Moscow, Varsovia, Charkow, Samara and Tifflis, and five
 
 A NOTE ON Pasteur's methods. 537 
 
 in Italy : — Na])les, Milan, Turin, Palermo and Bologne (these last two 
 recently created and endowed by the King). There is one in Vienna, 
 one in Barcelona, one in Bucharest, one in Buenos Ayres ; and, to 
 conclude, in Chicago and Malta two new laboratories are being 
 organised. 
 
 The Anti-hydro})liobic Institute of Paris is in constant relation with 
 all these laboratories, the directors of which have all studied Pasteur's 
 method at Paris, so as to apply it to their patients with all its jn'ogressive 
 improvements. 
 
 I will now give you the official statistics of the Pasteur Institute since 
 its opening, as embodied in the report which was read before the 
 President of the French Bepublic, at the inauguration of the new 
 Institute : — 
 
 From the lirst, the patients have been classified in three classes, 
 A, B, C. 
 
 The Class A contains all the patients v iiich have been bitten by 
 animals, known by certain proofs to be absolutely mad. 
 
 In Class B are those bitten by animals stated to be mad, by certi- 
 ficate from veterinary surgeons. It is the frame the most filled. 
 
 Lastly, Class C is for patients bitten by animals supposed to be mad. 
 Suspicion here is based on the circumstances of the accident. 
 
 The number of people treated in Paris, in the years 1886-1887, 
 and for the first half of 1888 is 5374. In 1886, when strangers were 
 numerous, there were 2682 people inoculated, 1778 people in 1887, and 
 914 up to the 1st July, 1888. The mortality, counting all the deaths, 
 including even those taken ill the day after treatment is — For 1886, 
 1-34 per cent.; for 1887, 1*12 per cent.; for 1888, 0-77 per cent. 
 
 Foreign statistics are in accordance with those of Paris. In St. 
 Petersburg, in the laboratory founded by His Imperial Highness, 
 Prince Alexander of Oldenburg, and endowed by him, there have been, 
 from the 13th July, 1886, to the 13th September, 1888, 484 patients; 
 the mortality numbering 2 '68 per cent. From information given by 
 Dr. Kraiouchkine, this mortality is explained by the extreme gravity of 
 the bites. 
 
 In Odessa, in the laboratory managed by Professor Metchnikofi', 
 Dr. Jamaleia has vaccinated — In 1886, 324 patients, by simple treat- 
 ment; mortality, 3-39 per cent. In 1887, 34.5 patients, by intensive 
 treatment; mortality, 0*58 per cent. In 1888, 364 ])atients, by the 
 intensive treatment; mortality, 0*64 per cent. During these three 
 years, 1135 patients have been submitted to the anti-hydrophobic treat- 
 ment, with a mortality of 1'41 per cent. 
 
 In Moscow, at the Anti-hydrophobic Institute, founded imder the 
 patronage of Prince Dolgorovtow, there have been vaccinated — In 1886, 
 107 patients, by simple treatment; mortality, 8 '40 per cent. In 1887, 
 280 patients, by intensive treatment; mortality, 1-27 per cent. In 
 1888, 246 patients, by intensive treatment; mortality, 1'60 per cent. 
 
 At Varsovia, M. Bujivid inoculated 297 patients by simple treatment, 
 the mortality being three j)er cent.; 370 patients by the intensive 
 method, mortality till now, 7ii/. Already sixteen months have elapsed 
 since the first application of this method, and two months since the 
 treatment of the last patient.
 
 538 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 In Samara, Dr. Parchenski vaccinated fifty-three patients, of whom 
 four were bitten by wolves. The mortality here (very high, 5-67 per 
 cent.), is explained by the fact of the treatment not being sufficiently 
 energetic and kept up, as explained by Dr. Parchenski. 
 
 At Charchow, probably for the same reasons, but without knowing 
 precisely, Dr. ProtopopofF vaccinated 233 jDatients, with a mortality of 
 3-80 per cent. 
 
 In Milan, Dr. Bai-atieri vaccinated 335 patients ; two are dead,^ 
 notwithstanding the treatment. Mortality, 0"60 per cent. 
 
 In Palermo, Professor A. Celli vaccinated, from the 1st of March 
 to the 30th September, 1888, 109 patients, without one failure. 
 
 In Naples, Professor Catani, assisted by Drs. Vestea and Zagari, 
 was forced to close his laboratory, not receiving any income from 
 the municipality from January till August, 1888. In that town, 
 Pasteur's numerous adversaries, notwithstanding a vote of confidence 
 and encouragement from the Academy, had succeeded in shaking public 
 opinion, and in disposing the municipality against Pasteur's method. 
 But during this period of seven months, nine deaths by hydrophobia 
 having occurred in Naples, the municipality agreed to give an 
 endowment. The Government and the province of Naples also 
 promised some help, and the laboratory has been opened once more ; it 
 is novv in full working order. Two hundred and forty-six patients have 
 been vaccinated in Naples — 199 since the opening of the laboratory 
 (22nd September, 1886) till January 1888, and thirty-four since its 
 re-opening. Mortality after vaccination being 1*5 per cent. 
 
 In Havanna, in the Anti-hydrophobic Institute of Dr. Santos Fernandez, 
 Dr. Tamayo inoculated 170 patients, amongst whom fifty had been 
 bitten by animals proved undoubtedly mad. Mortality being 0*60 per 
 cent. 
 
 In Pio de Janeiro, at the vaccinating station due to His Majesty the 
 Emperor of Brazil, Dr. Ferreira dos Santos vaccinated fifty-three 
 patients. Up to date, there have not been any failures. 
 
 The foregoing statistics are official. I have the documents in hand. 
 Other statistics I do not admit. After enumerating these results, I do 
 not add any commentary. They furnish the most eloquent answer to 
 the detractors of the Pasteur method, for no one can demolish them. 
 
 I will conclude by saying, that I hope Australia may be always 
 jirivileged, and continue to be kept free from hydrophobia by the severe 
 measures which do honour to its legislators. But, should there be any 
 ]iydroi)hobia here, I am confident Australia would not allow herself to 
 be surpassed by all the other nations, and that there would be a branch 
 of the Pasteur Institute established here ; and I prophesy of Dr. Wigg 
 that, knowing his love of truth and his professional integrity, he would 
 be amongst the first to vaccinate his own patients.
 
 IS CHOLERA QUARANTINE SCIENTIFICALLY SAKCTIONED. 539 
 
 IS CHOLERA QUARANTINE SCIENTIFICALLY 
 SANCTIONED 1 
 
 By K. R. KiRTiKAu, M.R.C.S. Eng., L.R.C.P. Lond. 
 
 Surgeon H.M. Bombay Army. Civil Surgeon, Thana. 
 
 India lias been tlie home of cholera for ages past. India's commercial 
 relations with England, I may even say with Europe, ai-e daily getting 
 stronger and stronger. The wonderful speed with which steam com- 
 munication between the two countries takes place, has rendered the 
 transportation of infectious and contagious diseases from India to 
 Euro])e more frequent. The chances of the introduction of cholera, 
 therefore, from the one country to the other, are daily increasing. 
 India is never free from cholera throughout the year, or at any rate, 
 at some part of the year. In some part of the country or other, there 
 is cholera present, either in an epidemic, or a sporadic form. 
 
 When we remember the formidable nature of this disease, it is but 
 natural that there should be a strong desire on the part of the authorities 
 who regulate the international communication of the different countries, 
 that the disease should not only be kept at arm's length, but stamped 
 out; that the ships from Indian ports, coming from an infected locality, 
 should not be allowed to be the importers of cholera into the harbours 
 which they touch. Eight days' quarantine, or ten days' quarantine, is 
 sometimes enjoined. This has been considered by some not so much 
 as a hardship, and as an infringement of one's rights, on account of 
 ignorance on the part of the advisers of the respective authorities 
 enjoining the quarantine; nor even so much as a personal grievance, 
 but, what is most ridiculous, a practice not borne out by the most 
 advanced and acce[)ted scientific principles of the day. It will be my 
 jmrpose to show this to you briefly. 
 
 It must be remembered, that cholera is a protean disease — insidious 
 and sudden — as sudden in coming, as it is in departing. No two 
 epidemics are alike, and each man who observes it clinically, observes it 
 as lie tinds it. Writers have therefore differed most mateiially some- 
 times, and this is the reason why the true etiology of the disease is 
 buried in so much mystery. 
 
 In India, the cholera question is looked at from two points of view. 
 We have what I woidd call the sceptics, or as Dr. de Chaumont calls 
 them Nihilists, who think, and very rightly too, that the true cause of 
 cholera is unknown. They believe that there is some telluric, climatic, 
 atmospheric, unknown condition, which influences its rise, spread, and 
 subsequent subsidence ; that cholera does not spread by human inter- 
 course, and that even if it were demonstrated that it did so spread, 
 nothing could be done to prevent such intercourse. They further 
 maintain, and .strengthen their position I think, by advancing the fact, 
 and it is a fact borne out by my individual experience of over fifteen 
 years, " that attendants on cholera cases, do not necessarily suffer from 
 cholera, nor ai-e they attacked in larger proi)ortions, or with greater 
 frequency than other classes of peojile, which they would certainly be, 
 had cholera been propagated purely by human intercourse by human
 
 540 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 contagion and infection." Further they say, that " isolation of the sick 
 and disinfection of the discharges, are valueless." — (Cunningham.) 
 
 There are others who maintain certain pet theories, who ignore 
 the experience of others, and force their own on the world. I class 
 them under the head of alarmists. Chief among these, are those who 
 attach undue importance to one or other particular cause, such as human 
 intercourse. This is rather a comprehensive term. Dr. Duncan, a young 
 Bengal Surgeon of the Indian Medical Service, who has recently been 
 awarded the " Parkes Memorial Medal," for 1886, for his essay on the 
 prevention of disease in tropical and sub-tropical campaigns, and who 
 is a vigorous, I should say an uncompromising, advocate of the human 
 intercourse theory, includes vnider these two words, the following 
 incongruous mass of one thing and another : — " suffice it," he says*, 
 *' to enumerate the air, the drinking water, the cooking water, the solid 
 food, the bedding, the tents, the bodies of the dead ; and dominating all 
 these, the dejecta of the sick or their effluvia." It is forgotten by this 
 class of thinkers, that when cholera breaks out in an epidemic form in a 
 town, several cases occur all at once, having no connection with each 
 other of any kind. Where cholera is endemic, one case may occur or 
 one hundred at a time, without personal contact. Some of these mono- 
 theorists attach so much, and such undue, importance to drinking water 
 alone, that they get completely lost in their solitary idea, and think of 
 no other equally potent, or even under some circumstances a more 
 potent, or perhaps the only mode of infection. Thus, for instance. 
 Dr. JNIadSTamara says: — "That if we only preserve the drinking water 
 from contamination, it is out of the question, cholera should become 
 ej)idemic in either town or country." In saying so. Dr. MacNamara 
 furnishes me with an argument against cholera quarantine. A cholera 
 case, according to him, may remain in the close vicinity of the drinking 
 water reservoir without danger, i.e., he would say : — " Guard the water 
 against the inroads of the affected person, and you need not fear his 
 presence." It has however been my experience, that other causes than 
 contamination of water have brought on cholera, such as tainted food 
 supply. Cholera has prevailed under my eye in Sibi, and in Thana, 
 notwithstanding a pure and uncontaminated water su]:)ply. In June 
 1879, during the late Afghan Campaign, I was in medical charge of the 
 outpost at Sibi, in Southern Afghanistan. Our water supply was run- 
 ning and abundant, coming down from the Nari gorge clear, sweet, and 
 uncontaminated. There was no cholera in its ripal villages. The river 
 runs north to south. Cholera, on the other liand, had been marching 
 from south to north, in the line of our communication, from Sukkur, 
 Jacobabad, through Kutchi Pat — a barren waterless tract in Balochistan, 
 extending over ten miles. It touched the towns of Haji-ka-shaho and 
 Bugh, killing several men along the southern course of the Piiver Nari, 
 to the north of which we had our outpost (infantry, cavalry, and native 
 followers) flocked together. This ei)idemic of cholera subsequently 
 i-eachod Dadur, and only thence came to us, as we received our rations 
 from th(! Dadur Depot Commissariat. Not long after, it i)assed through 
 the Bolan Pass, and thence it went on to Quella. Thence it travelled 
 on through the Sind Hor.se Cavalry post at Khooshdilkhan, and tln'oiigh 
 
 ' Op. cit., p. ai2.
 
 IS CHOLEKA CiUAHANTINE SCIENTIB'ICALLY SAKCTIONED. 541 
 
 the Khojak Pass on to Kandahar, at the speed at which human inter- 
 course can reach from place to place. Now, if we liad held the sole 
 theory of these drinking water alarmists, we should have felt ourselves 
 insecure in our outpost only, on account of our water supply, or rather 
 secure because our river was running north to south, and we might have 
 misspent our energies. But I knew it was no good lending myself to 
 one theory, and I was prej)ared for an outbreak, and as sure as anything 
 it came our way before it had travelled through the Bolan Pass. This 
 stands on the records of the Deputy Surgeon-General of the Sind 
 Division, under whose orders I was then working. 
 
 We have now to take cognisance of the germ theorists. The germ 
 theory is a mighty question, vast in its extent, difficult of verification, 
 and weighty in its results. It is at present in its infancy; it would be 
 presumptuous to discuss its merits here; it would be premature, and even 
 perilous, to consign it to oblivion. We are living in the age of microbes. 
 Koch, with all the advantages of modern microscoi)ical ajjpliauces, claims 
 that he has demonstrated that cholera is due to a specific bacillus which, 
 under certain favourable eii-cuu)stances, can live and multiply. Those 
 favourable circumstances are principally tlie alkaline state of the human 
 intestines. Koch further says that the acid secretions of the stomach 
 destroy it, that it is present in every cholera stool, and that it is the 
 cause of Cholera- A siatica. Now, Gentlemen, the e^■idence which connects 
 the particulate organism, or the comma bacillus, with the origin or 
 causation of the disease itself, is highly unsatisfactory. It has yet to be 
 proved what the contagium vivum of cholera is, and how it is carried 
 about, whether as a s])ore, or as a bacillus ])ure and simple; for be it 
 remeinbei'ed, according to the latest classification of Professor De Bary, 
 the cholera bacillus, whether it is a bacillus, or a vibrio, or a spirillum, 
 or the repi-esentative of a genus midway between bacillus and spirillum, 
 as Trouessart says it is believed to be, it is one of the endosporous 
 bacteria, i.e., having their spores formed endogenously, whether Koch has 
 been, or will be able to find its spore or not. 
 
 Klein thinks the poison of cholera is of the nature of a ptomaine. 
 Bellew, an officer of vast Indian experience, calls it an influenza of the 
 raucous membrane of the intestinal canal. 
 
 Such is the state of our present knowledge — theories beai'ing out 
 certain points, and conflicting on the other hand with certain other 
 equally well noted experiences. Now let me })roceed to examine how 
 our pi-esent stock of knowledge helps us in the consideration of the 
 question of quarantine. Dr. Duncan's work supplies me abundantly 
 with facts which can be used against the present system of quarantine : — 
 (1) Dr. Van Gazel, of Gangam, gives an instance of what occurred in 
 his district. "In 1885," he says, "cholera raged all over the Gangam 
 District, but Gopaulpore suffered immunity. The villages in the 
 neighbourhood of Go])aulpore were all affected, communication from 
 which daily occurred "with Gopaulpore. But the latter village had, 
 absolutely, no tanks whatever." Thus it follows, that if the tanks were 
 stopped from being contaminated, were covered up, closed entirely for 
 washing purposes, there would be no necessity for quarantine. (2) Dr. 
 Duncan says : — " Reviewing all evidence, we see that evidence, involving 
 practically all parts of India, coincides in one direction. The investiga- 
 tion of those in chief sanitary authority bear testimony, as conclusive as
 
 542 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 testimony can be, that cholera-polluted water is the cause of cholera 
 epidemics." Nevertheless, such evidence has been passed over as one- 
 sided, and held to be of no value. (3) Dr. Johnson, of Hong Kong, 
 declared at the Medico-Chirurgical Society, that the disease was 
 frequently introduced there, yet it never became epidemic; and this he 
 showed to be entirely due to the excellent water supplied and obtained 
 from lofty reservoirs on Victoria Park, and used by the inhabitants. 
 He was also in charge of a man-of-war, which entered Shanghai 
 harbour at a time when cholera was raging round him. Some of the 
 crew became infected. Immediately all on board were ordered to drink 
 distilled water. The ship steamed away north, and the epidemic 
 ceased. There were other ships also infected, which likewise went away 
 north ; but as they were using the water they had brought from shoi-e, 
 cholera continued, and only stopped with the stoppage of the tainted 
 water, and use of the distilled water instead. If, as Dr. Duncan says, 
 water is the only medium for conveying poison, as long as the water is 
 protected, there is no scientific reason whatever why harbour quarantine 
 should be enforced, supposing a ship came from an infected locality, had 
 no sick men on boaixl, but was kept out merely Ijecause it is the 
 rule, and it may be that a case of cholera may occur. This leads us to 
 the consideration of the question of incubation. How long can a man 
 be actually with the cholera germ in his system, and yet apparently 
 well. Dr. Pringle fixes it at two days. It is not very easy to determine 
 this. It may be ten days, or even more. (4) The next argument 
 against cholera quarantine is, that it is a noted fact that epidemics do 
 not arise in a town from one imported case, especially if the town is 
 healthy, and the cholera stools are carefully disposed of (burnt), and thus 
 effectually destroyed. (5) Professor Frankland's experiments show 
 that Koch's bacilli grow very quickly in sewage. Thus, where the 
 cholera stools are not brought into contact with sewage, there is no 
 necessity for jn-eventing ship's men from landing if the ship comes from 
 an infected locality, or even if they have a cholera case on board. 
 Frankland's experiments would seem to conflict with Koch's, however, 
 for we know that in sewage there are putrefying organic matters, and 
 Koch has shown that the existence of putrefaction arrests the growth of 
 cholera organisms. Here, then, is need for fui'ther research, as Pro- 
 fessor Koch himself allows. (6) The next argument against cholera 
 quarantine is the idea that " stools are the most important poison 
 bearers, if not the only poison bearers." If, therefore, you destroy the 
 stools, by burning them, you need not insist on quarantine. Koch and 
 Pettenkofer urge that tlae cholera stools are poisonous directly after 
 they are i)assed, whilst Thiersch would hold that a certain change is 
 necessary before they attain their infective power. Corrosive sublimate 
 is considered the l)est and most reliable destructive agent for orerms — a 
 five per cent, solution. I say burn them. (7) I may add that Professor 
 Lebert, of Breslau, does not believe in quarantine' at all. 
 
 In the face of Koch's theory, that the drying of cholera bacillus in 
 mere open air kills the germ, the process of disinfection is rendered 
 unnecessary, and cholera would seem to be shorn of all its pristine 
 gravity. "The dread of cholera must vanish ; and the necessity of 
 disinfecting, entailing such a large expenditure of money, time, and 
 energy to municipalities and health boards to find disinfectants and
 
 IS CHOLERA QUARANTINE SCIENTIFICALLY SANCTIONED. 543 
 
 germicides, should, a priori, vanish, especially in such a hot country 
 as India ; but it has been my experience that, in a temperature of 
 115° in the shade, and 130" in the o)jen, lasting for over six hours — 
 when medicine bottles have gone to pieces, and measure glasses cracked 
 from sheer heat — we could not kill cholera germs straight off (as would 
 be imagined should have happened of a necessity if Koch is right), when 
 cholera bioke out in our outj)ost in the hot plains of Sibi, in the 
 year 1879. If Professor Koch is right, well may Cunningham, Hunter 
 and Fayrer, who represent the sceptical school, exclaim, " Our task 
 is done ! Mere act of drying is enough disinfection ! We don't insist 
 on more !" Dr. Cunningham says the same thing. He says there is 
 abundant evidence to show that isolation of the sick, and disinfection 
 of the discharges, are valueless. Koch however recommends, as an 
 additional measure, boiling of clothes and bedding for an hour, and 
 soaking in a solution of cori'osive sublimate (four ounces to a gallon) for 
 two hours; or immersion for twenty-four hours in a weak solution of 
 carbolic acid (two per cent.) and chloride of lime (one per cent). 
 
 As long as the true period of incubation is not settled, quarantine by 
 sea cannot be fully established. In a report on the diffusion of cholera 
 and its ))revalence in Europe during the ten years 1865-74, submitted 
 to the Medical Officer of the Privy Council by Mr. Netten Ptadcliffe,* we 
 read as follows: — "The experience of this country since 1865 has 
 tended to show that cholera may be carried greater distances in a latent 
 or undetected form than had previously been suspected. The instances 
 I have already quoted, of bodies of emigrants travelling from infected 
 districts of the Continent across the German Ocean, and across 
 England, several days' sail out into the Atlantic Ocean before any sign 
 of cholera was manifested among them, are peculiarly instructive with 
 regard to the question now under consideration." What then is the use, 
 I ask, from a scientific point of view, of subjecting a ship from an 
 infected port, from India for instance, to mere eight or ten days' 
 meaningless quarantine 1 There is no rational answer. 
 
 The common mistake that is made in connection with the question of 
 quarantine by sea and by land is, that the term "human intercourse" is 
 understood to mean '•' propagation." The terms are made co-extensive. 
 The one may lead, I admit, to the other ; but is not, nor need be, 
 the sequence of the other. There may be ever so much human inter- 
 course ; but if, as the necessary condition of that intercourse, there 
 is every care taken to destroy or disinfect the discharges from a cholera 
 patient, then I submit, all the necessary precautionary measures so 
 far as we understand them, and so far as we can control them, will have 
 been adopted, and every possible danger averted. 
 
 The Vienna conference of 1874 unanimously accepted the conclusion 
 of the Constantinople conference of 1866, that "Cholera is transmissible 
 by goods employed for personal use coming from an infected place, and 
 especially by such as have been used by cholera patients ; and that 
 there are even facts which show that the disease may be conveyed to a 
 distance by such goods if they have been kept close and unexposed to 
 free circulation of air." This is what the Vienna conference admits. 
 If it be so, then it stands to reason that there would be transmission of 
 
 * EeportB of the iledical Officer of Privy Council. New Series, No. 5, p. 146.
 
 544 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 cholera possible by merchandise arriving from an infected locality. The 
 possibility of such an occurrence is even probable. Take, for instance, 
 the case of the Indian wheat and rice, and other articles of food that 
 annually leave the shores of India for the European markets. India 
 is no longer the curiosity shop it was in the olden days of the East 
 India Company. It is no longer the repository of the barbaric pearl 
 and gold. That envied position is now transferi'ed to your colonies. 
 India is now the granary of England, and is daily increasing in 
 importance. 
 
 To give you an idea in quantity, take the wheat sent out from India 
 in 1873. It was one and three-quarter million cwt. ; it is now sent out 
 to the extent of twenty-one million cwt. Up to 1875, the export of oil 
 seeds have averaged about four million cwt. ; " but," says Sir William 
 Hunter, " they were freed from duty, and by 1885 the quantity exported 
 had grown to eighteen million cwt." Tlie rice trade has not shown such 
 considerable increase, but still we send it out to Euro[)e in large 
 quantities enough to infect all England, or even Europe, if tainted with 
 cholera poison. Now wlien we come to think of the habits of the people 
 who gather the corn and the oil seeds from fields and forests of India, 
 and when we know they are by no means scrupulously clean, or mindful 
 of sanitary laws, if at ail they are made aware of them, I cannot helj) 
 thinking and even feeling a sort of apprehension, that the more our 
 Indian grain bags are exposed for sale in European markets, the greater 
 is the chance of cholera contagion being introduced from the east to the 
 west — from India into Europe. When ships carry such bags from 
 tainted localities, is it not reasonable to expect that they should be 
 subjected to quarantine rules ? But how are the authorities to know 
 where the bags come from — from tainted cholera districts, or otherwise 
 themselves tainted, or not? All this it is impossible to know; the 
 exporting merchants won't know it, and won't tell if they know it; the 
 inland field purchaser, or broker, would hardly be aware of the danger 
 of buying the grain in a cholera-stricken locality ; and what is the 
 result 1 Practically, the grain coming from a cholera-stricken country, is 
 exempt from sanitary rules and quarantine cordons; and the human 
 being — clean washed men and women, coming from cholera-stricken 
 localities — perhaps equally tainted, or maybe, quite untainted, have to 
 go through the rigid observance of quarantine rules ! Is it not all a 
 farce 1 I ask, therefore, are not our present quarantine measures highly 
 unscientific 1 
 
 What Sir Ranald Martin said years ago, applies with still greater force 
 to the circumstances of our own day : — " Quarantine can no longer be 
 adopted," he says, "as the means of preventing the entrance of cholera 
 into England, for it is incompatible with the present state of commercial 
 intercourse, and with the well-being of a commercial country." Far 
 ])etter, I say, therefore, would it be to direct our whole and sole energy 
 to the isolation of those who are actually sick, and to the destruction of 
 their excreta, than to waste our time, energy, and money in carrying out 
 what is a mere mockery of (juarantine — a shadow, instead of the 
 substance. Koch has said that cholera has never reached Europe from 
 India by merchandise; "we have," he says, "letters and parcels sent by 
 post; they have never carried cholera." This aftbrds an additional 
 argument against the jjresent quarantine arrangement. Yet it can never
 
 FEDERAL INSPECTION OP FOREIGN-GOING SHIPS. 545 
 
 be said tliat cholera may not be so transferred. I have handled 
 hundreds of daily cholera re])orts sent to me by village officers and town 
 officers from infected places, where cholera has often fiercely raged, but 
 neither have I, nor my assistants, ever suffered from the disease, and 
 hope never may. Pettenkofer very rightly observes, that a germ of 
 cliolera may remain latent even a whole year, he does not know exactly 
 how long. 
 
 Mr. John Simon, tlie great sanitary patriarch of England, has said, 
 and said truly, " that Her Majesty's Government has been now for 
 years past promoting the study of cholera in India, with the best lights 
 of contemporary European knowledge, and no one will doubt but that 
 here, as in other departments of medical research, truly scientific study 
 must eventuate in practical good." "If," says this veteran hygienist, 
 " the constantly developing and constantly accelerating commerce 
 between India and the rest of the world is not to carry with it a con- 
 stantly increasing terror of pestilence, the safeguards, I apprehend, will 
 consist, not in contrivances of quarantine to maintain from time to time 
 more or less seclusion of nation from nation, but rather in such pro- 
 gressi\'e sanitary improvements on both sides as will reduce to a 
 minimum on the one side the conditions which originate the infection, 
 and on the other side the conditions which extend it." Quarantine 
 separates, I most emphatically say, man from man in the most 
 unwarrantable manner, in the most cruel manner, and in an utterly 
 useless manner; commerce on the other, unites us, and strengthens the 
 bonds of mutual sympathy. Let us therefore, not only as men of science 
 and culture, but as the contributors to the commerce and the "human 
 intercourse " of the world, never forget the golden words of one of 
 England's greatest ])oets, that : — 
 
 " The bond of commerce was designed 
 To associate all the branches of mankind, 
 And if a bomidless plenty be the robe, 
 Trade is the golden girdle of the globe ; 
 Wise to promote whatever end He means, 
 God opens fruitful nature's various scenes ; 
 Each climate needs what other climes produce, 
 And offers something for the general use." 
 
 THE NECESSITY OF FEDERAL INSPECTION OF FOREIGN- 
 GOING SHIPS ARRIVING AT AUSTRALIAN PORTS, 
 COUPLED WITH ISOLATING AND FEDERAL QUAR- 
 ANTINE LAWS. 
 
 By A. E. Salter, M.B., Thursday Island. 
 
 It must be understood that I use the term " federal " to indicate that 
 these acts should be done under intercolonial treaty, not that we must 
 have intercolonial federation first. Of all those things which afi'ect the 
 welfare of mankind as a mass, and under the influence of which all 
 varieties of human beings come, irrespective of language, race, religion, 
 or climatic and geographical peculiarities, none is applied so absolutely 
 to all, and none is so important, as the liability to disease and death ; 
 
 In
 
 S46 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 and means for the prevention of the first, and averting the second, 
 are questions of the most vital importance to all the inhabitants of the 
 globe. The great political questions of the day are subjects which have 
 for their ultimate object selfish ends in view ; and nations, when 
 studying any of these questions, ask themselves, which is best for them 
 to advocate from their own jioint of view — which will benefit them the 
 most, and their neighbour the least 1 
 
 But in circumscribing and isolating preventible diseases, the benefit 
 of all the individuals of the different races of mankind is held in view ] 
 and if such a thing as unity of action among all states, having for 
 its object the suppression of certain infectious and contagious diseases 
 throughout the world were ever brought about, those diseases would soon 
 cease to be known, except as matters of medical history. Thisend attained, 
 would produce both a great improvement in the huuian race as a race, 
 and mitigate the sorrow and pain of the individuals of that race. But 
 such a thing as unity of thought among all the earth's nations on this 
 subject, or, perhaps I should say, better unity of interest, seems still a 
 long way off. It would be beneficial, however, if unity of system, 
 having for its object the isolation of infectious diseases, could be attained 
 among states which are conterminous, and one step would have thus been 
 made in the direction of the unity of nations for the same purpose. 
 The minds of men are in a state of perpetual excitement concerning 
 things which they believe must benefit themselves, their friends, or their 
 nation ; but there is perhaps nothing about which all their opinions 
 would be agreed so much as that it is good to prevent disease. It 
 is with the hope of helping towards this object in Australia that I 
 bring under notice the necessity for a unity of system among the 
 Australian colonies, by virtue of which virulent, infectious, and 
 contagious diseases may be no longer carried from port to port as 
 has been hitherto the case, but may be removed and treated as early 
 as possible. I shall not indicate any particular places which are more 
 suitable than others for the purposes of isolation, though I shall refer to 
 a few chai'acteristics of these Straits, which well qualify it for such 
 a filtering station. Possibly other places exist which may suit better. 
 
 We require similarity of quarantine law, in order that gi'eater safety 
 may be given to the inhabitants of Australia, to the healthy passengers 
 in ships, and to those who may be sick on board ship; and so that 
 anomalies, such as have happened under existing multiple systems, may 
 cease to be known. For a very considerable time a system, having as its 
 object the interception and isolation of infectious diseases brought to 
 this country by sea — such system to be maintained by the united 
 Australian colonies — has attracted the attention of the statesmen and 
 sanitary authorities of Austx'alia. 
 
 Some have objected to our present quarantine, on the ground that it 
 has been tried in Europe and America and found almost useless, and 
 in the case of Great Britain, abandoned ; but, even these will, I think 
 agree, that the inspection of vessels ai'riving at the first port of call on 
 the Australian coast, and the removal of any cases of infectious diseases, 
 is a necessity. 
 
 As to the question of quarantine in Europe, it has been a much 
 debated one, and the sanitary authorities of England have come to the 
 conclusion that sufliicient benefit did not result from it to comjiensate for
 
 FEDERAL INSPECTION OF FOREIGN-GOING SHIPS. 547 
 
 the injury to trade caused by it. Accordingly, England has only a 
 system of inspection, and removal of contagious and infectious cases at 
 the port of call. 
 
 Now, the comparison between (^reat Britain and Australia is not a 
 good one, because, as has been ])ointed out, Great Britain has a most 
 excellent internal sanitation, and Australia has just as bad a one. 
 This is a difference between the two countries which time ought to 
 overcome; but there are differences which appear to me of more 
 importance, since they cannot be got rid of — they are geographical and 
 meteorological. The Australian colonies are isolated from other 
 countries much more comjiletely than Great Britain is. The continent 
 of Australia has an innnense coast line, at various points of which 
 vessels arrive, and thence travel along her shores for days, and thousands 
 of miles. In Great Britain such journeys are impossible, and did they 
 take place even under the English system of inspection, it is certain 
 tliat vessels would not arrive at ))orts having cases of small-pox, scarlet 
 fever, or cholera on board, and lie compelled to go out of them with 
 their cases still on board. Yet this is precisely what happens in 
 Australia. England's internal sanitary arrangements are unsurpassed; 
 but even they are being continually improved, and the authorities 
 expect to get great benefits from the Local Government Act just passed, 
 while everywhere isolating hospitals for special diseases of an infectious 
 nature are being built. As to Australia's internal sanitary arrange- 
 ments, it is correct to say that no scheme carried out under Intercolonial 
 Treaty exists ; from which it follows that, while one colony may be 
 expending large sums on its own internal sanitation, its neighbour may 
 be doing nothing at all. It is to be hoped that a commencement in the 
 direction of unity in this very important matter may be made by the 
 establishment of federal medical inspection, and isolating stations. 
 
 As to meteorological differences between England and Australia, the 
 temperature of the former is very much lower than that of the latter. 
 The winter of Great Britain is almost sufficient, itself to inhibit the 
 vitality of the infecting particles where they become exposed to its 
 influence outside the houses. And last, and most important of all, 
 Australia has no united plan for the isolation of those cases of disease 
 arriving by sea which, as I have pointed out, Engldnd has, and which 1 
 am now advocating for Australia. 
 
 Having in view these great differences between the two countries, I 
 take it that the result obtained by a comparison between them is not 
 sufficiently valuable to be entertained. At any x-ate, it seems to me 
 that for those who will persist in arguing from this comjiarison, the only 
 conclusion is, that if it is a bad thing to have quai-antine because England 
 has not got it, that is, if it is a bad thing to differ in this law from her, 
 it is a good thing to resemble her ; and therefore, those persons will be 
 in favour of isolating stations which — as Australia is not like Great 
 Britain, one empire, but several colonies — must be maintained under 
 Intercolonial Treaty ; that is, a federal inspection and isolating system, 
 and federal quarantine laws, under which the infecting cases would bt^ 
 removed before the vessels carrying them reached the centres of 
 population. During the last eighteen months, it has quite frequently 
 happened that vessels have passed through Torres Straits, having one or 
 more cases of small pox on board, and thus freighted have proceeded past 
 
 In 2
 
 548 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Cape York, southwards along tlie eastern coast for nearly two tlionsand 
 miles, reacliing Sydney at last, wliei-e the infectious cases have been 
 removed, if they have not already died before reacliing that port. That 
 is, we have a vessel passing within a mile of a port where, if the patients 
 could have been landed, they could have received that attention whicli 
 can be given with so nmch greater advantage ashore, while the passengers 
 remaining in the ship proceeding on its voyage, after being cleansed and 
 disinfected, would have travelled more safely, and the shipowners would, 
 in the event of no more illness breaking out, have been saved the 
 expense of a number of days in quarantine; and superadded to these 
 advantages, such highly infectious and contagious diseases as were on 
 board would have been kept away from the centres of population, and 
 possibly, such a contingency as the infecting of families outside the 
 quarantine station at Sydney have been avoided, the disease being left 
 at the least thickly populated part of Australia, instead of the most 
 thickly populated. 
 
 Under federal quarantine or federal inspection, another advantage 
 and a very material one would be gained, in addition to the sweeping 
 away of the present inhuman and barbaric state of things ; the advantage 
 to which I refer, is the co-operation of the charterers of steamships, in 
 the detection of suspicious cases. These latter deserve the greatest 
 credit as a class, for the way in which they have always assisted the 
 Health Department in the detection of cases of di.sease. Still, it is not 
 part of their business to co-operate witli that department, much less is 
 it to their advantage under the present Laws; but under the new regime, 
 which I trust some day to find adopted, and which I wish to indicate in 
 this ])aper, they would have every inducement to assist in the detection 
 and expulsion of such cases. It would be so clearly to their advantage, 
 and to the conducement of their comfort, that they would only too 
 willingly seek to discover any disease. Where now a master of a shi]>, 
 if he were unscrupulous enough, might misstate the number of his 
 passengers and crew, on account of his intention to conceal one of them, 
 who appeared sickening ; iinder the more favoui-able circumstances, he 
 would be only too glad to indicate the case and get rid of it, seeing as 
 he must, how advantageous it would lie for his owners and passengei's, 
 not to have a source of infection, which hourly was threatening to spread 
 itself in spite of all his precautions. 
 
 Again, the necessity for isolating stations at convenient ports, is as 
 great as the necessity for infectious disease hospitals ashore, such as are 
 now found to work so well in Great Britain. This is a greater necessity ; 
 for it is possible, that sick persons ashore may get the best attention, 
 but a person on board ship, affected with a deadly contagious or 
 infectious disease, must expect to be looked u])on with dread by all on 
 board ; and we must all know that the facilities, even on the best 
 appointed steamship, can be but indifferent, compared with those which 
 lie may reasonably expect ashore. Humanity alone urges the establish- 
 ment, without further delay, of such isolating stations, which may be 
 called the disease filters of Australia. 
 
 Many people ai-e, perhaps, unaware of the course usually pursued 
 when a person on board ship is found to be suffering from a disease 
 which the master has reason to believe may prove to be an infectious 
 one. To such, it may be news to learn that the sick ai'e placed in one of
 
 FEDERAL INSPECTION OP FOREIGN-GOING SHIPS. 549 
 
 the ship's boats, over which a tarpaulin is erected to protect the invalid 
 from the sun, wind, and rain. This portion of the ship's furniture being 
 tlie most isolated and easiest disinfected, and the least expensive to 
 destroy, is the place chosen for the future home of the pest stricken 
 patient, until he is put ashore. I do not think it is necessary to enlarge 
 upon the condition of the poor mortal condemned to pass eight to ten 
 days of his existence under such circumstances, at a time too when he 
 wants all the help he can get from his fellow-beings, and all the skill 
 likewise. As the greater number of vessels passing this port do not 
 carry medical men, the unfortunate sick have not much to depend upon 
 in this respect. No doubt the boat is the best place at the captain's 
 disposal; he does his best for the man who is infected, and also for those 
 not infected, by placing him there, but for the person to remain under 
 such circumstances after he has passed close to a port, should be quite 
 beyond a civilized nation's ideas of humanity. The facts of the case, I 
 feel sure, only require to be generally known to the Australian people 
 for them to terminate so bad a condition of things. 
 
 One more proof of the necessity, by analogy. It is admitted that it 
 is good that ships should be inspected, and their diseased passengers 
 isolated, at Port Phillip Heads, at Sydney Heads, at Moreton Bay, and 
 not at Melbourne city, nor Sydney city, nor Brisbane city. Is it not 
 then still better that the ship should be inspected and its cases isolated 
 at some port further removed in the line of call, such as Torres Straits. 
 
 I now come to those particulars in connection with Torres Straits, 
 which specially fit it to be an inspecting and isolating station. It is to 
 the East Australian Coast, what Port Phillip Heads and Sydney Heads 
 are to their respective cities, for very few vessels indeed do, and still 
 fewer will, in future, pass outside these straits when coming to East 
 Australian ports. Whenever they do so come outside, they must pass 
 to the north of New Guinea. The course over ninety per cent, at least 
 adopt is to come along from Java to Torres Sti-aits, and through the 
 channel between Goode Island and North West Reef — through the 
 passage known as Prince of Wales Channel — on to the passage between 
 Albany Island and the mainland, and south to Cooktown, Sydney, 
 Melbourne, and Adelaide. 
 
 One other point has Torres Straits in common with the Heads before 
 referred to, it is the pilot station for the channel through which the 
 vessels pass down the coast; it is there the pilots are taken on board, 
 although the port may not be entered — a matter which is only of 
 importance in so much as it goes to prove that no more hardship would 
 be entailed upon a vessel in compelling it to be examined at Torres 
 Straits, than is entailed by compelling it to be examined at Sydney 
 Heads, and the result, as I have tried to explain, would be much 
 more to its owner's advantage. At present, it is as if it were decided 
 better that ships should be examined at Port Melboui-ne and the 
 Circular Quay, instead of before reaching those populated localities. If, 
 however, it is better to isolate your infectious diseases at the boundaries 
 of the chief ports that is at their entrances, it is better still to isolate at 
 those entrances still more remote to the continent itself. 
 
 It has been argued by some, that it is no use establishing such 
 stations and having such insjtectionK, because the disease may not be 
 developed at the time of the ship's arrival at the inspecting port. Now,
 
 550 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 that the disease may be undeveloped, is perfectly true, but it is not in 
 itself any reason why the stations should not be formed, for if it were, 
 it would be a reason why stations should not exist at Port Phillip 
 Heads or Sydney Heads, or the entrance to any other port. Those 
 stations are there to detect and stop disease, if it be found present, and 
 they can do no more; if they do it once in twelve months, they prove 
 their usefulness. As a matter of experience, too, these diseases have 
 generally happened before arrival, even at Port Darwin, and during the 
 last epidemic of sniall-pox in China, ship after ship passed this port with 
 cases of small-pox on board. In my opinion, these intercolonial isolating 
 stations should be a commencement, in part, of a system of sanitation of 
 the whole of Australia. And, at all events, from every point of view, a 
 place should have been in readiness for the cases which have occurred 
 in the past, and most assuredly will occur again in the future. 
 
 It is, after all, an outer line of defence. It may be carried, but it 
 shoiild be there; and as a nation should be prepared to defend itself 
 against warlike neighbours, so should it be prepared to intercept infectious 
 disease at its different gates. As the entrance to its harbour should be 
 guarded by torpedo mines, so should that entrance be made to act as a 
 filter to waylay infectious diseases, and prevent their further march. 
 
 Is it necessary to say more 1 The matter seems to me to be one of 
 those facts which commend themselves to the common sense of all, and 
 only requires to be known in order to be accepted. 
 
 As to the need of a uniform quarantine law, I think the citation of a 
 few examples of what actually has taken place under our existing 
 multiple system of quarantine law is sufficient to prove the urgent need 
 of a change. 
 
 During the small-pox outbreak in Tasmania some of the colonies 
 enforced quarantine against Tasmania, others only treated the vessels 
 to inspection, and others did not do that. There was no good reason 
 why they should not have followed one uniform system; and it made 
 the law appear ridiculous when they did not. Suppose, for instance, 
 that Victoria rendered twenty-one days quarantine imperative against 
 ships fi'om Tasmania, but New South Wales deemed inspection alone 
 sufficient, what would result 1 Why, Victorian passengers would proceed 
 per steamer from Tasmania to New South Wales, and thence per 
 steamer or railway to Victoria, the time taken up only being a few days 
 longer than by the old direct way of travelling, and the risk of persons 
 coming into Victoria liable to the disease being just as great. With 
 the law uniform, this could not occur. What one colony enforced, the 
 other would enforce. 
 
 One more example of anomaly, resulting from difference in quarantine 
 law. Early in this year the law of Queensland said, " No ])erson shall 
 land at a Queensland port who has had communication with a Java port, 
 unless he do fourteen days quarantine." The quarantine law of New 
 South Wales said, "Java is a clean country, we do not intend to 
 quarantine any person arriving therefrom." What then happens? 
 Passengers in Batavia wishing to come to Queensland, take ship for 
 Sydney, and arriving there take the railway to Brisbane, having been 
 delayed by a day or two, no more, so far as travelling time is concerned, 
 but having l)een put to much extra expense, and perhaps, kept in Java 
 a week or more waitinsr for a steamer.
 
 THE EVILS OF SPECIALISM. 551 
 
 It is no wonder that people, under those circumstances, hxugh at the 
 eccentricities of the law, and at the same time complain of the expense 
 it puts them to, without achieving the result intended. I might cite 
 other examples similar to these, but it cannot be necessary. Were there 
 unity of quarantine law, these things would be known no more, and 
 much just, but very unfavourable, criticism avoided. 
 
 In conclusion, it is my earnest desire to see unity of purpose among 
 the Austi'alian colonies, in producing unity of quarantine law, working 
 in combination with a system of intercolonial inspecting and isolating 
 stations, culminating in the production of a system to which other 
 nations may point as an example of good law and of humanity. 
 
 THE EVILS OF SPECIALISM. 
 By DuxcAN Turner, L.R.C.P. Lond., L.R.C.S. Ed. 
 
 That specialism must exist in medicine and surgery at the present day, 
 no one will deny. Kept within reasonable bounds, it has its uses; but 
 if allowed to go on multiplying, and so to speak, run riot, it is fraught 
 with numerous and dangerous evils. In my humble judgment it is a 
 cankering sore, which will gradually drain and irretrievably injure the 
 dignity, position, and usefulness of the profession at large. It is not 
 the intention of this paper to point out how to keep specialism in its 
 jilace. My attempt is simply to call the attention of the profession to 
 its mischief, in the hope that some general professional opinion on the 
 subject may be brought to bear to curb it, and restrict it within proper 
 lines. That specialism has great attractions and temptations is true. 
 Indeed, the bed of the specialist is generally so rosy that it is no wonder 
 so many are led into the ranks. For the hard-worked practitioner to 
 emerge from the toils and hardships of general practice to the ease and 
 elegance of specialism, is like escaping from a wilderness of thistles into 
 a Garden of Eden. Moreover, special ])ractice is easy — it is money- 
 making; and socially, the specialist stands as high, if not higher, with 
 the general public as the all-round practitioner. But when the profession 
 is divided and sub-divided into a multitude of sections, that our status 
 must ultimately be lowered, is certain. Quackery will creep in, and it 
 is doubtful whether any legislation we are likely to get in modern 
 democratic days will in any degree check it. Already, we have numbers 
 of people calling themselves eye and ear doctors, who have no 
 education whatever. Why is this? Simply because the laity know 
 there is " money in it," while the public outside are ready to run after a 
 specialist, whether he is educated or not. Not least among the evils of 
 specialism is, that it takes away a great many fees from the hard- 
 worked general ])ractitioner, and that too, in cases he could manage as 
 well, or perhaps better, than the specialist. 
 
 I am not going to run down specialism in r/loho. Some of its forms 
 uo one oVjjects to. Diseases of the eye have for many years been 
 regarded as a proper sphere for specialism, and it must be acknowledged
 
 552 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 that the best discoveries in the treatment of eye diseases have been made 
 by special practitioners. The same may be said of diseases of other 
 special organs. But none of the great discoveries in medicine or surgery 
 can be claimed for specialists. The mischief is, that the mind of the 
 specialist gets contracted, like that of other special workmen. After all, 
 he is only a superior workman. I have heard of workmen in Birming- 
 ham who make nothing but hinges all their lives, and no doubt, they 
 attach a vast importance to their calling, and occasionally wonder what 
 the world would do without them. I have no means of knowing their 
 mental calibre ; but I make a shrewd guess that their thoughts are 
 pretty well confined to the qualities of the iron they use, and t)ie pay 
 they are to get. Machinery has in many instances replaced such work- 
 men, and as machinery has ah^eady been made to do elaborate work in 
 the way of calculation, possibly some machine will be invented to do the 
 work of some specialists, just as well, if not better. 
 
 The human body cannot be split up for medical treatment into fifty or 
 sixty different pieces, and any practitioner who gives exclusive attention 
 to one organ, to the neglect of the others, is sure to blunder, and is, as 
 a rule, unsafe. No doubt there is something to be said in respect of 
 some of the external parts of the body. It has been already admitted 
 that there is no objection to a moderate amount of specialism on such 
 organs of sense as the eye and ear. But when specialism seizes on the 
 internal organs, and one man takes the heart, another the liver, a third 
 the kidneys, and so on, what are we to expect? At present we have 
 no representative specialists for all these organs, but we have them for 
 most, and there are signs that others ai-e coming. 
 
 Is it not time for us to raise our voices against such abuses, which are 
 calculated to undermine, and ultimately seriously injure, what a dis- 
 tinguished Victorian statesman called the noblest of all the professions. 
 The world has recently beheld a spectacle which, I am afraid, will for a 
 long time be remembered with shame — a set of specialists wrangling 
 over the afflicted body of a distinguished Imperial patient. Who will 
 deny that the whole thing will undoubtedly lower the entire profession 
 in the eyes of the world 1 
 
 Among the drawbacks of specialism is hair-splitting, that is, the 
 invention of fanciful diseases and the consequent multiplication of 
 indefinite medical terms, much to the confusion of the young student, 
 and also of the ordinary practitioner. 
 
 I remember in my student days poring over a large volume well 
 known to you — I mean Erasmus Wilson on skin diseases — and I have 
 a keen recollection that, after several days of fighting with it, I put it 
 down in disgust, coming to the philosophical conclusion — one worthy of 
 Lord Dundreary — that skin diseases were among the things that " no 
 fellah could understand." Now that our knowledge in this direction is 
 extended, and I have had other means of studying these common 
 ailments, I have no doubt whatever that Wilson split up eczema into at 
 least four diseases that liave no justification for a separate existence. 
 Did time ])ermit, I could mention many other diseases dealt with by 
 specialists in the same way. Each specialist is discontented with the 
 name adopted by a brother specialist, and must invent one of his own. 
 
 Now, 1 ask you, can any tiling be more tantalizing to the student or 
 to the practitioner (for we are students all our lives), than this wading
 
 THE EVILS OF SPECIALISM. 553 
 
 through a needless multiplicity of names 1 Especially is it confusing 
 and harassing to the hard-worked general i)ractitioner, who is supposed 
 to be equally Avell up in all the diseases that flesh is heir to. In France, 
 the Academy of Medicine put some check on this process ; bub in Great 
 Britain nothing of the sort has ever been attempted, if we except 
 the effort made in that direction by the London College of Physicians. 
 But I feel sure tlie day will come, when there will be a representative 
 intercolonial medical congress to agree upon certain names for certain 
 diseases, and so avoid this terrible and endless confusion. 
 
 In Melbourne, gynaecology is tlie only specialism that has attained 
 that prominence, when it is viewed with some disfavour by the pro- 
 fession at large. I regret to say that I think there is some reason 
 for this. I am not going to utter a word against the gynsecological 
 practitioners of this city. Many of them are known to be honourable 
 men, and zealous in their calling. But, as I hinted in a former part of 
 this paper, it is one of the characteristics of the human mind, when it 
 dwells on one subject for a length of time, that the understanding gets 
 wai'ped, and it sees things through a coloured atmosphere, which is 
 always more or less harmful to the judgment. The specialism of 
 gynaecology is eminently a money-making one ; no wonder, therefore, 
 that it is such a favourite with the medical profession. At the same 
 time, it is certainly one in legard to which there is great danger of 
 abuse of the trust the jjublic put in us, so that its professors should be 
 specially on their guard not to lay themselves open to the adverse 
 criticisu) of their professional brethren. Our specialists must take 
 warning that, however great favourites they may be with the public for 
 the time being, or however large their yearly income, they cannot 
 for any length of time brave the opinions of their medical brethren ; and 
 there are several instances in recent medical history, where a continuance 
 in such courses brought ruin on those that persisted in them. 
 
 But it is when we come to gyniecology that we find this delightful 
 multiplication of terms run riot. For example, for that common disease 
 chronic metritis, I find in different text-books at least eight names ; and 
 some of the other diseases of the female generative organs fare as badly. 
 We all know how much faith a woman puts in her medical adviser. 
 We likewise know how many of the ailments supi)osed to be connected 
 with the generative organs of women are pui-ely imaginary, or at most, 
 quite harmless. How easy it is then for an unscrupulous practitioner to 
 fill his pockets full of gold from his nervous female patients 'I Turning 
 to our own sex, we know what rich harvests quacks make from the 
 unsuspecting, who are under a delusion about some purely imaginary 
 disease of sexual functions. If ours, which is generally called the 
 stronger sex, is liable to delusion in this way, need we wonder at what 
 occasionally happens to the weaker one 1 An immortal poet, and a keen 
 observer of human nature, has said — 
 
 " Then gently scan your brother man, 
 Still gentler, sister woman." 
 
 The changing fashions that prevail in the treatment of female diseases 
 are, I think, only equalled in their dresses. I am old enough to 
 remember when metrotomy was the panacea for all female ailments. 
 Being over a quarter of a century ia the profession, I have a vivid 
 recollection of how these fashions burst upon us with a flourish of
 
 554 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 trumpets, only to die away after a year or two, if not to be entirely 
 forgotten, at least to take a back seat. Some thirty years ago, metrotomy 
 was accepted as a panacea for almost all tliat female flesh is heir to. 
 Then came Dr. Henry Bennet, with his inflammations, ulceration.?, and 
 caustics. A few years afterwards, the late Dr. Tyler Smith brought 
 uterine cervical catarrh so prominently before the profession that he had 
 a great many followers; and for some years, among London practitioners 
 at least, no woman could have an ache in her head or foot but it was 
 ascribed to this cause. Then came Dr. Graily Hewit, with his versions 
 and flexions, and how many pessaries were invented by different 
 specialists for their alleviation or cure, I would be afraid to say. 
 
 But it has been reserved for an American gynaecologist to make the 
 discovery in female operative surgery which is so much in vogue at the 
 present day, and judging from the frequency of its performance, has, 
 in this respect, eclipsed all others. I need hardly say that I refer to 
 the well-known operation of Emmet. 
 
 In this city especially, this distinguished specialist has found many 
 zealous disciples; but, I think, were he present at this Congress, he 
 would be ready to adopt for his motto — "Save me from my friends!" 
 That his operation has been abused, I believe it is the opinion of nine- 
 tenths of the profession in this country; and, what was at first a useful 
 and scientific proceeding, and eminently necessary in many cases, is now 
 got to be received with so much disfavour and suspicion, that the very 
 name stinks in our nostrils, and few men who value their reputation 
 would care to perform it. I hope the day will come when this operation 
 will be relegated to its proper and legitimate place, and no longer 
 practised in the wholesale manner we have been accustomed to witness 
 for some years past. 
 
 HYGIENIC CONDITIONS OF ABO, FINLAND. 
 By Axel R. Spoof, M.D. 
 
 The town of Abo, the number of whose inhabitants at the commence- 
 ment of 188S amounted to 27,592, does not yet enjoy a water supply, 
 though one has been in preparation for five or six years. Nor has the 
 town a public .sewer canal system, though to this end a project was 
 wrought out some years ago, and a report was made to the representative 
 of the town. The said project proposed that the cleaning take place by 
 means of sewers and surface irrigation; but this system, in view of our 
 long winters — about six months — during which vegetation is quite 
 dead, was considered to be inapplicable, and hence the project has not 
 been accomplished. In lieu thereof, the authorities have agreed that, 
 in the most populated parts of the town, the fluid excreta be conducted 
 into the river, which runs through the town, and falls into the sea 
 within the port district. The solid excreta is collected in pails 
 impervious to water, and is brought outside the town by means of light 
 carriages, for the most part by neighbouring farmers, who make use of 
 it as soon as possible. 
 
 The morbility and mortality in some of the most important epidemic 
 and chronic diseases are shown in the table following, which I have
 
 HYGIENIC CONDITIONS OF ABO, FINLAND. 
 
 555 
 
 compiled according to official reports by the Local Board of Health, whose 
 work began in 1880. 
 
 In order to as far as possible j)revent the propagation of infection, 
 each case of epidemic disease is immediately reported to the town doctor 
 — at present K. K. Kynberg — with indications of the dwelling of the 
 sick. Besides this, the Local Board of Health once a week collects a 
 report from each of the practising medical men, about the number of 
 cases treated by him in the pi*evious week. Blank forms are supplied by 
 the board for the purpose. 
 
 For statistical purposes, such means are further taken, that every 
 death is to be attested by the doctor who has treated the case, or by the 
 town doctor. 
 
 
 The Morhility at Abo 1880-87. 
 
 
 
 
 Disease. 
 
 ISSO 
 477 
 
 1881 
 
 1882 
 
 1883 
 
 1884 
 
 1885 
 21 
 
 1886 
 19 
 
 1887 
 
 Typhus abdomin. . . 
 
 31 
 
 189 
 
 37 
 
 56 
 
 23 
 
 Febris remittens 1_ 
 Febris intermittens j" 
 
 774/ 
 
 39 
 
 254 
 
 131 
 
 77 
 
 57 
 
 95 
 
 90 
 
 578 
 
 517 
 
 809 
 
 724 
 
 518 
 
 881 
 
 822 
 
 Mening. cerebro-spin. 
 
 
 
 
 
 
 
 
 
 epideiu. 
 
 
 
 
 . . 
 
 , , 
 
 4 
 
 ^ ^ 
 
 Dys-enteria 
 
 16 
 
 ii 
 
 ii 2 
 
 2 
 
 
 12 
 
 26 
 
 Variola & variolois . . 
 
 5 
 
 95 
 
 17 2 
 
 
 
 
 
 Scarlatina . . 
 
 26 
 
 5 
 
 231 117 
 
 98 
 
 116 
 
 106 
 
 15 
 
 llorbilli . . 
 
 555 
 
 46 
 
 13 1 
 
 4 
 
 811 
 
 72 
 
 3 
 
 Rubeola 
 
 
 
 
 
 5 
 
 158 
 
 14 
 
 Eiysipelas idiop. . . 
 
 37 
 
 48 
 
 44 27 
 
 13 
 
 19 
 
 74 
 
 86 
 
 Febris puerperalis . . 
 
 6 
 
 13 
 
 6 1 
 
 3 
 
 5 
 
 4 
 
 3 
 
 Diphtheria faucium 
 
 82 
 
 54 
 
 44 62 ) 
 
 9 
 
 8 
 
 f 36 
 
 24 
 
 Laryngitis crouposa 
 
 14 
 
 13 
 
 14 9i 
 
 \ 15 
 
 36 
 
 Pertussis . . 
 
 18 
 
 98 
 
 40 7 
 
 239 
 
 41 
 
 13 
 
 4 
 
 Pneumonia, croup et 
 
 
 
 
 
 
 
 
 pleuritis 
 
 353 
 
 303 
 
 205 237 
 
 209 
 
 196 
 
 185 
 
 147 
 
 Rheumatismus 
 
 149 
 
 169 
 
 179 121 
 
 150 
 
 153 
 
 94 
 
 95 
 
 The Mortality at Abo, 1880-81 
 
 DiSKASE. 
 
 Typhus abdomin. . . 
 Dys-enteria 
 Variola 
 Scarlatina . . 
 Morbilli 
 
 Erysipelas idiop. . . 
 Febris puerperalis . . 
 Diphtheria faucium 
 Laryngitis crouposa 
 Pertussis . . 
 Pneumonia, croup et 
 
 pleuritis 
 Phthisis pulmonum 
 Diseases of the brain 
 
 and nerves 
 The number of the 
 
 inhabitants was 
 
 1880 
 
 (?) 
 (?) 
 (?) 
 
 (?) 
 (?) 
 
 (?) 
 22,529 
 
 1881 
 
 18 
 
 2 
 
 39 
 
 3 
 3 
 1 
 9 
 
 56 
 130 
 
 37 
 
 6 
 62 
 3 
 2 
 3 
 3 
 4 
 3 
 
 26 
 
 89 
 
 64 1 55 
 .. 24,916 
 
 12 
 
 3 
 19 
 
 2 
 1 
 7 
 2 
 3 
 
 34 
 70 
 
 27 
 
 25,480 
 
 1S84 
 
 11 
 
 1885 
 
 18 
 
 58 
 
 2 
 
 3 
 
 31 
 
 86 
 
 37 
 81 
 
 55 
 
 54 
 
 25,052 
 
 25,796 
 
 9 
 2 
 
 19 
 
 3 
 2 
 6 
 
 9 
 
 70 
 113 
 
 81 
 
 26,365 
 
 1887 
 
 2 
 
 "1 
 
 *8 
 23 
 
 42 
 125 
 
 80 
 
 27,186
 
 556 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 Amongst the means which aim at the prevention of disease, or at 
 least, at the mitigation of its influence, especially with regard to the 
 working class, may be mentioned : — 
 
 (a) The town supports an infirmary for epidemic diseases, which at 
 present, ought to be organised anew; and in connection with it an oven 
 for disinfection, and a lodging for people whose dwelling and clothes, 
 &c., are to be disinfected; and besides this, a town doctor, two district 
 doctors, two midwives, and four district nurses are paid by the town. 
 
 The oven for disinfection on Merke's system (Germany), is kept at the 
 free disposal of all, for disinfection in cases of epidemic diseases, as well 
 as for cleaning from vermin objects belonging to any one of the town 
 establishments. The oven is also at the disposal of others, on payment 
 of eight shillings per oven, and four pence per bag. The things are 
 brought to the oven in sj)ecial carriages, and are received at one end of 
 the building, and, if small, collected in bags and placed in the oven, 
 which is then closed. Into it is let a continual stream of steam, of 
 four atmospheres pressure, mixed with hot air. The temperature 
 within the bags rises to somewhat above 100° C. Disinfection having 
 gone on for an hour, the oven is allowed to get cool; the objects are 
 taken out at the opposite end of the oven, and are brought to their 
 owners in hired carriages. 
 
 Families dwelling in small rooms, and in whom some epidemic disease 
 has broken out, are taken into the disinfecting lodging house, where 
 they will be undressed and bathed, and afterwards dressed in the clothes 
 of the establishment; whilst their own clothing and utensils are disin- 
 fected in the oven, and their dwelling is disinfected by the sanitary 
 police for half-an-hour, by means of sulphur spray (1-1000) mixed with 
 tartaric acid (5-1000), and again made safe by soda spray (1-100). 
 
 In order to provide, in case of necessity, the citizens, especially those 
 without means, with nursing attendance, there are four district nurses. 
 For the attendance which the nurse has rendered to a patient, she may 
 neither demand nor receive remuneration of any kind whatever. From 
 Wealthy patients the Board of Health collects a moderate tax, which 
 goes to an assistance fund for nurses that have grown old or infirm 
 in the service. The instruction of the nurses is arranged agreeably to 
 tlie princi[)les laid down in Miss Florence Nightingale's " Notes on 
 Nursing." 
 
 (b) Private associations, limited companies, or employers, have 
 procured sound dwellings in different parts of the town, which afford to 
 the industrious and regular workman a chance, at a moderate rent, to 
 get light, clean, and comfortable houses; of which he may, if he likes, 
 become the owner, by paying during the course of eighteen years, 
 annually, a somewhat higher rent. Such dwellings are built on the 
 Muhlliouse system, and at the end of 1887 there were four terraces, 
 consisting in all of nineteen wooden liouses, each containing three 
 apartments and a kitchen, with a bake-oven. Of such a workman's 
 domicile I send you a ground plan, with intersection and situation, 
 together with a copy of the statutes for the Abo Workman Domicile 
 Company, Limited. 
 
 In order to countej-act the great mortality amongst tender children, 
 which arises from unhealthy dwellings and careless treatment, there was 
 oiganised two years ago, an Abo Child Protecting Association, after the
 
 HYGIENIC CONDITIONS OF ABO, B'INLAND. 
 
 557 
 
 Berlin manner, witii the object of taking cai-e of tender cliildren up to 
 the age of three years. These are left in charge of nurses, carefully- 
 selected and controlled. The parents also, must contribute monthly 
 sums, larger or smallei-, towards the payment of the mu'ses, but always 
 through the Association. A copy of the statutes is also forwarded. 
 
 Associations for mutual assistance in case of sickness or death are 
 organised at the following larger industrial establishments, viz. : — 
 Wm. Crichton and Company's Shipbuilding and Steam Engine Works, 
 The Abo Iron Manufacturing Company, The Aura Sugar Refining Com- 
 pany, and the P. C. Rettig and Company Tobacco Works. The balance 
 of tliose four associations amounted last December 1887, to 45,931 marks 
 25 pennies Finnish money, about £1700 English. Besides this, there 
 exists a common Abo Workmen's Sick and Burial Fund, founded in the 
 year 1879, whose members at present number 529, and the surplus 
 26,000 Finnish marks, somewhat above £1000. By paying to this fund 
 an entrance fee and a monthly contribution, a workman will guarantee 
 himself or his family fixed subsidies, in case of disease or death. 
 
 Statistics. 
 
 
 Members. 
 
 Sick Subsidies Paid 
 
 Funeral Subsidies 
 
 
 (Marks <fc Pennies.) 
 
 FOR 
 
 Members. 
 
 1880 
 
 114 
 
 
 650-25 
 
 
 4 
 
 1881 
 
 17 
 
 
 977-25 
 
 
 2 
 
 1882 
 
 30 
 
 
 986-25 
 
 
 1 
 
 1883 
 
 50 
 
 
 1081-25 
 
 
 1 
 
 1884 
 
 138 
 
 
 1956- 
 
 
 1 
 
 1885 
 
 62 
 
 
 2505-50 
 
 
 1 
 
 1886 
 
 89 
 
 
 3952-50 
 
 
 8 
 
 1887 
 
 173 
 
 
 4990-50 
 
 
 12 
 
 With regard to the hygiene of childhood, there ought yet to be 
 mentioned: — (1) The Poor Child's Working House, and (2) the Public 
 Schools of the town, which must not be confounded with the Public 
 Lyceums and Female Schools of the State. 
 
 The Poor Child's Working House aims at procuring work and frugal 
 meals for poor children, w^ho would otherwise stroll and beg round the 
 town. These are for cliildren from four to fifteen years of age, who, so 
 far as is known, have never been punished for crimes. The manager 
 has to procure employment for children over twelve 3'ears. The children 
 are taught an easy handiwork. A child who has entered the working 
 house has no right to leave it the same day, before the house is closed 
 for the evening. If a child does frequent a school where instruction is 
 given in the forenoon, it receives in the working house dinner and 
 supper; and, if the school is working in the afternoon, breakfast and 
 dinner. This woi'king house is supported by voluntary contributions 
 from the citizens, the Savings Bank, and from private persons. 
 
 The Public or Common Schools of the Town. — According to the law 
 of 1866, concerning the common primary schools, every town community 
 is obliged to establish and support primary schools to such a number 
 and extent, that all the children that do not, at home or in other schools, 
 get the corresponding, or a more extensive knowledge, may be taught
 
 558 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 gratis, from the eighth to the fourteentli year of age. From six to ten 
 years of age, both sexes are taught togetlier; but from the eleventh 
 year upwards, each sex is to be held in separate apartments or schools. 
 At the commencement of this year, i.e., that of September 1888, the 
 total number of children in those schools was about 2100. 
 
 The school establishments amount in all to fifteen, of which seven are 
 provisionally in buildings originally constructed for other purposes, and 
 eight in school-houses built and fitted up for the purpose. Of such a 
 school-house, I forward a ground plan and a photograph. The ground 
 plan shows the arrangement of ventilating channels, the system being 
 an aspirating one, furnished with a separate funnel for sucking away 
 the impure air. The air space is replenished on an average twice an 
 hour. The temperature of the air, when streaming in — at 14° or 15° 
 Celsius without, and a middling strong, cold wind from the north — varies 
 between +14° and + 35° Celsius. 
 
 The dimensions of the class-rooms, which are shown by the ground 
 plan, vary but very little — the length from 7"97 to 8*75 metres, the 
 breadth from 6"66 to 6'84 metres, and the height from 3"72 to 3-86 
 metres. 
 
 The subsellia of the said schools are two-seated, with movable seats. 
 The dimensions of the subsellia are shown by the following table: — 
 
 s»,i 
 
 Distance from 
 
 
 -a . 
 
 II 
 
 11 
 
 a 
 til 
 
 Numb 
 
 ofth 
 
 Subselli 
 
 The breast border 
 
 of the table to 
 
 the seat. 
 
 The seat to 
 tlie floor. 
 
 The breast border 
 
 of the table to 
 
 the floor. 
 
 .2 Sa 
 
 I. 
 
 20 
 
 34 
 
 54 
 
 41 
 
 25 
 
 105 
 
 n. 
 
 24 
 
 35 
 
 59 
 
 41 
 
 25 
 
 105 
 
 III. 
 
 26 
 
 39 
 
 65 
 
 42 
 
 26 
 
 111 
 
 IV. 
 
 27 
 
 42 
 
 69 
 
 46 
 
 29 
 
 115 
 
 V. 
 
 28 
 
 45 
 
 73 
 
 48 
 
 80 
 
 120 
 
 VI. 
 
 30 
 
 47 
 
 77 
 
 50 
 
 81 
 
 125 
 
 All these uuiiibers are given in centimetres. 
 
 SOME REMARKS ON THE PRINCIPLES AND PRACTICE 
 OF VENTILATION FOR COLD AND WARM CLIMATES. 
 
 By W. V. Jakins, L.R.C.P., L.M., &c.; Fell. Obst. Soc. Lond. 
 
 In the few minutes in which I purpose to occupy your attention, it is 
 not my intention to describe the large number of systems for ventilation 
 in general and occasional use, rather would I classify them, pointing out 
 the advantages and disadvantages of each; preferring to dwell more in 
 detail on those displayed in our International Exhibition. 
 
 Ventilation may be considered natural, when supplied by windows, 
 skylights, and doors, which inevitably induce draughts, so that every- 
 where we find artificial ventilation applied to overcome these draughts, 
 and to ensure an equable supply of fresh air. This is attempted in 
 a simple manner, by outlets in the centreflowers of ceilings, in cornices,
 
 VENTILATION FOR COLD AND WARM CLIMATES. 559 
 
 just below cornices, and in chimney breasts — outlets sometimes simple, 
 sometimes with valves. Simple outlets for heated or foul air commonly 
 do not act at all ; when they do act, I find them acting the reverse way, 
 not as outlets, but as inlets for cold air, in windy weather inducing 
 <lraughts. Outlets with valves generally act well, those in chimney 
 breasts frequently emit smoke from the chimney; but in producing an 
 outlet for heated air they suck in cold air, for the entry of which special 
 j)rovi.sion has to be made, otherwise draughts come through window 
 frames, key holes, and under doors. Inlets for fresh air are usually 
 made through the ceilings, walls, cornices, skirtings, or floor. In calm 
 air they are insufficient, in windy weather they cause draughts. Tobin's 
 tubes, in which the cuiTent of fresh air can be readily regulated by 
 a butterfly valve, is the most efi"ectual means with which I am acquainted 
 for supplying fresh air. Yet these are imperfect, for the air passes 
 through them in a circling manner to the ceiling, there the circles break 
 and the cold air falls down in a shower on our heads. In equable 
 weather, this system acts fairly well. In still weather, like all other 
 systems, it fails; and in like manner in windy weather, in spite of 
 tlie valves, it causes drauglits. Moreover, no provision is made in 
 Tobin's system for letting out foul air. 
 
 With the imperfections I have described, mechanical means are 
 generally resorted to for the supply of definite quantities of fresh air, in 
 certain given directions, and at a certain velocity ; these inlets are fi-equently 
 furnished with revolving fans, which foi'ce the air through skirtings, walls, 
 or ceilings. When properly adjusted, as to size of outlet, they are 
 frequently of service, though far from perfect. The principle of revolv- 
 ing fans has been further developed by the use of air blasts, in which the 
 fresh air passes through some cooling or heating process, and is then 
 forced with some velocity into the room, by water motor, steam power, 
 gas or petroleum engine, or electricity. Sometimes a water blast 
 is used, which cools the air without any extraneous means. Several 
 forms of blasts ai*e in the Exhibition. I need hardly say that an air 
 blast always induces draughts. Punkahs are another form for so-called 
 cooling a room ; of course, they do not affect a thermometer, although 
 they may increase the evaporation from our skin, and thus produce 
 coolness; the Iceberg and other electric fans act thus, like punkahs, by 
 simply stirring up the air. 
 
 Mechanical forms of outlets generally take the form of exhausts ; 
 which may be a simple tube, a tube with a cap more or less modified a 
 few inches beyond its extremity, or the cap may be replaced witli 
 endless varieties of cowls, to which is sometimes added an inner 
 archimedian screw. The vacuum principle is sometimes employed ; 
 a jet of gas in a tube causing a rush of air alongside it out into the open 
 air, as in an inlet water blast ; a jet of steam is sometimes used in the 
 place of gas ; revolving fans are often of great use as outlets. To all 
 these forms of outlets, the same objections may be offered as to the 
 inlets — they are all more or less dependent on the wind velocity outside 
 the house ; and the adjustment as to outlet and inlet can never be so 
 nicely regulated as not to cause draughts. 
 
 Now, with all these more or less pronounced failures in ventilation, 
 let us consider a moment some of the principles involved in the 
 <;irculation of air. In the first place, cold and warm air, of themselves,
 
 560 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 will never mix together, nor will warm air go out through openings 
 in a room to cold air ; also, cold air will not of itself go through 
 openings in the walls or ceilings into a heated room, except as a wind ; 
 therefore, ventilation, to be without draught, must be mechanical ; it 
 must be possible easily to regulate it to a nicety, both as to outlet and 
 inlet. We have to get rid of the heated air near the ceiling, which 
 contains carbonic oxide and sulphurous acid, and we have to get 
 rid also of the carbonic acid on the floor. Authorities agree in saying 
 that the carbonic acid, when heated, rises to the ceiling — that is, a gas 
 with a specific gravity of 1525, by being heated, rises above the level of 
 heated air, which has a specific gravity of 1000 — a gross absurdity; for 
 although heat may expand a gas, causing it to fill a larger space, it 
 cannot, to any degree, alter its weight. 
 
 I confess, that all my life I have been following authorities more 
 or less, in my efibrts to get rid of foul air, and it was not till last winter, 
 in a lecture given at the Health Society's meeting, that I was able to 
 grasp the true jirinciples on which successful ventilation is based. This 
 has led me to investigate this new scheme. I therefore purpose briefly 
 to give you my results; for I am persuaded that, although there is much 
 room for improvement in details, this colony has the honour to have 
 produced the first and only correct system of ventilation, and one which 
 is based on true scientific principles. 
 
 Now the first principle contended for is, that as cai'bonic acid is half 
 as heavy again as common air, its outlets should be about the floor. 
 Next, that as air improves in quality the nearer we go heavenwards, so 
 the air should be drawn in from any height that may be necessary 
 through inlets near, or in the ceiling ; also, that the indrawn, for it is 
 not inforced, air, be introduced in a centrifugal fashion, not according to 
 the capacity of the room, but according to the number of people it may 
 have to contain ; this prevents the formation of heated air near the 
 ceiling, and it also prevents the accumulation of carbonic acid in the 
 corners of a room. These three principles are, I am satisfied, simply 
 perfect. 
 
 Now for the evidence. On a hot afternoon I experimented in 
 an office, dimensions 12ft. x 10ft. x 10ft. high; two sides of it 
 were air proof — lining boai'ds packed with charcoal ; the other two 
 sides bluestone walls, having a window with fixed sashes ; the door was 
 closed, four adults present ; ventilating fan six inches high by twenty- 
 four inches across in the centre of the ceiling, going at the rate of 
 300 revolutions a minute, introducing 1000 cubic feet of fresh air a 
 minute ; part of the skirting covered with perforated zinc, open about 
 four inches by six inches. In spite of this large quantity of fresh air 
 entering this very small room, the flame of a candle was not deflected in 
 any part of it, not even a few inches underneath the revolving fan ; but 
 along the walls, in places about six feet from the floor, it was difficult 
 to keep the candle alight ; at the outlet in the skirting, the flame was 
 strongly drawn towards the perforated zinc. While sitting on a chair 
 ])ushed close to the wall, where the candle was nearly blown out, no 
 draught was perceptible. From this and other matters, I am inclined 
 to define a draught as a strong current of air proceeding more or less 
 across a room ; and I would add, that a strong current of air, proceeding 
 along the walls only, is not felt.
 
 VENTILATION FOU COLD AND WARM CLIMATES. 5G1 
 
 In corroboration of this experiment, a leading medical man now present 
 had told me that fourteen men sat in that small room one very hot 
 afternoon this summer (1888), without the slightest inconvenience. 
 
 Now for one more test. On New Year's afternoon I visited the 
 raox'gue; three bodies on the slabs, two much decomposed; a hot 
 oppressive north wind blowing. I suppose, for architectural or financial 
 reasons, this system of ventilation was reversed, i.e., the heavy gases 
 were sucked up from the floor through two four-inch tubes for about 
 twenty feet in height to the ceiling, where the fan, about two feet in 
 diameter, was revolving at the rate of about 250 times a minute, 
 throwing out about 800 cubic feet of foul air a minute, through the side 
 lights (about three feet by one foot) on the north side. If the side lights 
 on the south side had been open, instead of those on the north side, the 
 strong north wind would have helped, instead of opposed, the eviction 
 of the foul air. A still better plan would have been to cast out the bad 
 air through the roof; nevertheless, with the doors closed, the ofFensive- 
 uess was slight. A candle flame was deflected nowhere throughout the 
 spacious room (about 48 ft. x 24 ft. x 20 ft. high) ; it was immediately 
 extinguished when placed near the exhaust pipes on the floor. Water 
 slightly purple with Condy's fluid in a basin in the centre of the floor, 
 did not change its colour. 
 
 These two experiments of mine form, I think, suflficient grounds for 
 our thoroughly testing this system, for if the details be satisfactorily 
 arranged, it must not only supersede all other systems, but what is of 
 far more importance to us, we shall be able to keep our hospitals and 
 public institutions cool and sweet, and thereby lessen their rates of 
 mortality. Our governing bodies will also be enabled to lessen the size 
 of these institutions, as so much cubic feet per inmate will not be 
 required. Foul air on board ship, and heat apoplexy in the Red Sea 
 passage, will become things of the past. Our mines, torpedo and 
 submarine boats will be able to depend upon a good supply of pure air. 
 Railway and tramcars and cabs need be no longer offensive ; dairies and 
 meat safes will probably some day be cooled on this principle. Hospitals 
 for infectious diseases (small pox, yellow fever, scarlet fever, <i:c.), if the 
 air from the outlets be passed through a small Bunsen's gas or other 
 furnace, this foul air will become immediately purified, and the reproach 
 of these hospitals will be abolished. All public buildings will have fresh 
 air, free from draughts, and the carbonic acid in churches will no longer 
 cause us to sleep through the sermon. 
 
 In conclusion, I may say that I have found this revolving fan 
 practically noiseless; and at the morgue, the water flowing away after 
 acting as a motor could be carried off in a two-inch pipe. 
 
 For warming cold air in our public institutions, the air of entry can 
 be passed through a small Bunsen's gas or other furnace — a cheap as 
 well as safe and convenient method. 
 
 For cooling hot air, the air of entry is passed through an ice chest, a 
 freezing mixture, or through a metallic coU under water. 
 
 lo
 
 562 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 WHAT BECOMES OF THE TYPHOID GERM IN 
 SEWAGE FARMS? 
 
 By Andrew Shields, M.D. 
 
 The question now put takes for granted, that typhoid germs reach 
 those irrounds wliere sewage irrigation is practised. In water-closet 
 towns, typhoid excreta must often l^e added to the ordinary sewage, 
 and where this is placed on the land, the gei'ms of the disease must be 
 deposited there. This being granted, the question arises — "What 
 becomes of these germs after reacliing the farm?" Is that their final 
 destination, where they are either destroyed, or deprived of the power 
 of doing further harm 1 
 
 On the other hand, does filtration through the soil accomplish this 
 only imperfectly, and still leave the effluent water a source of danger 
 to the public health 1 
 
 While percolation may purify the sewage so far as the senses can 
 discern, and the dead organic matter become broken up into soluble 
 salts, &c., for the food of plants, does the process at the same time 
 remove all disease germs, including spores and poisonous products. 
 I am not aware that this particular aspect of the subject has been 
 thoroughly determined. 
 
 That a sewage farm may be so managed as to prevent the occurrence 
 of typhoid fever, or other zymotic disease, on the farm itself, must be 
 admitted. The evidence on this point seems generally well established. 
 So far back as 1863, Sir Robert Christison, in an address on public health, 
 expressed his opinion respecting the effects of sewage irrigation in tlie 
 following terms: — "If there be any doubt as to the general salubrity 
 of the now famous meadows of Craigentinny, there is none at least as 
 to the total absence of ague among the inhabitants. I have recently 
 been making careful inquiry respecting tliis famous and somewliat 
 unsavoury institution. Many years ago, my own prejudices were all 
 against the meadows. I have been compelled to surrender them. I 
 am satisfied that neither typhus or enteric fever, nor dysentery, nor 
 cholera, is to be encountered in or around them, whether in epidemic 
 or non-epidemic seasons, more than in any other agricultural district of 
 the neighbourhood. I think it right, in reference to the late Intro 
 duction of the Craigentinny system of irrigation into the vicinity of 
 other large towns, that these precise facts should be known." 
 
 The correctness of these views has been confirmed by subsequent 
 experience; and we find Dr. Carpenter, of Croydon (England), at the 
 annual meeting of the British Medical Association held in Glasgow, 
 August 1888, stating : — "That sewage farms, if properly managed, do 
 not set up either parasitic or epidemic disease among those working on 
 the fann, or among the cattle fed upon its produce." 
 
 The fact, liowever, that those engaged on the farm do not sufier from 
 typhoid fever, or other diseases of a like kind, does not settle the 
 question now under consideration. There is no evidence that persons 
 working on the farm, or the families residing in the neighbourhood, are 
 in the habit of using the outflow water for household purposes. If it 
 could be shown that the effluent at these farms was constantly used by
 
 WHAT BECOMES OF THE TYPIIOTn GEHM IN SEWAGE FAHMS. 563 
 
 old and yoiinn" alike, and that no disease had arisen from drinking such 
 water unboiled, then a inost convincing proof would have been estab- 
 lished. But so far as we know, no proof of this kind is available, or 
 likely to be so. 
 
 It may be said that this is putting the matter in an extreme form, 
 and that it would be absurd to expect people in their sound and sober 
 senses to run such a risk. We admit the experiment would be a 
 liazardous one, and indeed far too dangerous to be put to the test ; but 
 this only shows the weakness of the argument, viz., that the water 
 must be safe because instances are known where it has been drunk 
 without any bad effects. 
 
 It must be evident, that an occasional occurrence of this kind is no 
 criterion that such water is free from poisonous germs. It is well 
 known that some persons are less susceptible to infectious disease than 
 others, on account of age or other conditions. Exposure to the contagion 
 of small-pox does not always result in infection. 
 
 Dr. Carpenter allows there would be risk in using the water from 
 sewage farms, for he adds: — "It is not however argued, that the 
 efHuent water is safe for dietetic purposes." He thinks, however, that it 
 is "fit for discharge into any ordinary stream, provided the area ti'eated 
 is not less than an acre for each 250 persons." * But if the water 
 is not fit for household purposes, is it safe for discharge into a stream 
 which aftbrds a water supply for domestic use 1 It is true Dr. Carpenter 
 does not explain what he means by an "ordinary stream," but it may 
 be inferred that he means a stream which supplies water for human 
 consumption, otherwise there would be no point in the statement. 
 
 No one disputes that the outflow from a sewage farm may be 
 discharged into any water-course which runs direct into the sea, 
 without being further used. If all sewage farms were on the sea coast, 
 or on tidal estuaries, it would be a matter of no practical importance 
 whether the germs of disease passed out with the effluent water or not. 
 It is altogether a different thing when the filtered sewage flows into a 
 stream which supplies a number of inland towns with drinking water. 
 This is a subject of special interest in our Australian colonies, where 
 the pollution of I'ivers and ci'eeks is now a matter of the gravest 
 concern. 
 
 Sewage farms are now much advocated in Europe, and already the 
 principle is in operation and finding favour in Australia. It would be 
 well, therefore, to ascertain whether the process can be carried out as 
 safely inland as on the sea coast. It is agreed that neither chemical 
 analysis, nor the senses, can determine this point, and experiment 
 cannot be made Avith human life. Until, therefore, bacteriological 
 science has settled the question definitely, we are not justified in saying 
 that the effluent from a sewage farm is fit to discharge into a stream 
 which supplies tow ns or villages with drinking water. 
 
 The experience of Lausen, quoted in the sixth report of the Rivei's 
 Pollution Commission, seems to prove beyond a doubt that the poison 
 of typhoid may undergo what appears a very efficient natural filtration, 
 without losing its activity. (See Lancet, August 13, 1887.) In that 
 epidemic, the typhoid germs or spores had " filtered through a mile of 
 
 * British Medical Journal, August 25, 1888. 
 
 lo 2
 
 564 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 earth,"* and yet retained their vitality and power to cause an outbreak 
 of fevei'. Although the filtration, in the case now mentioned, inter- 
 cepted particles of wheaten flour, it was not sufficient to prevent the 
 typhoid microbes from passing through. 
 
 Considering then that typhoid germs are not only living, but 
 probably higlily tenacious of life, and capable of multiplying in river 
 Avater, as found by Wolff'huegel and Riedel, the danger of allowing 
 them to pass into ordinary streams becomes more apparent. Their 
 power of living in river water and causing an outbreak of typhoid fever 
 has recently been shown in America, as given in the following extract 
 from the "Annual of the Universal Medical .Sciences," Vol. V., p. 228: 
 — " The capacity of river water, as a medium for the propagation and 
 cultivation of pathogenic germs, has been illusti'ated in the Ohio 
 Valley. At many towns on the Ohio River, extending a distance, 
 by river, of over 800 miles, nearly every town obtaining its water 
 supply from the river was more or less infected by typhoid fever." The 
 epidemic of typhoid fever was attributed to this sovirce, because it was 
 demonstrated by Brouardel's method that the typhoid bacilli existed in 
 the water of the Ohio River. This shows that the self-purifying power 
 of rivers does not hold good with respect to the typhoid poison, what- 
 ever it may do in the case of other kinds of matter. 
 
 In conclusion then, we affirm that, although land-filtration has a 
 remarkable power of clarifying sewage, and of breaking up the organic 
 matter, that of itself, is no proof that the effluent water is free from 
 typhoid microbes and fit for discharge into streams which supply water 
 for human consumption. How far typhoid excreta should ever be 
 allowed to mix with water at all, except what finds a dii'ect and quick 
 passage into the sea, is a matter of much pi-actical value at the present 
 time, when sewage farms are gaining favour in these colonies, but the 
 question is one which we do not enter upon at present. 
 
 * Sanitary Record, July 15, 1887.
 
 SKCTIONAL MEETINGS. 565 
 
 SECTIONAL MEETINGS. 
 
 The meetings of tlie Section were held in the Chemical licctuie Room 
 of the University. In the absence of the President and the Vice- 
 Presidents, Dr. McCrea, of Victoria, presided at the first meeting ; the 
 President, Dr. MacLaurin, taking tlie chair upon tlie following days. 
 Letters expressing regret at absence, and wishing the Congress every 
 success, were read from the Vice-Presidents, Drs. Waylen, Johnston, 
 and Smart ; from Dr. Alfred Carpenter, Vice-President of the British 
 Medical Association; Professor Kelly, of King's College, London; Drs. 
 Edward Ballard ; Biown, of Belfast ; and Spoof, of Abo. Numerous 
 diagi'ams and publications, illustrative of sanitary matters, were at the 
 disposal of members, for wliich the thanks of the Section were given to 
 the Local Goverment Board, Whiteliall ; the Central Board of Healtli, 
 IMelbourne ; tlie Medical Officer of Health, Belfast ; and Dr. Spoof, of 
 Abo. 
 
 Upon the Question of Cholera Quarantine. 
 
 Drs. McCrea (Victoria), Creed (New South Wales), Whittell (South 
 Australia), and Sprixgthorpe (Victoria), supported the present system 
 of (juarantine, as the best preventative measure under our special cir- 
 cumstances, without expressing any opinion upon the course which miglit 
 be most suited to a country so differently situated as England was. 
 
 Dr. KiRTiKAR admitted that his paper applied rather to European 
 practice, and to European authorities his argument was, "Why take 
 our grain, and refuse admission to our people ? " 
 
 Upon the Question of Leprosy in Australasia. 
 
 Dr. MacLaurix mentioned a recent case, occurring in a Chinaman of 
 a Ijetter station in life than the ordinary. 
 
 Dr. MiLFORD (Sydney) said that leprosy had been found in patients 
 of European origin up in the bush, tlie origin being apparently bad food 
 and hygiene. In 1878, two such cases were reported. 
 
 Dr. Jakins (Victoria) pointed out how Victorian cases had all been 
 hopeless, though the Bombay Government quoted a large percentage of 
 recoveries in their special sanator-ium. 
 
 Upon the Question of Australia as a Itesort for Consumptive Patients. 
 
 Dr. M'MuLLEN (New Zealand) considered that it was no wonder if 
 ignorance upon the point prevailed in England, seeing the absence of 
 exact knowledge of our different climates amongst ourselves. 
 
 Dr. Jakins (Victoria) had known many cases of arrest since his 
 ariival in 1864. Some got worse if they remained on the sea-coast, 
 others if they went inland. The only test was a practical trial. 
 
 Dr. Mackintosh (South Australia), after thirty-two years' experience 
 in South Australia, considered tliat, if cases came out early, they were 
 greatly benefited, even cuied ; but that, if tlie lungs were breaking 
 down, the hot winds aggravated the symptora.s, and hastened death. 
 
 Dr. Toll (Health Officer, Port Adelaide) agreed that South Australia, 
 especially the nortliei-n parts, suited the early stages, l)ut was injurious 
 in the latter sta^e. He found that most cases were sent out too late.
 
 566 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Dr. Hudson (New Zealand) knew many cases, even of cavity, which 
 had Ijenetited very much by coming to Australasia. As an English 
 winter was almost certainly fatal, it would be scarcely right to tell 
 English physicians not to send any but the early cases. Certainly, 
 l:)etter ventilation was wanted on the voyage, and more discrimination 
 as to the place to which the case was sent. 
 
 Dr. Creed (New South Wales) agreed that it would be unwise to 
 forbid patients coming to a place where they Avere likely to improA'e. 
 What was wanted was more definite directions. 
 
 Dr. 8PRINGTH0RPE (Victoria) believed that one outcome of the Section 
 would be more exact knowledge on our own part of the climatology 
 of Australasia. Then the best destination for patients, the seasons, 
 conveniences, itc, would soon be recognised at home also. 
 
 Ljjon the Question of SiJecialism in Medichie. 
 
 Dr. Jakins (Victoria) considered that, as no man could be thoroughly 
 acquainted with all branches, it was a good thing for both the public 
 and the profession, that specialism existed. 
 
 Dr. Hudson (INew Zealand), as a general practitioner, coincided. 
 
 Dr. Hooper (Victoria) thought that specialism could be objectionable 
 only when it ran riot. 
 
 Upon the Question of Pasteur^s Mode of Exterminating liahbits. 
 
 Dr. WiGG (Victoria) apologised for being unable to bring forward 
 his paper as promised. He had gone carefully into the proposal o£ 
 M. Pasteur ever since it had been first suggested. He was so satisfied 
 that it would be most unwise to introduce such a remedy into our 
 conditions, without requiring the most stringent tests, that he had 
 l^rought the matter before the Royal Society of Victoria, where his 
 A'iews had been unanimously endorsed, and resolutions to that effect 
 l)rought under the notice of the Government. Since M. Pasteur's 
 representatives had come out, he had gone carefully over their labora- 
 tory, Arc, on the island in Sydney Harbour, and he had come to the 
 conclusion, that necessary information was withheld ; that the rej^re- 
 spntati\es of M. Pasteur seemed anxious to rush the experiments 
 tlirough in a few weeks ; that the arrangements were too clever to be 
 practicable for our purposes ; nor could he find any work being done. 
 
 Dr. Taylor (Queensland) stated that JNL Pasteur's representatives 
 were reported to have complained that the Rabbit Commission had not 
 treated them with sufficient fairness, and asked what truth there was 
 in such rumour. 
 
 The President (Dr. MacLaurin, Sydney) had been until recently a 
 member of the Commission. While a member, he was sure that there 
 was every desire on the part of the Connnission to facilitate the work 
 of the representatives. In his opinion, the ideas of Pasteur's repre- 
 sentatives upon the question were too indefinite, and insufficient to gi\e 
 satisfaction to the public of these colonies. The Connnission had had 
 to undertake its own experiments, which were of ;in elaborate character. 
 Tt was quite possil)le that M. Pasteur's representati\es were dissatisfied. 
 Perliaps the stringency of the regulations was objectionable to them. 
 After \ery careful investigation, the Connnission had concluded that
 
 SECTIONxVL MEETINGS. 5G7 
 
 Pasteur's plan was not efficacious here. Thus, speaking simply for 
 himself, and not for the Commission, the microbe recommended produced 
 constipation in I'abbits, and not diarrha>a, as in chickens. Hence it was 
 not excreted ; and tliere was no reason why other individuals should 
 become attacked, and practically, others were not, when tlie animals 
 were not domesticated. Possil)ly some little personal feeling had crept 
 into the question, l)ut the Commission simply wanted the truth. 
 
 Upon the Quesdoti of the Attitude of the State toioards Q'uacks and 
 
 Quackery. 
 
 Dr. ^iuLLEN (Victoria) upheld the Medical Practitioners' Act, 1865, 
 as equitable, though imperfect in details. He considered it impossil>le 
 to proliibit quackery, and to be unjust for the State to do more for 
 (|ualified medical men than register them, restrict to them certain 
 recognised titles, and legal status. He considered the action of the 
 ( Jhief Secretary of Victoria, in not allowing the police to prosecute 
 unqualified practitioners, as perfectly legal. 
 
 Dr. Creed (Sydney), as Cliairman of the recent Commission which 
 liad exposed the extent of quackery in New South Wales, spoke from 
 a full knowledge of the subject. He agreed that proliibition was 
 impossil)le, but maintained that the spurious should be labelled spurious; 
 that for State requirements only the genuine should be selected, and 
 that the public should be put in a position to discriminate the true 
 from the false. 
 
 Dr. MoRGAX (Newcastle) pointed out how badly they were in need of 
 reform in New South Wales, where the quacks were a powerful body, and 
 did infinite harm to the public. Further, they were recognised by the 
 State; for unfjualitied men acted as Coroners and Justices of the Peace, 
 give medicrd evidence, signed certificates of death, and held hospital 
 appointments. 
 
 Dr. Springtiiorpe (Victoria) pointed out that the defects in the 
 Victorian Act were — the mode of election of the Board, the absence of 
 power to erase names, the scanty requirements for registration, and the 
 absence of explicit powers of prosecution. The complaint against the 
 Chief Secretary was, that he had actually forbidden the police to act 
 upon information received, though they had so acted for many years. 
 At present no one would prosecute, and quacks were flocking over fi'om 
 New South Wales. 
 
 Dr. Taylor (Queensland) urged the necessity of reform as a matter 
 of vital importance. 
 
 Upon the Qtiestioii of the /Sanitary Comlition of the Different 
 
 Colonies. 
 
 Dr. Taylor (Queensland) regretted that, owing to unavoidable circum- 
 stances, Queensland was not represented in the list of colonies which 
 had reported tlieir sanitary status. 
 
 Dr. WiiiTTELL (South Australia), tliough not advocating centralisation 
 in all tilings, considered that the great want in sanitary matters was a 
 powerful central authority. He had thought it a mistake when, last 
 year. Local Boards of Health had been established, and the powers of 
 the Central Board curtailed. After a year's experience, he was more 
 convinced than ever that such establishment was a mistake.
 
 568 INTEKCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Di\ A. Shields (Victoria) said that the Central Board of Health for 
 Victoria was the most abused body in the colony, and had a very hard 
 uphill light to wage — so that such testimony was reassuring. 
 
 Dr. Appleyard (Tasmania) pointed out that Tasmania enjoyed a fair 
 Registration Act, and a stringent Vaccination Act. 
 
 Dr. Bonnefin (Victoria) considered the state of Melbourne more 
 than scandalous. He looked for reform, mainly in the education of the 
 public, and considered that medical men should woi'k towards this 
 object more than they did. 
 
 Dr. Leger Erson (New Zealand) considered the present sanitary 
 executive in New Zealand, as worse than useless. 
 
 Dr. Morgan (Newcastle) deplored the sanitary condition of New 
 South "Wales. It was simply, that the public and the local authorities 
 were entirely ignorant of what should be done. The profession owed it 
 to itself, to band together and make its influence felt, in the direction 
 of speedy reform. 
 
 Dr. Springthorpe (Victoria) trusted that the Section would not 
 separate without taking some practical step towards showing the 
 Governments of the different colonies the opinion held by it, upon 
 the sanitary condition of the colonies. 
 
 It was thereupon decided that the President (Dr. MacLaurin) and the 
 Secretary, Dr. Springthorpe, should draft a series of resolutions for tlie 
 consideration of the Section. The following resolutions were accordingly 
 drafted, and unanimously agreed to: — 
 
 (1) "That this Section of the Intercolonial Medical Congress, 1889, 
 
 urges upon the notice of the different Governments of Aus- 
 tralasia the necessity which exists for fresh legislative 
 enactments in all the colonies, with a view to obviate the 
 grave dangers to public health which everywhere prevail, and 
 which, in many cases, are due to easily removable causes." 
 
 (2) "That, in the interests of the public, this Section of the Congress 
 
 urges upon the various Governments of Australasia the 
 necessity for amendments in the laws relating to the position 
 of medical practitioners, in oi'der that the public may be in n 
 position, at all times, to protect themselves against the imposi- 
 tions of unqualified persons." 
 
 (3) " That copies of these resolutions be forwarded by the Secretary 
 
 to the Federal Council, and also to the Governments of the 
 different colonies." 
 
 It was then decided that Dr. Springthorpe should bring these resolu- 
 tions under tlie notice of the general meeting of the Congress, so tlmt, 
 if possible, they should receive the sanction of the whole Congress. 
 
 The Section then adjourned.
 
 SECTION OF ANATOMY AND 
 PHYSIOLOGY. 
 
 PKESIDENT'S ADDRESS. 
 By T. P, Anderson Stuart, M.D. 
 
 Professor of Anatomy and Phyaiology, and Dean of the Faculty of Medicine in 
 the University of Sydney. 
 
 In an address on Anatomy and Physiology, one may either speak of 
 the subject matter, as one would before a number of specialists in these 
 branches of learning, or one may treat them in a more general manner 
 as one would before a purely lay audience ; speaking, for instance, of 
 their value as a discipline, or means of education, or of their value in 
 relation to the art of healing. Further, one may deal with them his- 
 torically as they were in the past, descriptively as they are at present, 
 or prophetically, one may form anticipations of their future. I think I 
 shall be most in harmony with the nature of this meeting, if T take up 
 more or less of all these lines. 
 
 On the Scientific Culture. 
 
 Before an audience of scientific men I do not need to advocate the 
 training of the mind in science and scientific methods, as a means of 
 education and culture. That the scientific mode of thought and habit 
 of mind fosters the love of truth for its own sake, and constitutes a 
 thoroughly effective mental discipline, no member of this Congress will 
 doubt. That there is, in the cultivation of science, something which 
 imparts a culture in as true a sense as does the study of letters, I do not 
 need to ui-ge here. That the recognition of a scientific culture as such 
 is spreading among men, anyone who notes the signs of the times can 
 perceive. But this tardy and partial recognition has come only after 
 being fought for and struggled for, and the struggle is not yet over. 
 Thus it has all too often happened, that the scientific man has had 
 to waste in contention, time and energy which he would fain have 
 given to his proper work. It should be added that the struggle is 
 not peculiar to Australia — it comes from the older lands. In a sense, 
 therefore, the legend of the University of Sydney is only too true — 
 " Siclere mens eadem mutator 
 
 The attitude of the ancient Universities of Oxford and Cambridge is 
 worthy of notice in this connection, for in these homes of culture,
 
 570 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA, 
 
 medical schools have been revived withiii the last few years. In some 
 departments, Cambridge is already worthy of the designation of the 
 " great " school of medical science, and Oxford is making steady progress ; 
 and it is of interest to us in this place to note that both these schools 
 of medicine date their real revival from the establishment of schools 
 of physiology. Perhaps, in some measure connected with this 
 academic recognition of medical science, there has, in recent years, I 
 am told, been a distinct improvement in the manners and habits of 
 medical students. Bob Sawyer is now as dead as Julius Csesar. And 
 yet, let the tree be judged by its fruit; for when we think of the con- 
 fidential relations which must of necessity exist between medical adviser 
 and patient, when we remember the varied and oft-repeated temptations 
 that beset the medical man in his practice, and when we think how 
 seldom he has been found wanting, surely that medical and scientific 
 education cannot have been a bad thing, when it could make such men 
 out of such students. 
 
 The Physician must be a Physicist. 
 
 The progress of Physiology during its period of marked progress — 
 say the last quarter of a ceutury^ — shows very clearly that the energies 
 at work within the body are in no wise different from the energies at 
 work in the world without it. The sole difference is in the stage on 
 which they play their parts. Time was, and not so very long ago, when 
 a " vital " force was believed in as it now no longer is, and the 
 phenomena of life were thought to be approachable only on lines some- 
 what different from those on which we would take up the phenomena of 
 the world around us. But now, the whole tendency of the time is to 
 show that vital manifestations are phenomena to be studied as other 
 phenomena are ; and more and more is it clear, that the methods and 
 laws of Physics are to be applied in Physiology. The physiologist is 
 but a student of ])hysics in so far as concerns organised things, to the 
 I'ight understanding of which he must add also a knowledge of their 
 structure. And — like the exj^erimental physiologist — the physician, 
 too, is constantly called upon in diagnosis and in treatment to make 
 experiments, to record observations, and to work out problems more or 
 less j)hysical — in optics, in acoustics, in hydraulics, in mechanics, in 
 electricity, and so on. For instance, the physician now employs 
 electricity to obtain heat and light, to coagulate blood, to modify the 
 nutiition of the tissues, as in the restoration of wasted nerve and muscle, 
 and the dissolution of tumours, &c. The physician even uses the 
 galvanometer, and prescribes doses of electricity in milliamperes, as he 
 would prescribe degrees of teuiperature, or weights of drugs.
 
 president's address — SECTION OF ANATOMY AND PHYSIOLOGY. 571 
 
 But it may be urged that the physicist must needs be so good a 
 mathematician, that a fair knowledge of physics is beyond the average 
 mathematical attainments of the average student of medicine. This, 
 however, is not the case — some mathematics he must know, but not so 
 much as is often assumed; for indeed tliere are not wanting examples of 
 men of high attainments in physics who were of but moderate mathe- 
 matical attainments. I mention this, because I desire to urge the study 
 of pliysics as a vecessary part of the training of the medical man, and 
 accordingly, I wish to show that a lack of an advanced knowledge of 
 mathematics need not stand in his way. 
 
 The proper position of the study of physics in a curriculum is not 
 difficult to settle. It must be at the beginning, and it is a matter of no 
 importance what it is called — it may be part of a preliminary scientific 
 training, or it may be the beginning of the medical course — it is enough 
 if it be there. But this raises the question of what the preliminary 
 training of a medical man should be — a question of extreme importance 
 in these colonies where medical schools are young, and, like other young 
 things, plastic, because free from the trammels of use and wont; and 
 largely free also, though unfortunately, from the influence of a medical 
 public opinion — an influence, the absence of which on many grounds,, 
 is gi-eatly to be deplored, but a contribution to the creation of which 
 will, I trust, be one of the chief results of this Congress. The question 
 takes us even further back — it takes us back to the school training. 
 
 I confess that I am not sure how far the teaching of what is ordinarily 
 called science may be introduced into primary schools, but I have no 
 hesitation in saying, that some measure of elementary scientific teaching 
 should be given to all cliildren, without distinction. To the boy who 
 will afterwards get such teaching at the University, where, in all 
 likelihood, he will begin at the beginning, it is not a matter of such 
 moment; but for the great majority of boys, who will jiot get any 
 instruction at all in natural science if not at .school, it is a matter 
 of the very greatest importance. Of course, what I say of boys, I say 
 equally of gii-ls. 
 
 It is unfortunately the case that, as yet, the best teachers are nearly all 
 literary and mathematical teachers, and consequently, the Ijest teaching 
 is still exclusively of a literary and mathematical nature. So long 
 as the teaching of natural science in schools is a sort of extra thing, 
 done at odd times, done in most iusufticient measure and too often 
 in an inetticient manner; .so long as the study of letters and abstract 
 mathematics thus completely overshadows the study of everything else, 
 so long must the pre.sent unsatisfactory state of matters continue. 
 
 In parenthesis, as it were, I would strongly urge the teaching 
 of drawing to every child in the school. I do not necessarily mean
 
 572 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 more than the drawing of a straight line, of a good curve, of a proper 
 angle, and such like, so that in after life, ideas may more frequently be 
 conveyed by figures instead of by words only. The efficiency of this 
 description by pictures, as a training of the faculty of observation 
 and of the mind, is not, I think, questioned in theory, though sadly 
 neglected in practice. The ancient Mexicans — -a wonderful race — had 
 no other mode of recording ideas. I would likewise urge the more 
 frequent training of children in the art of verbal description. All sorts 
 of objects should be placed before them, and they should be required, 
 after due observation, to write down in words just exactly what they 
 find. Such an exercise would be at once a training in observation, 
 in composition, grammar, spelling, and writing. All teachers of science 
 complain of the many young men and women who come to them 
 with their eyes wide open, and yet seeing nothing whatever. This 
 faculty of description is in a large measure to be acquired by practice, 
 as every teacher of anatomy can testify. 
 
 The New Medical Curriculum of the University of Sydney. 
 
 Amongst other things, we have secured for students the training in 
 physics, of which I have spoken. Sydney, as regards the medical 
 curriculum at least, is now well in the van of progress. Thus, in 
 Australia, we were thinking on the same lines as they have been in the 
 United Kingdom. The time is evidently ripe for the change. Here, 
 we had carried out, what there they are still only thinking about. 
 
 Perhaps I might be permitted to say a word on the curriculum 
 which we have striven to make as perfect as practicable, and which — as 
 finally passed by our governing body only last month — is, of course, 
 probably the latest thing of the kind. 
 
 As a giiarantee of a sufficient general education, we require a degree 
 in arts or in science, or failing a degree, a year's attendance on the 
 classes of the first year of the arts course, together with the examina- 
 tion at the end of that year. As an alternative, we have now as an 
 entrance examination, certain subjects of the Senior Public Examination. 
 After this follows a course of five years' duration. The student is 
 mainly concerned in the first year with physics, chemistry, and biology ; 
 in the second and third years with anatomy and physiology ; in the 
 fourth and fifth years with the more special departments of medical 
 science. 
 
 In every department, practical instruction is insisted upon. It is our 
 desire to educate and train, rather than merely to instruct and cram. 
 Further, we recognise that, while examinations of some sort are 
 necessary, they are not an unmixed good ; and in our practice, we have 
 to some extent anticipated the remedies suggested in that much-needed
 
 president's ADDRESS — SECTION OF ANATOMY AND PHYSIOLOGY. 573 
 
 signed protest, and the accompanying comments, published in the 
 November number of the Nineteenth Century. We try to minimise the 
 evils of the examination system as follows : — In the degree examinations, 
 the results of the class examinations, which are compulsoxy, and are 
 conducted during the course by the teacher aloiie, may be taken into 
 account ; there is an interval of two years between the first and second 
 examinations ; the teacher is co-ordinate in every way with the associate 
 examiner ; in every subject a practical or vivd voce examination follows 
 the written paper ; there is no separate honours examination — honours 
 depend on the high excellence of the student throughout his whole career. 
 
 We have made compulsory a course of ophthalmic medicine and 
 surgery, and a course of psychological medicine. Requiring attendance 
 on a course of instruction in logic and psychology, is a new feature. 
 Thus the student becomes acquainted systematically with tlie general 
 methods of science — with, as it were, the grammar and syntax of science, 
 and is introduced to many of those problems of philosophy which have 
 occupied the minds of men in the past, and which, from the nature of 
 his daily work, can hardly fail to occupy his own. Also, by making 
 it part of the Bachelor's course, we avoid that annoyance so often 
 experienced by the Bachelor proceeding to the Doctorate, when he 
 finds that he has still to pass in logic at a period of life when such 
 examinations are peculiarly distasteful. These are steps in the right 
 direction, which I am bold enough to commend to the attention of 
 the General Council of Medical Education and Registration, and of 
 most British licensing authorities. 
 
 Another point worthy of notice here is, that at the end of the first 
 three years of our medical curriculum, the student can, with some extra 
 work, obtain the Bachelor of Science degree. The science and medical 
 curricula are now made practically identical as regards the first year, 
 and we reckon that the next two years' medical study will, with some 
 additional and advanced work, make up the requisite three years' work 
 in science, so that the best and most industrious students of medicine 
 can acquire a degree in science. We thus seek to emphasise the fact, 
 that the earnest man of medicine, is a man of science in the truest 
 sense of the term. 
 
 The Improvement in Teaching Methods. 
 Nothing, I am frequently told, strikes men who have received their 
 teaching in the not very distant past, so much as the great care that is 
 now taken to see that every student, in each department, shall have the 
 maximiim of practical work and the relative minimum of book work. 
 The illustration of lectures is now carried to an extent before unheard 
 of. I have heard it remarked that we make things too easy for students
 
 574 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 noAvadays. I cannot think that ; for with the advance made in teaching 
 methods, there has been an enormous expansion of the subjects in every 
 direction. I think we may assume that the best text-books contain a 
 statement of what is fairly established. On this assumption, an 
 examination of some of the standai'd text-books is very instructive, as 
 showing the rate and extent of the expansion of our sciences. Thus 
 " Quain's Anatomy " was first written by Jones Quain alone; in the 
 later editions, there are always three editoi'S. The third edition, in 
 1834, had no illustrations, and only 467 pages (when its actual 855 are 
 reduced to the present standard); the sixth edition, in 1856, had 
 356 figures in 1096 pages (its 1635 being reduced to the present 
 standard); and the last, the ninth edition, in 1882, has 1194 figures 
 in 1617 pages. 
 
 Some Account op what Anatomy and Physiology have been 
 Doing during Recent Years. 
 
 "While the influence of the doctrine of evolution has extended to 
 every department of knowledge, it has influenced our own branches of 
 science more directly than any other, and to it we owe much of oiir 
 progress. It is as pre-eminently the working conception of anatomy, 
 as the law of the conservation of energy is now that of physiology. 
 
 The progress of physiology has led to that of preventive, as compared 
 with curative, medicine; and though the modern system of preventive 
 medicine is only about forty years old, its development is now the great 
 and high end of the efforts of medical men. The triumphs of sanitary 
 science are now to be sought in every clime — in the barrack and in the 
 field, in hospital construction and in hospital nursing, in the sanitary 
 arrangements of the house, of the city, and of the entire community. 
 In this connection, it is greatly to be deplored that the Legislatures of 
 the world — not of these colonies only — do not see it to be their duty to 
 do more in the way of sanitary legislation ; for, as has been so wisely 
 said, the best way to make a people happy, is to keep them healthy. 
 This advance in sanitary matters has been greatly aided by the spread 
 of natural knowledge amongst the people, by their greater disposition to 
 ascribe their troubles to natural and often })reventible causes, rather than 
 to wholly inevitable workings of an unseen power, whether good or bad. 
 
 In curative medicine, physiology, through pharmacology, has played 
 a great part lately, and is playing a greater part every day. Pharma- 
 cology, i.e., the precise knowledge of the mode of action of drugs 
 and other influences affecting the organism — rests almost solely on 
 physiology. But on the other hand, physiology owes much to the 
 younger science. From pharmacology, indeed, everything is to be 
 expected. Huxley, in his address before the London Meeting of the
 
 PRESIDENTS ADDRESS — SECTION OF ANATOMY AND PHYSIOLOGY. 575 
 
 International Medical Congress in 1881, said of |)liarmacology : — " There 
 can surely be no ground for doubting that, sooner or later, the 
 pharmacologist will supply the physician with the means of affecting, in 
 any desired sense, the functions of any physiological element of the 
 body. It will, in short, become possible to introduce into the economy 
 a molecular mechanism which, like a very cunningly devised torpedo, 
 shall find its way to some particular group of living elements, and cause 
 an explosion among them, leaving the rest untouched." A perusal of 
 Lauder Brunton's " Pharmacology, Therapeutics and Materia Medica," 
 tends to convince one that the goal is nearer than many think, for it is 
 becoming clearer that there is a very close connection between the 
 physiological action of a body and its physical characters, such as its 
 •chemical constitution, its atomic weight, and its spectrum. 
 
 To{)Ographical anatomy has made such strides quite lately, that its 
 <lescriptions have had to be practically re-written. This is largely the 
 result of the method of freezing, by which the exact relations and form 
 of the parts are preserved ; this method has its counterpart in minute 
 anatomy in the freezing and embedding methods, as for instance, in the 
 paraffin method, which gives such beavitiful series of sections in ribbons, 
 all the sections being good and each in its proper place. In my student 
 days, it was the fashion to say of human anatomy that it was played out, 
 and I was quite of that mind. I do not think so now. There are still 
 many good ears to be gleaned from the stubble in the field of human 
 anatomy. 
 
 Embryology has made gigantic strides in recent times, unfolding 
 not only the story of the origin of the individual, but also, in 
 some measure, that of the origin of his kind. In teratology, it has 
 cleared away many difficulties by showing that monsters ai'e not lusus 
 naturce, sports, or freaks of nature, but are simply perversions of the 
 normal type. In osteology, comparative anatomy and embryology have 
 continued to throw much light on the meaning of the different centres 
 of ossification in the bones of man, showing that the different centres 
 represent distinct bones in other types. The homologies of muscles have 
 been well worked at, and many ligaments and fasciie have been shown 
 to correspond to bones or muscles in other forms. Anomalies occurring 
 in the human body have thus, in many cases, been explained. The 
 mode of development, and the comparative anatomy of the supra-renal 
 bodies, promise to throw some light on the nature and office of these 
 mysterious bodies. The pineal body or epiphysis cerebri, seems to be 
 the vestige of an early vertebrate eye, or other sense organ. As to the 
 pituitary body, or hypophysis cerebri, much doubt still remains — either 
 it is a vestige of the old mouth of the vertebrate ancestor, or it is a 
 vestige of a sense organ — and indeed there are many points in the
 
 576 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 development of the eye, and in that of the pituitary body and of its 
 surrounding structures, that appear to be very remarkably alike, as if 
 there had been a pituitary eye, or other sense organ, corresponding to 
 the pineal sense organ, before the present mouth was evolved. Tlie 
 coccygeal body seems to be the vestige of the post-anal segment of the 
 hind-gut, and the connection of the alimentary canal with the neural 
 canal, through the neurenteric canal, may yet explain many things. 
 The carotid body of man and mammals, which has a structure very 
 like that of the coccygeal body, may it not be a vestige of the tissues 
 around the second visceral cleft, to which it corresponds in position? 
 The thyroid body, too, has been shown to have intimate relations 
 physiologically to the nervous system, and has been connected with 
 cretinism and with myxcedema; so that while still much remains to be 
 done, something definite seems now to be known. 
 
 Pathology has made great strides, by adopting the methods of the 
 physiologist, and now it is hardly possible to separate the two sciences. 
 Pathology, by adopting the experimental method, anticipates nature's 
 experiments, which, as Foster remarks, are often too complicated, occur 
 too seldom in circumstances favourable for observation, and oftentimes 
 are too cruel altogether. 
 
 Bacteriology has grown out of pathology, and is carried on by purely 
 physiological methods; taken along with aseptic surgery, it has already 
 done much, though it is really only beginning; thus it has greatly 
 helped in the diagnosis and treatment of suppuration, pyaemia, 
 septicaemia, rabies, &c., and the surgeon now opens without hesitation 
 cavities which he shunned only a quarter of a century ago. 
 
 Ophthalmology owes everything to the physiologist, and mankind 
 owes much to ophthalmology. The right understanding of defects in the 
 structure of the eyeball and its contents, has led to their easy recognition 
 and treatment, and thus happiness has been secured to hundreds of 
 thousands who would have spent their lives in misery. The remarkable 
 increase, especially of young be-spectacled people among us, is not 
 so great an evil as many would think, and some say. It is not that 
 prevalence of eye- troubles is on the increase in the same proportion 
 as the use of spectacles, but it is in great measui'e simply because 
 defects of vision are now successfully treated by spectacles, which, in 
 earlier days, could not be treated at all. You doubtless remember that 
 it is only thirty years since Mackenzie, author of the well-known book on 
 '' Eye Diseases," used to recommend his hypermetropes — then known as 
 asthenopes — to emigrate, in order " to follow the jmstoral pursuits of an 
 Australian colonist," so that they might have as little necessity as 
 possible for near vision. That single physiological instrument, the 
 ophthalmoscope, invented by Helmholz less than forty years ago, what
 
 president's address — SECTION OP ANATOMY AND PHYSIOLOGY. 577 
 
 has it not done for eye diseases, whether of the fundus or of the 
 refractive media 1 and see, too, how it has carried us a step farther 
 back, for by letting us inspect the retina, it has virtually let us see a 
 portion of the brain, with all its vessels and tissues spread out to our 
 view, and so has given birth to the whole department of medical 
 ophthalmoscopy. 
 
 Physiological chemistry, from which we cannot separate pathological 
 chemistry, has profited by the general advance in organic chemistry, and 
 we need not be dissatisfied with the apparently slow progress in this 
 most intricate subject. It has already done much for the practitioner 
 of medicine in diagnosis, and its contributions to treatment in the way 
 of artificial digestion of food stuffs, and of alimentation per os and p^r 
 anum have proved of the very greatest value. From physiological 
 chemistry, great things are to be looked for in the not very distant 
 future. 
 
 While the laboui's of so many have of late been directed to the life- 
 history of organisms of such exceedingly insignificant size as micrococci, 
 bacteria and bacilli, and yet, with activities so immensely important to 
 all living things, at the same time there has been steadily accumulating 
 a more intimate knowledge of the ultimate structural elements of the 
 higher organisms — of cell-structure and cell-function — a knowledge 
 which also concerns masses of extremely small size. This increased 
 knowledge of the cell, owing to the universality of its object, is destined 
 to exercise the greatest influence in anatomy, physiology, and pathology. 
 
 Improvements in the methods of histological research — of fixing the 
 ever-changing protoplasm, and of staining it — improvements in the 
 making of lenses, together with improved methods of illuminating the 
 object — have disclosed the fact that, within the cell, a series of visible 
 transformations occur, which accompany its activity. A certain group 
 of these changes leads to the cleavage, or reproduction, of the cell; 
 the substance of which, for this end, passes through an orderly series 
 of stages which, Avith certain accidental variations, retain their essential 
 characters in all cells yet examined. Every month reveals some new 
 object in which this process of " karyokinesis " is discovered, and it 
 seems hardly too much to say that, in this visible process, whereby the 
 ultimate constituents of the tissues are reproduced, we have one of the 
 fundamental characters of organised things. Perhaps undue stress has 
 as yet been laid on the nuclear changes, because these have been so 
 prominent, owing to the easy pigmentation of part of the nuclear 
 substance. That important changes go on in the surrounding cell 
 substance during karyokinesis is evident, from the re-arrangement of 
 the granules in the substance, and from other appearances. These 
 visible changes are but an indication that change — change visible and 
 
 Ip
 
 578 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 invisible — is to be sought in the cell, which is thus as much the physio- 
 logical, as it is the anatomical, unit. But the histological unit of the 
 complex organism is so much akin to the whole body of the unicellular 
 organism, that it is with good reason that so much attention is being 
 directed to the study of the lower forms of life. 
 
 There can be now, to my mind, very little doubt that there is a 
 *' cellular " anatomy, or, using the word in its physical rather than its 
 chemical sense, a " molecular " anatomy which, though invisible to us, 
 is yet hardly less varied than is the visible structure of larger masses. 
 We would, on this assumption, account for — I do not say explain — 
 the different results that flow from the development of such apparently 
 similar things as one ovum and another — they were really very different 
 from the beginning, only we had not the means of appreciating the 
 difference. 
 
 Comparative physiology will one day show us that there is as intimate 
 a connection between the vital manifestations of the various kinds of 
 animals, as comparative anatomy has already shown to exist in regard to 
 their structure. Indeed, if we assume that function and structure are 
 correlative, then a complete comparative physiology follows a complete 
 comparative anatomy, as a necessity. Accordingly, Goltz, who has made 
 out so much of the physiology of the frog, and then shown that what 
 he observed in the frog was largely to be found in mammals, says that 
 he will not be surprised if he some day sees a dog without a cerebrum 
 feed itself, since Schrader has proved that a frog without its cerebrum 
 can still catch flies. Perhaps such a dog will also be able to run about, 
 and to see as a rabbit can, without its cerebrum. 
 
 On the Functions op the Cerebrum. 
 No one can read Macewen's address at the meeting of the British 
 Medical Association, in Glasgow, without seeing that a new era 
 has dawned in surgery. Thanks to the labours of the anatomist, in 
 accurately describing the arrangement of the convolutions and sulci, and 
 their relations to the cranial walls and surface markings. Thanks next 
 to the pathologist and physiologist, for determining the relation of certain 
 parts of the brain's surface to the movements of the different parts of 
 the body of man and of the lower animals. Thanks, lastly, to aseptic 
 surgery, in enabling grave operations to be performed with wonderfully 
 little risk to the patient from the operative procedure itself ; the surgeon 
 is now able to cure or relieve many cases which, before the year 1870, 
 were altogether beyond the pale of surgical interference. The first 
 work was done as a matter of pure science; the first workers had no 
 idea that so soon would their labours be turned to practical account. 
 Even the general public cannot fail to recognise the stride surgery has
 
 president's address — SECTION OP ANATOMY AND PHYSIOLOGY. oTO 
 
 taken, when it is told that the surgeon can, from a consideration of 
 symptoms only, so accurately determine the situation of, say a tumour, 
 or of a depressed piece of bone, or of an effusion of blood, or of an 
 abscess on or in the brain or spinal cord, cut down on it, and remove 
 the one or evacuate the other, with such security that, as in Macewen's 
 cases, eighteen recoveries followed twenty-one operations; and the three 
 that died were allm extremis when operated upon. While then, clearly, 
 ■we have established some physiological connection between the cerebral 
 cortex and the peripheral parts of the body, when we enquire what is 
 the nature of that connection, we are immediately in difficulties, and 
 this leads me to speak of the physiology proper of the cerebrum. 
 
 The March number of " Pflim/ei-'s Archiv " contains a most interesting 
 and important work by my former teacher, Professor Goltz, of Strasburg, 
 in which he describes the results of his recent work on the brain. The 
 most important case he descril)es is that of a dog, in which was removed, 
 at three operations, the entire left cerebi-al hemisphere, including the 
 corpus striatum and the optic thalamus. The dog lived in perfect 
 health for fifteen months, when it was killed, in order to ascertain 
 the exact condition of the nerve centres. 
 
 When the immediate results of the operation had passed away, the dog 
 appeared — apart from the effects of its having only one eye — a quite 
 healthy and well-l)red animal, friendly to friends, but yet disposed to 
 growl when enemies were about. In the various movements of its body 
 and limbs, it did not manage the right side just so well as the left, but 
 this was noticeable only by an attentive and pi-actised oljserver. While 
 the tactile sensibility of the right side was distinctly diminished, there 
 was not a spot which was not sensible. It held a bone with its 
 forepaws, using them as hands, and when food was placed on a board at 
 some little distance in front of the bars of its cage, it would first try to 
 get it in by using the left forepaw, but if this failed, did not hesitate to 
 try with the right forepaw, so that it still could voluntarily control the 
 movements of the right side. Briefly, then, while the sensibility of the 
 right side was diminished, no part was insensible, and while it preferred 
 to use the muscles of the left side, it could move any one of the muscles 
 of the right side. Thus, each side of the cerebrum must be connected 
 with every voluntary motor area, and with every tactile sensory area 
 of the body. 
 
 The bearing of this case on our notions of cerebral function is 
 obvious. It entirely discountenances the notion of the existence of small 
 circumscribed centres on one side of the cerebrum, that have an in- 
 dispensal)le connection with muscular and sensory areas on the opposite 
 side of the body; or that in these cerebral ai-eas alone arise the will- 
 impulses which eventuate in voluntary movements of the opposite side. 
 
 Ip 2
 
 580 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 The dog could use every muscle of the opposite side, and from every 
 part of that side it could be stimulated to movements that could be the 
 results only of conscious sensation, and yet the so-called centres were 
 simply not there. Had the cortex only been removed, the recovery 
 might have been due to the basal ganglia taking up the functions, 
 but then they too were not there; and, further, Goltz says that 
 he will soon publish a case in which one crus cerebri was severed 
 without being followed by permanent paralysis, either of sensation or 
 of motion, on the opposite side of the body. Evidently, then, one 
 side of the cerebrum can take up the functions of the other. 
 
 The next question that arises is, can any part of one side take up the 
 functions of any part of the other side, or can only the symmetrically 
 corresponding part of one side take up the functions of the corresponding 
 part of the other ? For the answering of this question, Goltz gives some 
 material. 
 
 After destruction of the anterior part of one side of the cerebrum, an 
 inexperienced observer would say that the dog was quite normal, though 
 a trained observer woiild notice that the limbs innervated from the 
 intact side are preferred, and are more deftly managed. 
 
 After deep and extensive destruction of the anterior moieties of both 
 cerebral hemispheres, while no muscle is paralysed, yet movement is 
 })ermanently and gravely alfected; the dog walks heavily and clumsily; 
 it cannot feed itself at all, or does it only with difficulty, and it can no 
 longer use its forepaws as hands. It no longer gives the paw when asked. 
 
 From these experiments, Goltz concludes that the frontal lobes of the 
 cerebral hemispheres contain parts which can take the jilace of each 
 other. If one is destroyed, the animal's movements remain fairly 
 normal only so long as the frontal lobe of the other side is uninjured. 
 
 On enquiring a little more minutely into the question, it would seem 
 that it need not, of necessity, be just the symmetrically corresponding 
 part of the opposite frontal lobe which takes up the functions; for 
 if the so-called hind-leg centre be removed from the left side of the 
 cerebrum, the dog shows both motor and sensory disturbance of both 
 the hind and the fore limbs of the right side of the body; but in a 
 little time, this disturbance disappears. If now the symmetrically 
 corresponding part of tlie right side of the cerebrum be removed, a 
 similar disturbance is noted, chiefly affecting both the fore and hind 
 limbs of the left side; but after a longer period than before, this 
 too, nearly disappears. (In neither of these cases ai'e the disturbances 
 confined to the limbs.) Now, had the right centre alone taken up 
 the work of the left centre, after the latter had been removed — had 
 thus the one centre alone innervated all the limbs, the disturbance after 
 the second operation ought to have equally affected all the four limbs.
 
 PRESIDENTS ADDRESS — SECTION OP ANATOMY AND PHYSIOLOGY. 581 
 
 Such results would be analogous to the effects of electrical stimula- 
 tion of a so-called centre, which, having taken up the functions of its 
 fellow, should evoke movements of both sides — if weak, it evokes 
 movement only of the op])osite side. Further, if small portions of one 
 side be removed at several operations — the operator waiting in each 
 case till after the permanent condition has been established, i.e., till 
 after the transfer of function has been effected — then each succeeding 
 operation is followed by a repetition of the same group of symptoms 
 as the one before it was followed by, only the symptoms are developed 
 to a greater degree each time. Now, had the centres of one side 
 already taken up the functions of the portions removed from the 
 other side, it could scarcely be that the same group of symptoms would 
 follow each succeeding operation. 
 
 After extensive destruction of both occipital lobes, the tactile, 
 auditory, olfactory and other senses are impaired, but movements 
 are just about as cleverly carried out as in a normal dog. It may still 
 give the fore-paw when asked, and may perform many other such 
 movements. 
 
 If both sides of the cerebrum be operated on, but not symmetrically, 
 for instance, if the first operation destroyed an anterior and the second 
 operation destroyed a posterior moiety, the dog shows no more motor 
 disturbance after the second, than it did after tlie first operation. 
 
 If it be objected, that such cases do not help us to understand how it 
 is that very small lesions often produce very marked symjitoms, it may, 
 with equal justice, be retorted that the doctrine of circumscribed centres 
 does not help us in those cases of extensive destruction of cerebral 
 matter which we from time to time meet, without there ever having 
 been any symptom whatever. 
 
 In regard to the immediate results of the operations, i.e., the 
 disturbances manifested before that condition is established, which may 
 be considered as the tinal condition due to the removal or destruction 
 effected, and with which alone we have hitherto been dealing, Goltz 
 makes the following general statement : — That what is seen in the first 
 period after a given lesion, is the counterpart of what is seen in an 
 animal after a more extensive lesion, but at a later period. Tlji.s 
 is especially the case with symmetrical lesions of the anterior |)arts of 
 the cerebrum. What is seen only for a few days with smaller lesions is 
 the condition which remains permanently after greater lesions. 
 
 If, then, we review these observations, we are forced to conclude that, 
 while the different parts of the cerebral cortex are not of equal value, 
 as Flourens taught; and while, therefore, there is a sort of localisation, 
 yet there does not exist anything like that minute localisation, in 
 the existence of which many of us were inclined to believe only a
 
 582 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 short time ago, and of which Goltz has been the constant and consistent 
 opponent. At that time, it was thought that one had just to go 
 all over the cerebral cortex, and divide it into areas as we would mark 
 out a map of Australia into its colonies and counties. Some of these 
 areas would receive impressions, others would originate impulses^ 
 and all would be "centres." 
 
 If, then, this simple arrangement has been destroyed, what have 
 we to put in its place 1 It does not follow that we can put anything at 
 all. As Goltz says, " Our real task is simply to settle accurately 
 what kind of acts may still be carried out, and what may not be carried 
 out, after definite lesions of the nervous system. Only a complete 
 description of the facts can help in the performance of this task. I 
 believe the time has not yet come when we may bring together 
 these facts under a short formula or law." 
 
 Evidently, then, we must wait for " more light." We must simply 
 go on recording the facts of cerebral pathology as John Abercrombie 
 did fifty years ago, and as Goltz is doing now. When a sufiicient 
 number of observations have been recorded, the meaning of all will 
 come out clearly enough. 
 
 On our Museums and their Classification. 
 
 The worker in science must, of course, have ready access to collections 
 of natural objects, and the time seems to have come when we should in 
 these new countries, where so much is done by the State, either directly 
 or indirectly, endeavour to classify more fully the contents and aims of 
 the different museums. I am quite aware that this is already done to 
 some extent, but I know also that to a considerable extent it is not 
 done, and before tlie evil is much greatei-, and therefore less easily 
 remedied, I think we should make an effort to prevent duplication 
 of collections, since it but leads to inefficiency as well as to waste of 
 money. 
 
 It is, of course, only recently that museums of anatomy and physiology 
 have been established in Australia, but already in a short time much 
 has been done, and I take this very good opportunity of urging on 
 practitioners of medicine the desirability, nay, the duty that for the 
 general good lies upon them, of sending for preparation and conservation 
 iu an approjn-iate museum any noteworthy specimen which they may 
 acquire in their practice. And it should be understood that when 
 museums are beginning only, as in Australia, they cannot afford to be 
 fastidious. It is a mistake to supjiose that only rare things are accept- 
 able. Almost anything may be sent at first, for until such time as good 
 collections have been got together, anything may turn out to be useful, 
 and only the curators can know what is wanted.
 
 president's address — SECTION OP ANATOMY AND PHYSIOLOGY. 583 
 
 Ox Libraries op Periodicals. 
 
 Everyone here has, doubtless, felt the want of access to complete sets 
 of scientific serial publications, without which, original work is nowadays 
 quite imi)ractical)le. The want is all the more expressed in Australia, 
 owing to the comparative isolation of scientific men. As " iron 
 sharpeneth iron," so in the older countries one learns much by conversa- 
 tion with men engaged more or less in the same pursuits as one's self — here 
 we are often singly distributed, and frequently at great distances apart. 
 Until the meeting of this Congress in Adelaide last year, and of the 
 Australasian Association for the Advancement of Science in Sydney 
 only a few months ago, there was no organised mode of bringing together 
 from a distance men engaged in the search after knowledge. Living 
 then in new places, and very much alone, we do not benefit by that 
 atmosphere of knowledge and the love of knowledge that at once 
 stimulates to investigation, corrects observation, and suggests new lines 
 of research. As the means of locomotion improves, as population 
 increases, as our Universities and our schools become more fully equipped, 
 as our citizens become more inclined to spend their means and end their 
 days in the land where they have amassed their wealth, and when, in 
 consequence, we have a larger cultured and leisured class, then gradually 
 men here, as elsewhere, may learn what is going on by conversation 
 with men; but till then, we in Australia are very specially dependent on 
 men's writings, instead of on their living presence. 
 
 A complete Periodical Library is indeed one of our greatest wants. 
 Original work ajipears first in journals and transactions, which should, 
 therefore, be at our command as soon as possible after publication. In 
 Sydney, I have endeavoured to supply this want; in the first place, by 
 recommending for purchase by the University complete sets of the most 
 important periodicals, and recently, by bringing about co-operation 
 amongst our nine greater libraries. I find that there is an immense 
 quantity of scientific serial literature in Sydney, but that, alas, it is in 
 a most unsatisfactory condition — important series, if not fragmentary, 
 are incomplete. Other, and often less important journals are in 
 duplicate, and even triplicate, and yet withal, some of the most important 
 are not represented at all. The work of making a general catalogue is 
 now well in hand, and I hope to have it completed before many months 
 are ovei*. The enquirer will be able to see at a glance if a journal is in 
 Sydney, what numbers there are, and where it is to be seen. The 
 librarian will see what sets he can complete by exchange or purchase, 
 and what sets, being taken by other libraries, may perhaps be 
 discontinued by his own. My aim, briefly, is to have in Sydney at least 
 one complete set of every periodical that is worth having. My dream 
 is to have in Sydney a special Library, where all such periodicals may
 
 584 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 be consulted. For many years, however, my catalogue will probably 
 suffice. The catalogue will, I trust, be of value also to workers in other 
 centres of Australia, where I hope something of the same sort may be 
 done, so that a copy of every journal may be in the Continent some- 
 where. Delay is dangerous and costly. These sets are, many of them, 
 rare now, and if procurable at all, cost an ever advancing sum of money. 
 It is not unworthy of being pointed out before leaving this subject, 
 that our periodical medical literature is the pride of our profession — 
 no other calling has anything like it. In a few months, it places the 
 whole woi'ld in possession of every discovery or suggestion that is likely 
 to minister to the repair of injuries, or to the prevention or cure of 
 disease. Compare this with the times that are gone. We have it on 
 good authority that, for forty years after they were given to the world, 
 the teachings of John Hunter were scarcely known in France. There 
 are thus no secrets with us. Our experience and knowledge are at once 
 placed at the disposal of every man, woman, and child throughout the 
 ■world, and so keenly do we feel this publication to be our plain duty, 
 that we exclude from our society all who would attempt to conceal a 
 remedy for any evil. 
 
 Quasi Cursores Vitai Lampada Tradunt. 
 
 And now I must bring to a conclusion what has proved a rather 
 lengthy essay. I dare not hope that many woi'ds of mine will be 
 long remembered, though I do hope that certain general impressions 
 may remain from what I have said — as, that never were the seekers 
 after truth in the medical sciences so numerous and so unwearying 
 in well-doing, as they are now ; never were their labours more varied 
 nor more likely to end in the relief of suffering ; never was the future 
 bi'ighter, nor more full of promise. 
 
 But, Gentlemen, standing as we do between the rich past, and a 
 probably richer futui'e, does not a gi-eat responsibility, moral and 
 intellectual, rest upon us 1 As we lean upon the past, so may we 
 expect that the future will seek to lean upon us. The physician- 
 evangelist, Saint Luke, says : — '• Unto whomsoever much is given, 
 of him shall be much required;" and he continues, saying what is 
 not so often quoted, "To whom men have committed much, of him they 
 will ask the more." It behoves us then, not merely to hand on 
 undimmed the lamp of intellectual life, but so to feed and trim it, 
 that we may hand it on burning more briglitly than we received it. 
 
 Gentlemen, let us join in breathing the ancient sentiment — "let 
 medicine flourish" — let us echo its very words, 
 
 floreat res medica !
 
 DEMONSTRATIONS AND EXHIBITS. 585 
 
 DEMONSTRATIONS AND EXHIBITS. 
 
 By T. P. Anderson Stuart, M.D. Edin. and Syd. 
 
 Professor of Anatomy and Pbysiologj' in the University of Sydney, 
 President of the Section. 
 
 (a) Demonstrations of the Following Points in the Structure 
 OF THE Eye, viz. : — 
 
 (1) The suspensory ligament of the lens in the eye of the ox is 
 probably merely cemented to the capsule of the lens. 
 
 (2) There is beyond all doubt a hyaloid membrane bounding the 
 whole anterior face of the vitreous body in the eye of the ox. Both 
 these points were repeatedly demonstrated to members of the Congress. 
 
 (6) Demonstrations of Instruments and Models. (These Notices 
 are for the most part merely preliminary; fuller 
 Descriptions are yet to be given in some Cases.) 
 
 (1) A simple mode of showing that the form of the chest is at least 
 largely a mechanical matter. — A looj) of crinoline steel, of appropriate 
 size, is held between the finger and thumb. When held loosely and 
 suspended vertically, it shows the form of the transverse section of the 
 quadrupedal chest. As it is brought towards the horizontal, it shows 
 the form of the human foetal thorax. Gradually, as the plane of the 
 portion which is now gripped firmly, and which corresponds to the 
 vertebral column, is brought to the vertical, and then leans somewhat 
 backwards, the slope and curve of the adult human ribs ai-e reproduced, 
 and so also, of course, is the shape of the transverse section of the adult 
 human chest. 
 
 (2) Simple models to illustrate the structure of the medulla oblongata. — 
 One shows how the fourth ventricle is lozenge-shaped : — A rubber tube, 
 about ten centimetres long and two centimetres wide, is slit along the 
 seani for a distance of some four centimetres, in the middle of its length. 
 On doubling up the tube, so that the slit comes into the angle, or on 
 pulling outwards the middle of the edges of the slit, the lozenge, &c., 
 is at once seen. 
 
 (3) The other one makes clear the relations of the grey matter of the 
 medulla oblongata to that of the spinal cord. — The figure of the 
 transverse section of the grey matter of the cord is painted on the ends 
 of a flexible rubber stopper, with a central axial canal in it, and the 
 stopper is split open down one side, corresponding to the posterior 
 median suture of the cord ; the interior of the canal is painted too. 
 On widely 0])ening out the stopper, the disposition of the grey matter 
 of the medulla is at once seen. 
 
 (4) A variable spring electrical interrupter. — This was first con- 
 structed in 1887. A clamp may be moved by a double thread screw 
 along the spring, which is fixed at one end, and figures engraved on the 
 spring tell the rate of vibration for that length of free spring. The free 
 end of the spring, armed witli a platinum style vibrating over mercuiy 
 (the level of which may be varied), makes and breaks circuit, and
 
 586 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 an electro-magnet in this circviit keeps the spring in motion. Its uses 
 are very numerous — e.g., may be employed in place of tuning-forks, 
 with a chronograph as a time marker. By the use of the screw, 
 one can pass from one rate of vibration to another, without any 
 interruption to the movement of the spring; and even with a single 
 spring, but of course still more with one or two extra springs of different 
 thicknesses a very great range of rapidity may be obtained. When 
 used with an induction coil, the current driving the spring may itself be 
 the primary current, or the spring may carry a T-shaped platinum wire, 
 that makes and breaks another primary, though with a sliding induction 
 machine, the latter is not needed. It may thus be used as a very 
 efficient tetanus spring. 
 
 (5) The kymoscope. — An arrangement for demonstrating many 
 phenomena of wave motion along tubes. It consists essentially of the 
 tube, wound in a uniform spiral, and fixed on a frame. Each round of 
 the spiral is one foot long, and there are tvventy-four turns. A vertical 
 glass tube is fixed in the upper part of each turn, so that the twenty- 
 four glass tubes are arranged side by side, close together, and equidistant 
 along the tube. The ends of the spiral tube are connected with a 
 valved rubber ball, such as one sees in an enema aj)])aratus. Com- 
 pression of the ball injecting tluid into the tube at one end, makes 
 a positive wave, and its expansion sucking fluid out at the other, makes 
 a negative wave, and the pressure is sami)led, as it were, at every foot 
 of the wave's progress — the samples being placed close together, and side 
 by side. Thus, the length of the wave is apparently shortened from 
 twenty-four to say two feet, according to the diameter of the spiral tube 
 chosen. Thus, a shortened wave of pressure is seen to travel along the 
 tube, permitting the form of the wave, and many of the phenomena 
 of wave motion to be demonstrated. It is extremely useful when used 
 as a model of the circulation. Pieces of wire gauze inserted into the 
 middle tubes increase the resistance here, and correspond to the 
 capillary areas. It permits beautiful demonstrations of most of the 
 physical phenomena of the circulation. 
 
 (6) A working model to demonstrate man}' of the physical phenomena 
 of the chest, and the influence of the lung tension on the heart and the 
 blood pressure. — On working the rubber diaphragm, the variation of 
 the intra-pleural and of the intra-pulmonary pressures are shown by the 
 manometers ; the lungs (represented by rubber bags, and seen through 
 the glass jar) expand and contract, so also does the heart, and valves 
 being added, the blood-flow onwards is seen. A coil of small rubber 
 tube represents the lung capillaries. The action of the diaphragm 
 (rei)resenting all ins})iratory muscles) on each of these parts separately, 
 namely, lungs, heart, vessels, is shown by separate models, the parts 
 being combined in the complete one. 
 
 (7) An instrument for marking microscopical preparations — by making 
 a circle one millimetre or less in diameter, on the cover glass around 
 the object to be marked, which thus lies in the centre of the little circle. 
 
 (8) A working model of large size, twenty -four inches in diameter, to 
 demonstrate to a class the mechanism of accommodation of the eye, as 
 also, the phenomena of myopia and hypermetropia. — A lever handle 
 works the springs representing the ciliary muscle (and iris), and so the 
 suspensory ligament is slackened, permitting the lens of crinoline steel
 
 DEMONSTRATIONS AND EXHIBITS. 587 
 
 to bulge forward, and to make the light rays, represented by flat watch 
 main springs, cross, as if at a focus, farther forward than before, and 
 so on. The model is anatomically correct. 
 
 (9) A working model, to demonstrate to considerable numbers the 
 phenomena of the Sanson-Purkinje images. — Concavo-convex glasses of 
 ju'oper curvature, represent the cornea and back of the crystalline lens 
 respectively. The latter forms the back of a chamber, covered in front 
 by a very thin rubber membrane, so stretched that it is transparent 
 enough to let the posterior images be seen tlirough it. When this 
 membrane is set at a particular curvature, by driving into the chamber 
 air, water, glycerine, or clove oil, the whole apparatus, of course, 
 represents the eye in negative accommodation. When the rubber bulb, 
 connected with the lens chamber, is now compressed, the membrane, 
 i.e., the anterior surface of the lens, as if in positive accommodation, 
 advances and becomes more convex; the middle images advance, 
 approach each other, become smaller and brighter, while the anterior 
 and posterior images remain stationary in every way. 
 
 (10) A working model, to illustrate binocular diplopia. — Representing 
 the eyeballs, are soft white woollen balls, with the pupil and iris 
 painted on them. The light rays are represented by long, light, sharp 
 pointed steel wires, which thus strictly represent the axial rays of a cone. 
 When the eyeballs are directed to an object, the wires are made to 
 traverse the pupil, and to strike the retina, in a line with the object. 
 Let now the eyeball be displaced, the light ray, coming from the same 
 object, will travel in the same line, but will now strike the retina at 
 a different place; and when now the displaced eyeball is put back into 
 its normal position, the wire will point to the position, in space, from 
 which the mind judges that the light, giving rise to the second image, 
 has come — that is, to the position in space in which the object should V)e, 
 so as to have its image fall on the retina at that spot. Thus, 
 mechanically, one can demonstrate the position of the images in the 
 different affections of the ocular muscles, and vice versd, in binocular 
 diplopia, from the position of the images, deduce which are the muscles 
 jH'obably implicated. The use of this model suggested a similar use of 
 two penny pieces, where the space containing the date on the reverse 
 may represent the corneal segment, either of a horizontal or of a vertical 
 section of the eyeball, and lucifer matches, straws, ikc, may represent 
 the light rays. This readily-made model has been found of use in 
 practice. 
 
 (c) Exhibits. 
 
 (1) Dissections of the pendants from the neck of the bell pig. 
 
 (2) A large cartilaginous skeleton, a ray, an eel, and a mullet, 
 prepared by the glycerine-gelatine method.
 
 588 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 THE NATURE OF VISION IN ANIMALS. 
 By James W. Barrett, M.D., M.S., F.R.C.S. Eng. 
 
 Assistant Surgeon to the Victorian Eye and Ear Hospital, and Demonstrator and 
 Examiner in Physiology in the University of Melbourne. 
 
 Some time back, Mr. Lang, of the Moorfields Hospital, London, and 
 the writer, were engaged in examining the eyes of animals, with respect 
 to their refraction {vide "Ophthalmic Reports," 1886). A reference to 
 the essay we published on the subject of the refractive character of the 
 eyes of mammalia, shows that many of the eyes of animals (mammalia), 
 are far from being emmetropic. At the time we made our examination, 
 a number of circumstances induced us to question the truth of the 
 common assumption, that mammals use their accommodation, not only 
 for purposes of near vision, but also for the purpose of overcoming 
 hyperopia. The circumstances may now be detailed : — 
 
 An examination of the eyes of rabbits, guinea-pigs, horses, cats and 
 dogs, mice, rats, and cows, showed that they were very frequently 
 considerably hyperopic, not infrequently astigmatic, and sometimes 
 myopic. The hyperopia and the astigmatism were sometimes very 
 considerable (vide tables), and it will be remarked that the refraction, as 
 indicated by the method we employed, viz. retinoscopy, did not vary 
 before and after the instillation of atropine ; further, an examination of 
 these hyperopic eyes at different times and under different circumstances, 
 never resulted in the discovery of any variation of the refraction. 
 
 These various circumstances induced us at that time to make the 
 following quotation, and append our criticism: — " Hirschberg writes: 
 * Ich will beilaufig bemerken dass vom teleologischen Standpunkt aus, 
 beim gegebensein der positiven accomodation durch willkurlich angeregte 
 Verdickung der Krystallinse, das axenkurze also hypermetropisch Auge 
 am zvveckmassigen erscheint.' The truth of this statement no one can 
 doubt, if they regard the matter in the abstract; but we simply ask, 
 what particle of evidence is there that the domestic animals use their 
 accommodation to any appreciable extent. It is absurd to suppose that 
 they possess an apparatus capable of overcoming eight or even four 
 diopters of hypermetropia, and so far, we have failed to satisfy ourselves 
 that they can overcome the lower grades." This criticism expressed our 
 views at the time, with respect to the animals already referred to. 
 
 A reference to our publication will show also that a cat, to whose 
 eyes strong atropine ointment has been so freely and frequently applied 
 as to paralyse the iris, can pursue and capture mice with as much ease 
 as under ordinary circumstances, and this too, when it is dependent on 
 its vision, and not on other senses, for indication as to the whereabouts 
 of its prey. In the case then of these animals, we utterly failed to find 
 any trace of accommodation. In the case of monkeys, however, there is 
 evidence of its existence. The examination of monkeys' eyes by 
 retinoscopy indicates changes of refraction during its progress, and so 
 indicates the existence of an accommodation apparatus. 
 
 With reference to the other animals, it will be noted that I have 
 assumed that atropine will paralyse the accommodation, just as it does 
 in man. It acts on the iris in exactly the same manner as it does in the
 
 THE NATURE OF VISION IN ANIMALS. 
 
 589 
 
 case of man, and I can see no good reason for supposing tliat it does not 
 act on any accommodation the animals may possess; at the same time I 
 wish it to be clearly understood, that my statements with reference to 
 the absence of accommodation in some animals, are based rather on the 
 constant result given by retinoscopy at difi'erent times and circum- 
 stances, than on the constancy of the result given before and after the 
 application of atropine. Thus I am unable to find evidence of the 
 existence of any accommodation whatsoever in rabbits, guinea-pigs, 
 mice, rats, horses, cows, cats, and dogs; and a search through the 
 published accounts of other men's work, fails to furnish evidence. 
 
 My next endeavour was to solve the question, by following an 
 ingenious suggestion by Mr. Lang : — On the eye of one of these animals 
 I performed an iridectomy. After a lapse of some weeks, I performed 
 a second iridectomy, exactly opposite to the first one, so that the 
 si)hincter papillae was totally destroyed. I then instilled eserine 
 frequently, and in strong solution, and ascertained the refraction by 
 retinoscopy. I then waited some days, and instilled atropine frequently 
 and in strong solution, and again estimated the refraction by retinoscopy. 
 
 Now in the case of man, the efiect of instilling eserine on the 
 accommodation is pronounced, and the average difference which would 
 be given by such an examination is 3 '58 D {vide "Ophthalmic Reports "). 
 In the case of young adults, the effect of instilling eserine is to cause a 
 temjjorary myopia of about 4-54 D. In the case of older persons, 
 presbyopes, the temporary myo])ia produced, is 3-58 D, the average ran<^e 
 of accommodation being 4*28 D. In the former case, the ratio of the 
 temporary increase to the normal range of accommodation is -65, in the 
 latter case •84. I therefore felt that if I could produce by this 
 alternate instillation of atropine and eserine in the eyes of animals, a 
 diflerence under the two conditions of say 2 D, that I should be justified 
 in assuming that the normal range of accommodation in such a case was 
 3D. I accordingly performed double iridectomies in a large number of 
 animals, and in four cases examined the eyes in the manner indicated. 
 I need only say that in order to be quite sure, I simply deluged tlie 
 animals' eyes with atropine and eserine solutions, and ointments, the 
 action of which had previously been tested on the uninjured eyes of 
 other animals. 
 
 The results of the examination are .shown in the following table : — 
 
 Tahle shovnnfi the Refraction as indicated by Retinoscopi/, after Cojnous 
 InstiUcdion of Ati'opine, and after Copious Instillation of Eserine. 
 
 
 Refraction under Atropine. 
 
 Refraction under Eserine. 
 
 Animal. 
 
 Vertical 
 Meridiau. 
 
 Horizontal 
 Meridian. 
 
 Vertical 
 Meridian. 
 
 Horizontal 
 Meridian. 
 
 Large black dog . . 
 
 Medium sized do<: 
 
 Large cat 
 
 Adult rabbit 
 
 E.+ID 
 L.-flD 
 E. 
 L. 
 R.-t-0-5D 
 E. + ID 
 
 -}-2D 
 
 4-2D 
 
 -}-2D 
 
 + 2D 
 
 -i-l-5D 
 
 -i-3-oD 
 
 -l-lD 
 -hlD 
 -i-lD 
 -i-lD 
 
 
 
 
 
 -1-2D 
 -i-2D 
 + 1D 
 + 3D 
 + 1D 
 -1-2-5D
 
 590 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 From this table it will be seen that, in the first animal, there was no 
 difference in the two sets of results in either eye. In the case of the 
 second animal, in the right eye the astigmatism disappeared under the 
 influence of eserine ; in the left eye, the hy perojiia was actually increased. 
 In the third animal, and in the fourth, the hyperopia was a little 
 decreased by the use of eserine. 
 
 Bearing in mind, however, the difficulties of practising retinoscopy in 
 animals {vide " Ophthalmic Reports," Vol. II., Part 2), and the very 
 slight differences between the two sets of results, it is evident that the 
 results must be regarded as identical ; and so far as this investigation 
 goes, there is not a particle of evidence that these animals exercise their 
 accommodation. This statement must however be taken literally, and 
 in its special application only. It is just possible that eserine and 
 atropine are unable to influence the accommodation of animals in the 
 same way that they influence the accommodation in men; but on the 
 other hand, they act on the iris in a manner exactly similar. I may 
 further say that, even if it could be proved that they are incapable of 
 affecting the accommodation, there still remains the obvious fact, that 
 prolonged examination by retinoscopy of the eyes of these animals never 
 indicates any change in the refraction. 
 
 Conclusions. — (1) That examination by retinoscopy fails to indicate 
 the existence of any accommodation in the case of rabbits, guinea-pigs, 
 mice, rats, cows, horses, cats, and dogs. (2) That such an examination 
 indicates the presence of some accommodation in the case of monkeys. 
 (3) That in the case of rabbits, dogs, and cats, no difference in the 
 refractive character of the eyes can be produced by the instillation of 
 atropine, or of eserine. (4) From these and the other considerations 
 adduced, it seems that in rabbits, guinea-pigs, mice, I'ats, horses, cows, 
 cats, and dogs, the accommodation is either quite rudimentary, or 
 altogether absent. (5) The vision in these animals must necessarily be 
 much inferior to that of man.
 
 SECTION OF PATHOLOGY. 
 
 PRESIDENT'S ADDRESS. 
 
 By W. Camac AViLKixsoN, M.D. Lond., M.R.C.P. Loncl., M.R.C.S. Eng. 
 
 Lecturer on Pathologj' in the University of Sydney. 
 
 My iii'st duty is to express my thanks to the Committee of this 
 Congress for the honour they have conferred on me, by inviting me to 
 preside over the Section of Pathology. The position is not one of my 
 own choosing, and has been assigned to me only by force of circum- 
 stances. It is a matter of great regret to us all, firstly, that the 
 decision of the Members of the Committee — all of them determined to 
 outvie one another in acts of self-denial- — should have prevented so 
 experienced a pathologist as Professor Allen from delivering an address 
 on pathology ; and next, that the mantle should have fallen from the 
 shoulders of so eminent a man as Dr. Bancroft upon one so young in 
 experience as I must confess myself to be. 
 
 In this, the Second Intercolonial Medical Congress, a special Section 
 has been created for the consideration of subjects belonging expressly 
 to the province of pathology. The subject of pathology, once eyed 
 askance as an extra, a superfluous luxury, now holds a place of the 
 first importance in a medical curriculum. Pathology enables us to 
 interpret aright the symptom-language of disease — a language sometimes 
 of clear, simple sentences ; sometimes of vague sentences, disconnected 
 from the context ; sometimes of sentences so confused or so complicated 
 as to baffle interpretation — and upon the right interpretation of this 
 language, scientific diagnosis rests. Until such a diagnosis is made, all 
 rational treatment is out of the question. Empiricism, pure and 
 simple, is our only resource ; and likely enough, fanciful systems will 
 arise to embarrass and mislead us, for almost of necessity they will 
 have an existence in a province where much doubt and uncertainty 
 must prevail. But, although pathology has already reached the dignity 
 of a science that claims special consideration, some care must be exercised 
 in the interests of the science, lest we separate it too far from those 
 studies out of which it springs, and to which it must always look for 
 support — those clinical studies in the wards of a hospital which, in their 
 turn, have a full and true value only when they are based upon sound 
 pathological principles. Only in the light of sound pathological 
 principles, does medicine cease to be a system of empiricism.
 
 592 INTEKCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 That pathology is a difficult subject to study, may be taken for 
 granted, seeing that it has to do with processes of life, and that, not 
 under healthy and natural conditions, but under strange and abnormal 
 conditions, depending partly upon external circumstances, and partly 
 upon processes at work in the economy itself. Disease, we may say, is a 
 condition that is determined by two main factors — the environment, and 
 the life of the body. There is an idea prevalent with many, that 
 pathology is a subject to be studied exclusively in the post-mortem 
 room. This is very far from the truth. Disease knows no existence 
 apart from life. Take away life, and the body is beyond the power of 
 disease. It is therefore a paradox to speak of studying pathology in 
 the dead body. No doubt with the naked eye and with the aid of the 
 microscope, we observe well-defined structural changes to be the effect 
 of disease, and in some cases may be able to trace out the course of 
 disease ; yet we learn very little of the course of disease, or its effects, 
 apart from structural changes. Even pathological anatomy, that deals 
 with these structural changes, is to be studied, not only in the post- 
 mortem room and the laboratory, but in the living body. Structural 
 changes induced by disease, include not merely those changes found in 
 the dead body, but also changes that may occur without causing death. 
 The important changes frequently present in superficial parts and in 
 supei"ficial tissues, in the blood, in the urine, and in other discharges 
 from the l)ody — especially from the lungs and digestive canal — belong 
 strictly to pathological anatomy. The fluid discharges from the body 
 receive, as a general rule, too little consideration, although in many 
 instances they yield most important information for the determination 
 of a scientific diagnosis. 
 
 The more we study the structural changes and conditions found 
 at the post-mortem in close association with the symptoms, objective 
 and sulDJective, of any disease, the better it will be for the science of 
 pathology and the art of medicine and surgery. It is only by this 
 method that we can expect to unravel some of those difficult problems 
 concerning renal disease. It seems very easy to classify chronic renal 
 diseases, and to assign distinct symptoms to distinct forms, but does it 
 not often happen that we find in the post-mortem room one form of 
 diseased kidney, when we have expected to find another form ? What 
 is still more important, do we not sometimes at the post-mortem 
 examination meet with renal disease that was not suspected during 
 life ? In these really important cases, the question arises. Were there 
 no changes in the urine at all ? Or, were these changes of such a kind 
 that only careful and repeated examinations could have detected them ? 
 I incline to the opinion (with some reserve, however, for it is founded 
 on small experience) that a more careful analyses of the urines that
 
 PRESIDENTS ADDRESS — SECTION OP PATHOLOGY. 593 
 
 come under our examination, according to the more exact methods of 
 later times, would probably show that in this country slight structural 
 changes in the kidney are far from rai^e ; possibly caused by climatic 
 conditions, sudden changes, lirc, or perhaps caused by the special habits 
 of the people ; and of such causes, excess of animal food in the diet is 
 one of the chief. In this, and in all diseases, one must bear in mind, 
 that surrounding conditions have their influence ujjon disease, and that 
 diseases, as we find them in this country, may not assume the typical 
 forms familiar to us in our studies in England and Europe, but may 
 acquire special characters ; and further, that distinct diseases, some new 
 to us, and some resembling, but not identical with, the diseases with 
 which we confound them, exist and depend upon local conditions. 
 
 I do not see how we can enter this field of enquiry with the best 
 chance of discovering the whole truth, unless we study disease as a 
 whole — as it shows itself, not only by its symptoms, but also by its 
 anatomical features. There is a great gain in division of labour, but 
 we should confine ourselves to the study of particular diseases, if such 
 division be necessary, and study these diseases in their entirety — from 
 the appearance of the first symptoms, up to the investigation of the 
 conditions that are found in the body after death, rather than that we 
 should make an arbitrary division of disease into stages, and examine 
 these stages apart from one another. There is no doubt that some men 
 are good observers with the microscope, but atrociously bad observers 
 with the stethoscope, and vice versa. For such men, it is certainly best 
 that they should become specialists with the one or the other instrument, 
 as the case may be. But this is not the rule, and experience tells us that 
 the best clinical observers are not content to pass on to others an exami- 
 nation which they can as well perform themselves. Structural changes, 
 considered apart, may entirely mislead us. No doubt these changes 
 are often definite enough, and in close relationship with the symptoms 
 observed during life. In other cases, structural changes exist without 
 causing any definite associated symptoms ; and often enough, symptoms 
 exist without any satisfactory anatomical changes to explain them. 
 Does it not therefore follow that to understand and explain disease, we 
 must study disease, not only in the post-mortem room, but also at the 
 bedside — not only through the structural changes induced by disease, 
 but also through the perversions of function that make up its clinical 
 history ? Structural changes can no more teach us the nature and 
 processes of disease than the structure of a nerve, as such, even in 
 its minutest detail, can indicate to us its mode of action. In all the 
 diseases primarily affecting the blood, can we not learn the structural 
 changes most thoroughly when we have the opportunity to examine the 
 blood during life ? In one of these diseases — pernicious anaemia, in its 
 
 iQ
 
 594 INTKRCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 most typical and fatal form — do we not find frequently extreme fatty 
 degeneration of the heart in the post-mortem room ; and yet, during 
 life, in spite of this degeneration, the pulse, if rather frequent, has 
 been still regular, and of good strength ? How strangely this regular 
 pulse of good tension, contrasts with the waxy pallor and extreme 
 irritable weakness inherent to the disease 1 In spite of these serious 
 structural changes, the heart is able to maintain a normal circulation. 
 Surely these anomalous conditions, so frequent in the history of 
 disease, are best investigated and explained when the clinical observer 
 is a pathologist, and the pathologist is at the same time a clinical 
 observer. Do we not know, too, of an important class of diseases 
 which we call nervous, that are accompanied by no structural changes 
 that we can definitely assign to any of these diseases ? No doubt, with 
 improved methods, we shall find some typical changes in time to come, 
 but we are the more likely to do this if we study these diseases in their 
 continuity. And is not past experience entirely in favour of the view 
 herein expressed, with respect to the study and teaching of pathology ? 
 This is the plan that I have been advocating in my own University. 
 It is in accordance with the plan that obtains in the medical schools of 
 Great Britain, and it is the plan which has led to such brilliant results 
 through the labours of those illustrious men in all countries, who 
 have spent their lives in studying disease. Who are the men to 
 whom we are chiefly indebted for our pi^esent more or less accurate 
 knowledge of the pathology of the kidneys and urinary apparatus ? 
 Surely Richaixl Bright, and after him, Grainger Stewax't, and John- 
 son ; Bartels and Senator, of Berlin ; and Lepine, of Lyons — all of 
 them, without exception, clinical physicians of the first rank. Through 
 whose labours have we become possessed of our present knowledge in 
 the pathology of the nervous system? It was "Waller who first gave 
 us the method of tracing out the diff^erent systems in tlie spinal cord 
 and brain. It was Charcot who first observed at the bedside, and 
 recorded the symptoms of certain diseases with unerring judgment and 
 accuracy, and then in the post-mortem room established on a certain 
 basis the relation between the clinical symptoms and certain definite 
 lesions of the brain and spinal cord. Where all had been confusion 
 and darkness, he brought light, and established order. And does not 
 Charcot himself bear witness to the invaluable labours of Hughlings 
 Jackson in the same field ; Charcot, Hughlings Jackson, Bastian, 
 Gowers, Bristowe, Kussmaul, Erb — these are the men who have taught 
 us nerve patliology, and they are all eminent clinical observers. May 
 we not ask, too, is not nerve pathology so intimately intertwined with 
 diseases — not only of the nervous system — but with diseases of the heart 
 and of the kidney, and with those important general diseases, syphilis,
 
 president's address SECTION OP PATIIOLOOY. 595 
 
 rlieumatism, gout — that nerve pathology cannot be studied unless we 
 are able to view in a comprehensive manner and from a clinical point 
 of view, the associated disturbances that so frequently present them- 
 selves. The same is true in regard to the pathology of other organs. 
 Advance in knowledge has come chiefly through the labours of clinical 
 observers — of Quain, Broadbent, Balfour, and Bamberger, in diseases of 
 the heart ; of Wilson Fox, AVilliams, Green, and many others, in 
 diseases of the lungs ; of Jenner, Lauder Brunton, Nothnagel, and 
 others, in diseases of the digestive tract. In exery disease, substantial 
 progress in knowledge has come through the labours of those who have 
 studied the disease from its beginning to its end in its various stages, 
 without interruption. That, then, is one of the tii'st principles that I 
 would advocate in the study of pathology. Every physician should, as 
 far as possible, master the pathology of those diseases which he sets his 
 heart to study; and every pathologist should have abundant opportuni- 
 ties to study disease, not only in the post-mortem room, but also in the 
 wards of an hospital. No doubt, as our knowledge increases, new 
 branches develop, and special branches become important enough to 
 form a special study. Such a study is pathological chemistry, which 
 may be said to be a branch of physiological chemistry. In such studies, 
 requiring nothing short of a full knowledge of some of the most com- 
 plicated chemical methods and laws, specialism is certainly imperative. 
 
 Again, there is another important method of investigation which has 
 been pursued by one of Germany's most illustrious sons with such 
 brilliant results. As in physiology, so in pathology, we require some- 
 thing more than physical and chemical tests ; we require the test of 
 living processes working in some measure under control ; in other 
 words, experimental evidence. John Hunter in England, and Majendie 
 in France, were the pioneers of the experimental method in the 
 investigation of physiological problems ; l)ut it was Cohnheim, of 
 Germany, who estaljlished the system of experiments upon animals, as 
 one of the recognised methods of pathological inquiry. Every page in 
 the great work of Cohnheim's life, bears witness to the value of tins 
 method ; yet it should not be forgotten, that Cohnheim was at tlie 
 same time in active co-operation with two of the most distinguished 
 physicians of Germany — Traube, who first used a thermometer for 
 clinical purposes, and was the first to give a rational explanation of 
 the variable nature of certain clinical signs by means of experiments 
 upon animals made at the inspiration of Cohnheini ; and Bartels, who 
 ■first, by careful daily records, showed that in renal disease, the daily 
 discharge of urine and the degree of dropsy were in an inverse pro- 
 portion to one another, and in other ways added much to the then 
 knowledge of the patliology of the urinary apparatus. 
 
 iQ 2
 
 596 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 The triumph of the experimental method in the study of disease (a.? 
 it was the triumph of Cohnheim's life), was the discovery of the 
 emigration of the white corpuscle in inflammation. The emigration 
 of cells from vessels had indeed been observed nearly fifty years before ; 
 but Cohnheim first proved by experiment, that the emigration of the 
 white cells j^layed an all-important role in the processes of inflammation. 
 This discovery made Cohnheim's reputation in Europe, Cohnheim being 
 then only 28 years of age, and entirely revolutionised the ideas then 
 held with regard to the nature of inflammation. By this same method, 
 too, Cohnheim proved that the vai'ious effects of eml^olism in certain 
 organs, depended essentially vipon an especial anatomical feature in the 
 arrangement of the arterial branches, and explained the complete 
 immunity of other organs from infarction in spite of embolism. The 
 •later years of Cohnheim's life were largely devoted to the study of 
 tuberculosis. Early in his scientific career, Cohnheim had called 
 attention to the presence of small whitish nodules in the choroid — 
 tubercles in the choroid — but this was an isolated and accidental 
 discovery ; his later investigations into the nature of tubercle were 
 made in his laboratory. Being extremely sceptical about Villemin's 
 view, that tu.berculosis was the result of a specific infection, he set to 
 work to produce artificial tuberculosis, by inoculating the cornea of 
 rabbits with tubercular material. By this method, he produced typical 
 local tubercular granulations, followed after an interval of some days 
 by disseminated miliary growths in internal organs. Thus, by the 
 experimental method, he convinced himself that Villemin's view was 
 right, and thenceforward, Cohnheim was an ardent advocate of the same 
 view. It was indeed Cohnheim who did so much to prepare the minds 
 of others for the ready reception of Koch's brilliant discovery of the 
 essential cause of tuberculosis. Cohnheim in fact had set the details of 
 his own investigations in such clear order and logical sequence, as to 
 form a chain of evidence that required nothing further to establish 
 the causal relationship of a specific virus and the morbid process. 
 Koch furnished proof, as complete as it was unassailable, that the specific 
 virus was a bacillus, the tubercle baccillus, with which we are all 
 familiar. Years before Koch startled the scientific world of Europe by 
 tliis masterpiece of his life, Cohnheim wrote : — " The more often I 
 have convinced myself of the exclusive and certain action of genuine 
 tubercular material, the more certain I feel that Villemin's \'iew of the 
 specific nature of the tubercular virus is alone in harmony with facts.'' 
 But while Cohnlieim, as the great exponent of the value of the experi- 
 mental method, lias shed a flood of light upon some of the most difficult 
 paths that we can tread in our pathological inquiries, he has not been 
 alone. A legion of men in other countries, lia\'e long since entered the
 
 president's address — SECTION OP PATHOLOGY. -lOT 
 
 same field of inquiry, and \ve know them by their works. Nor sliould 
 we forget those who, working in the neighbouring field of physiology, 
 Iiave thrown light upon many a difficult problem in pathology. It may 
 be said, that no discovery is made in pathology, that does not sooner or 
 later come to have its application to pathological processes. A few 
 years ago, Flennuing published his observations upon the process of cell 
 division. In a sei'ies of beautiful specimens, he showed in how complicated 
 a manner this di\ision takes place. Quite recently, this discovery has 
 been of the greatest service to Baumgarten, in his investigations into 
 the nature of the tubercular process in different organs. The common 
 view is, that the presence of tubercle bacilli in tissue sets up a reactive 
 process in the tissues. This reaction consists of the emigration of white 
 cells, that so to speak, form a line to resist invasion by the bacilli. 
 Thus the early tubercular formation is held to be made vip essentially 
 of white cells, or granulation cells. Baumgarten, who is one of the 
 first authorities on tubercle, and who, in fact, discovered the tubercle 
 bacillus in lung tissue coincidently with Koch, but was not able to 
 isolate it, combats this view, and supports his own position by very 
 elaborate and beautiful experiments, with ai'tificially-produced tuber- 
 culosis. The whole strength of his argument rests upon the process 
 of caryokinesis, observed by Flemming. Baumgarten asserts that, in 
 artificial tuberculosis, the histogenesis is the same for all organs : and 
 that in organs rich in epithelial elements, such as the livei', kidneys, 
 lungs, and the intestinal canal, the epithelial elements participate to a 
 preponderating extent in the formation of genuine tubercle cells, 
 especially in the eai'ly stages. By special methods he shows that, 
 shortly after inoculation of the iris, caryokinetic changes — the surest 
 sign of active division in cells — are to be seen in the fixed connective 
 tissue cells of the inoculated tissue, and also in the endothelial and 
 connective tissue elements of the vessel walls. The essential epithelioid 
 cells of the tubercular formation are formed by caryokinesis of these 
 fixed cells. If wliite cells are present, they show no signs of caryokin- 
 esis. Any changes in them are merely degenerative. The important 
 element of the morbid growth is the ej^ithelioid cell of this parentage, 
 which is never branched, but proliferates to form fresh cells of a like 
 kind. These cells, as they multiply at the centre, press upon the 
 peripheral parts, and may sometimes thus destroy the bacilli. It is 
 only at a later stage that leucocytes appear, in consequence of inflam- 
 matory action induced in the vessels by the j)resence of this new 
 formation. Since the leucocytes never show any caryokinetic changes 
 at any stage of the process, it seems clear, that they do not actively 
 participate in the essential process. Indeed, Baumgarten states that, 
 as soon as leucocytes appear, the essential process of caryokinesis is
 
 598 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 ari'ested. In oi'gans rich in epithelial structures, such as the kidneys, 
 the liver, &c., caryokinetic changes are seen to aftect, not only the 
 fixed connective tissue cells and the endothelial cells of the capillaries, 
 but in a striking way, even the epithelial elements that constitute the 
 specific tissue of these various organs. Thus the dominant process of 
 caryokinesis affects the specific cells, and with these caryokinetic 
 changes the formation of the essential epithelioid cells of tubercle 
 everywhere takes place. 
 
 In the light of these important observations, how radical must be 
 the change in our views respecting the structure and origin of a tuber- 
 cular formation, if indeed the tubercular process in human beings 
 is similar to the process thus obserA-ed in animals. Accoi'ding to 
 Baumgarten's view, the new endothelioid and epithelioid elements in a 
 tubercular formation are not derived from leu.cocytes at all, but from 
 the fixed connective tissue cells of the tissue — and what are they but 
 the endotlaelial cells of the lymph spaces — from the endothelial cells of 
 the blood-vessels and lymphatics, and from the specific epithelial cells 
 of glandular organs. This view, that is in entire opposition to the 
 latest views upon the structure of a tubercular formation, is certainly 
 well in accord with the law of heredity, that reigns in tissue elements 
 as elsewhere. It almost seems that we are hastening back to the old 
 view consistently held by Virchow, Ranvier and Strieker, that the 
 fixed connective tissue cells ai-e no passive jiiarticipators in j^athological 
 processes. And let us hope, that this discovery of Flemming will in 
 like manner throw a new light upon the extraordinary and anomalous 
 process of cell division that obtains in malignant neoplasms, and help 
 us to better understand their nature and origin. 
 
 Again, we cannot forget the prolific seeds that have fallen upon the 
 field of pathology fi-om another quarter, and yielded a wonderful 
 harvest of results in the elucidation of some of the most difficult and 
 important problems in the whole range of science. Now-a-days, every 
 pathologist must know something of the nature and life history of 
 those lowly organisms, whose place in the multifarious world of 
 living creatures has been assigned only conditionally and after much 
 hesitation. Foremost among the men who have worked in this field 
 of science, and won such glory to themselves, are INI. Louis Pasteur and 
 Dr. Kobert Koch. "We are all familiar with tlie marvellous influence 
 exerted In' M. Pasteur's discoveries in settling some of the most 
 difficult i)i-oblems in patliology, especially those concerning the 
 causation of .specific diseases. These are indeed fitting occasions for 
 making a grateful reference to those great lights in the path of science — • 
 those men wlio, like M. Pasteur, by their loyal de^'otion to the cause of 
 science, ])y their steady perseverance in spite of disappointment, in spite
 
 president's address — SECTION OF PATHOLOGY. 599 
 
 of actual discouragement, liave clone such noble work in quickening 
 industrial life and stinuilating its activity, and in promoting, besides 
 the wealth, tlie health and happiness of nations. Too often the grand 
 and useful achievements of these great men who have devoted — aye, 
 and in many cases sacriliced — their life, their all, to the cause of science, 
 are forgotten. Science, thi'ough her votaries, does her beneficent 
 work quietly, unostentatiously, in the laboratory, in the study, never 
 in the market place, and the incalculable benefits she showers upon 
 nations are the wonder of a day. Pasteur is one of those citizens 
 of the world to whom all gladly pay honour. He is no ordinary man, 
 he is a genius, inspired with a desire and power to discover new things, 
 and apply his great discoveries to the service of mankind. By a sort 
 of inspiration, Pasteur explained the nature of fermentation on the sure 
 basis of experimental evidence, and from these investigations was led 
 into new and interesting fields of scientific inquiry. Step by step the 
 horizon opened before him, till his inquiries into the nature of fer- 
 mentation, and of certain infectious diseases, heralded the dawn of a 
 new era in science — a new era in the study of medicine. All honour 
 to M. Pasteur for his epoch-making discoveries. Yet, let us not forget 
 that more than two hundred years ago, in that wonderful little countiy, 
 Holland (which was then in advance of the rest of Europe in literature, 
 science, and art), Leeuwenhooek invented the microscope, and discovered 
 and figured, with his own hand, those different varieties of microbes 
 about whicli we hear so much now-a-days. 
 
 By means of Koch's famous method of cultivation on solid media, it 
 is a comparatively easy matter to separate one species of micro-organism 
 from another, and thus to obtain pure cultivations. Then, a further 
 study of these bodies in a perfectly pure state by different experiments, 
 assigns to each one of them definite characters. But are the characters 
 and appearance of organisms so constant as to justify any scientific 
 classification ; or, on the other hand, is it true that one form of micro- 
 organism can be produced at will from another form, by merely altering 
 external conditions 1 If, indeed, a micrococcus can be converted into a 
 bacillus, and vice versd, then there is no reason why function should not 
 become modified with change of form ; no reason why a virulent 
 organism should not become innocuous, and an innocuous organism 
 acquire virulence. But here it is right to draw a distinction. It is 
 a well-known fact, that loss of virulence takes place under certain 
 conditions. Any condition that prejudices the life of the organism, must 
 prejudice its function. Thus, injury by physical or chemical, or even 
 physiological, means, is found to weaken the virulence of the anthrax 
 bacillus. Pasteur's attenuated virus is obtained by moderate heat. 
 Chemical agents, notably carbolic acid, bichromate of potash and weak
 
 600 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 sulphuric acid, diminish the virulence in the same way. Further, there 
 is sometimes a curious physiological antagonism between different forms 
 of organisms. Curiously enough, the virulence of the anthrax bacillus 
 may be diminished, and even destroyed, by the action of the cocci of 
 erysipelas ; and, stranger still, even by the action of a colour-producing 
 organism — the bacillus prodigiosus. These alterations of function, 
 however, are in no sense capricious. They are constant, and become 
 themselves definite characters belonging to the species. A gain in viru- 
 lence, under artificial conditions, is of comparatively rare occurrence. 
 Pasteur claims to have worked up the virulence of the antln'ax bacillus 
 by passing the virus through young guinea pigs of different ages in an 
 ascending series, and certainly a few drops of lactic acid are found to 
 have the effect of greatly increasing the virulence of an attenuated 
 virus of symptomatic anthrax. In both cases, however, it is only that 
 a virus already weakened, becomes again strong. Upon the results of 
 these investigations, rests the whole question whether we have any 
 right to relegate species and varieties to definite groups on account of 
 peculiarities of shape, the mode of growth and multiplication, and 
 other physiological features. Are the physiological and morphological 
 cliaracters always the same for the same variety under ordinary con- 
 ditions, or are form and function so variable under altered conditions 
 that all attempts at classification are hopeless ? Buchner at one time 
 protested that he had, in a definite experiment, converted the virulent 
 bacillus of anthrax into the harmless bacillus that grows so i"eadily 
 in hay infusion. He now admits that the conclusion was based upon 
 faulty observation, and was essentially false. But there are other 
 experimenters, notably Zopf, who claim to have converted micrococci 
 into bacilli, and vice versa ; but the observations of Zopf have not 
 been corroborated by any of those investigators who, on account of 
 their special training and expei-ience in the extremely delicate methods 
 of investigation, have the first claim upon our credence. In this 
 science, as in every science, there is need for special training and 
 long experience, before trustworthy results can be obtained. Even if 
 the observations be not faulty, errors in experiment may very easily 
 creep in. The mere observation of round forms among bacilli, is no 
 proof that a bacillus has been converted into a micrococcus. The 
 round form may be assumed by the bacillus at a certain stage in its 
 existence, when spore-formation is the rule, but this round form is 
 no micrococcus, but has the power of again becoming a bacillus. 
 
 Again, alterations of form may be due to degeneration. Like other 
 forms of life, these micro-organisms may become diseased ; unhealthy 
 in appearance and action. Some practice too is required in the use of 
 tlie staining reagents, else misleading observations may be recorded.
 
 president's address — SECTION OF PATHOLOGY. 601 
 
 But the most frequent source of error is want of due precaution in 
 excluding all possible risk of contamination by foreign material. But 
 Avliile perhaps we may argue that, as yet, transmutability of species has 
 not been observed to occur vinder artificial conditions, we have no right 
 to assume that it does not occur under any circumstances. We cannot 
 assume that these lowly organisms have laws of their own, unlike the 
 laws that govern the rest of the living world. We must assume that 
 variability of form, such as we know to occur in tlie life of plants 
 and animals, occurs also in the life history of these lowly organisms. 
 Therefore, on the ground of analogy, it is likely that species may be 
 changed, and function modified. In the plant world, especially under 
 the influence of cultivation, there is no limit to variation ; but often 
 this variation so far from introducing characters belonging to a new 
 species, becomes itself a sure sign of the species itself. Confusion and 
 difficulty, however, may arise if any phase in the complete cycle of 
 events in the life of the organism, plant, or animal, be overlooked. 
 Tlius, the discovery of spores in the life of the anthrax bacillus — a distinct 
 phase in itself — and the dis-association of this phase from the phases of 
 life that precede and follow it, may give rise to the erroneous view, that 
 a bacillus may be changed into a micrococcus. This modification of 
 form is essentially bound up with the nature of the organism, is one 
 of its leading characters, and always ajopears when conditions are 
 favourable. For the identification of a new species, new attributes 
 must be found, which are not only constant, but are also transmissible 
 to later generations. Changes of form or function that depend entirely 
 on extei'nal circumstances, appearing with these circumstances and 
 disappearing with their removal, are not attributes at all. Attributes 
 primarily depend, not upon the extei^nal conditions, but upon the 
 inlierent nature of the organism. Hence, no new species can be the 
 result of capricious modification or degeneration. While then external 
 conditions may induce changes, these changes are regular and not 
 capricious, and remain only so long as the external conditions persist. 
 Such variations become characters of the species, and in spite of them, 
 it is possible to classify with precision the different forms of organisms. 
 We are thus driven to the conclusion, that it has not been shown by any 
 trustworthy experiment, that there is any great variability of form 
 in these lowly organisms. Indeed, every careful bacteriologist is 
 surprised at the constancy of form and function tliat obtains in these 
 organisms. 
 
 Of all the interesting questions that have been simplified, and to 
 some extent explained, by bacteriological research, none occupies so 
 conspicuous a position as tlie question of immunity. It is an extraordinary 
 fact, first proved by Jenner, that an attack of a mild or modified fonn
 
 602 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 of a specific disease, may protect against a virulent form of the disease. 
 It is the purpose of vaccination to confer this immunity. 
 
 I feel that, in the public interest, I should make more than a passing 
 reference to this important question of immunity by vaccination. Ever 
 since M. Pasteur entered the field in the interests of the pastoralists of 
 Australia, the sulDJect of bacterial disease has occupied a prominent 
 place in the public mind, and one special phase of it — immunity by 
 vaccination — has attracted special notice since M. Pasteur's own 
 delegates performed their famous experiment at Junee. The demon- 
 stration at Junee was an event of no little importance to the public, 
 seeing tliat a Minister of the Crown took part in the rejoicings, and 
 eveiy colony sent its most skilled veterinarians to form their own 
 judgments, probaljly with a view to advising their respective Govern- 
 ments on this question of vaccination in Cumberland disease. This, at 
 least, I can say, that steps are now being taken by the responsible 
 authorities in New South Wales for the introduction of Pasteur's scheme, 
 and this action is in the main the outcome of the demonstration witnessed 
 at Junee. I maintain that, at the present time, with our exti-emely 
 imperfect statistics, any such action would be precipitate and unwise. 
 Competent authorities in England are far from satisfied with Pasteur's 
 method. In Germany the method is not approved, although anthrax 
 is common in certain parts of Prussia. In Italy the principle, and not 
 Pasteur's application of it, has found some favour; but it is applied, 
 not to save sheep, but to save cattle. In Hungary, too, Pasteur's method 
 has been used, though with some important modifications. But in all 
 these countries, there are trustworthy statistics to show the serious 
 pi'oportions assumed by outbreaks of the disease among animals, and 
 the localities of such outbreaks. In New South Wales, we have no 
 positive trustworthy evidence that anthrax is the cause of a high rate 
 of mortality among either sheep or cattle. What evidence we have is 
 of a most meagre kind, and we do not yet know but that, as proved to 
 be the case in Germany after scientific investigation, some of the 
 outbreaks might prove not to be outbreaks of anthrax at all. At any 
 rate, one is justified in demanding that, before Pasteur's scheme be 
 introduced for a trial, the Government should be assured on none but 
 the most scientific evidence, that anthrax exists in dangerous proportions, 
 causing a higli rate of mortality among animals ; that the high rate of 
 mortality is due to anthrax, and to nothing else ; that the outbreaks are 
 confined to certain localities, and tliere cause an alarming number of 
 deaths. These conditions are indispensable for the useful application 
 of Pasteur's metliod. Again, we should know on authority, independent 
 of M. Pasteur, that this scheme is not only useful, but also free from 
 danger, or else we run the risk of increasing the evil, instead of
 
 president's address — SECTION OF PATHOLOGY. G03 
 
 remedying it. Finally, and most important of all, it has to be shown 
 that Pasteur's method is the only and best method l)y which we can 
 successfully attempt to limit the extent of this disastrous disease. 
 
 It is of the first importance that, in forming a judgment on this 
 matter, we should be careful to exclude all statements and I'ecords of 
 experiments that are not satisfactory or trustworthy. Many sanguine 
 observers have either overlooked fatalities, or attributed them to 
 cai'elessness or accident. False conclusions, too, have been based upon 
 insufficient premises. Thus it does not by any means follow that a fall 
 in the rate of mortality in a district, after the use of vaccination, is due 
 to the use of vaccination. It is well known, that the rate of mortality 
 may be high in one year and low in the next, even when no vaccina- 
 tions have been performed. It would be manifestly illogical to contrast 
 the results of vaccination during a year of low mortality, with the 
 results of the disease in a year when the mortality was high. This 
 method of reasoning has been vised by the advocates of Pasteur's 
 method, and not only stands self-condemned, but ci'eates a strong 
 prejudice against the system of vaccination altogether, as a method of 
 checking anthrax. There are, foi-tunately, investigations and actual 
 practical results obtained in Europe by the application of Pasteur's 
 metliod which are open to no such objection, and are well wortliy 
 of close attention. 
 
 Such demonstrations as that given at Junee are of little assistance 
 to us in considering the question, for it has long been established as a 
 scientific fact beyond dispute, that if sheep be inoculated with an 
 attenuated virus of anthrax, they are protected not absolutely, but to a 
 very marked degree, against the virulent and fatal disease. We may 
 take it for granted that, in the hands of Pasteur's own pupils, the 
 demonstration was made in a manner that would be as satisfactory to 
 scientific men, as it was to the members of the board of inquiiy. Yet 
 the result of the demonstration might have been anticipated by anyone 
 competent to form an opinion. In fact, the demonstration found us 
 where it left us, and added nothing to the knowledge of facts upon 
 which the advantages and disadvantages of Pasteur's system rests. 
 
 I intend to enter somewhat fully into the real merits of this important 
 public question, because although such a demonstration helps us not at 
 all to appreciate the merits and demerits of Pasteur's system, there are 
 some persons who are eager to introduce the system on the strength of 
 this demonstration. Fortunately for us, the numerous experiments 
 and practical trials that have been made to test the real value of this 
 method, have been so fully recorded, that we are in a favourable posi- 
 tion to criticise the claims and assertions of the advocates of Pasteur's 
 scheme. It is .solely upon the basis of these recorded results that we
 
 604 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA, 
 
 must consider how far M. Pasteur is right in advocating the practice 
 of vaccination, to prevent the disease commonly known as anthrax, or 
 Cumberland disease. Although to Pasteur alone belongs the honour of 
 having explained the raison d'etre of immunity after vaccination, and 
 of being the first to prepare a vaccine of known and constant strength, 
 the idea of vaccinating animals to protect them against virulent anthrax 
 certainly originated with Toussaint. It may be stated as an axiom, 
 that the value of a vaccine depends on its power to secure immunity, 
 without endangering the life of the animal vaccinated, or of other 
 animals. Pasteur, after making extensive experiments in his labora- 
 tory, asserted that he had succeeded in preparing two vaccines of 
 different strengths and both attenuated, which, if inoculated according 
 to his plan — the weaker one first, and the other a fortnight later — 
 secured immunity in sheep and cattle against anthrax. These vaccines 
 ai'e prepared by no secret method, and may be prepared in different 
 ways. Pasteur prepares his weaker vaccine, vaccine No. 1, by main- 
 taining cultivations of the bacilli in sterilised chicken broth at a 
 temperature of 43° to 42° C. for twenty-four days ; and the stronger 
 vaccine in the same way after twelve, instead of twenty-four, days 
 cultivation. It was a remai-kable enough discovery, that heat thus 
 diminished the virulence of the organism ; but more remarkable and 
 more important still was the discovery that, when once the virulence 
 had been reduced, the bacilli might be exposed to a lower tempera- 
 ture, say 35° C, highly favourable for their growth, and readily 
 allowing spore-formation to take place, without any risk of the 
 bacilli regaining their lost virulence under these new conditions. 
 The degree of virulence established by artificial cultivations, remained 
 constant. This discovery is the basis of jjrotective inoculation. 
 Pasteur's plan of operation was so clear, and the discovery so important, 
 that it was only to be expected that workers in the same field of inquiry 
 would investigate and thoroughly check his method and results 
 Nothing could be fairer or more pregnant with sound practical wisdom, 
 tlian tlie criticism of Koch, of Berlin, who alone at that time had an 
 undoubted right, by virtue of his own investigations, to review the work 
 of Pasteur. In the first place, Koch proved that immunity under 
 artificial conditions of inoculation did not guarantee innnunity under 
 natural conditions. Animals may resist anthrax by inoculation, and 
 yet not resist invasion by the germs, especially in the lasting form of 
 spores, when they have entered the stomach. Experience, too, has 
 shown that cattle, whicli are but little susceptible to antlirax by 
 inoculation, die in a startling manner when the food containing these 
 malignant spores of anthrax is of a kind to injure meclianically the 
 mucous uiembrane of the dii-estive tract. Koch showed also that of
 
 president's ADDKESS — SECTION OF PATHOLOGY. G05 
 
 seven sheep that had resisted infection by inoculation witli vii'ulent 
 anthrax, two subsequently succumbed when food containing the bacilli 
 found entrance to the digestive canal. Hence, there could be no doubt 
 that immunity under artificial conditions is no guarantee of immunity 
 under natural conditions. Koch further showed that Pasteur's vaccines, 
 prepared by his own hand, were not of constant sti^ength. Sometimes 
 they were too strong, sometimes too weak, and this variable sti*ength 
 was proved to be due to the slight degrees of variation of temperature 
 that occur in the best regulated machines. At the same time, Koch 
 suggests his own simple method of ol)taining two vaccines resembling 
 Pasteur's vaccines in everything but this tendency to vary in strength. 
 He found that Pasteur's weaker vaccine is strong enough to kill mice, 
 but not guinea-pigs or I'abbits ; while Pasteur's second vaccine is strong- 
 enough to kill mice and guinea-pigs, but not rabbits. Therefore, Koch 
 says : — " The cultivations that are strong enough to kill mice, but not 
 guinea-pigs, are to be used as vaccine No. 1 ; and the cultivations that 
 are strong enough to kill both mice and guinea-pigs, and yet spare 
 rabbits, are of the proper strength for vaccine No. 2." In this way, 
 proper vaccines can be obtained and checked. 
 
 Apart from such laboratory experiments, we have numerous carefully 
 recorded results of practical trials that help us in some measure to 
 judge of the wisdom of Pasteur's scheme. In these practical trials, the 
 object has been to determine how far the method is successful in 
 securing immunity, and its freedom from danger. The records of 
 experiments made in France and Italy show that out of 116 sheep 
 thought to be protected by Pasteur's method, no less than thirty-five 
 succumbed through virulent infection prodviced by inoculation. In 
 Russia, of sixty-two sheep similarly inoculated, only fifty proved to be 
 absolutely protected. Kitt gives us some valuable records. He 
 obtained vaccines from Pasteur's own agent, and by the usual tests 
 proved them to be pure cultivations of anthrax l^acilli, containing 
 spores and threads. After inoculating, in strict accordance with 
 Pasteur's plan, four sheep, one lamb, and two bullocks, the two bullocks 
 and only one sheep survived subsequent inoculation with virulent 
 matex'ial. Kitt concluded that the vaccines were probably too weak, 
 and that the bullocks had not been protected, but had survived the 
 genuine unmitigated disease. Thus it would appear, that complete 
 immunity is not easily secured, vmless a virus is used of such strength 
 as to cause severe symptoms, or, may be, endanger the life of the 
 animal. As a rule, the first vaccination is free from danger, but the 
 second inoculation has caused death in as many as ten to fifteen per 
 cent, of the animals. When thei'e is the risk of such a high percentage 
 of deaths, it cannot be said that the preventive inoculation has any
 
 606 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 particular advantage. No doubt these high percentages of deatlis are 
 not the rule, but where there is no risk in the inoculations, there is no 
 great protection secured. To emphasise the risk of protective inocula- 
 tion, it may be well to quote some statistics. In Kapuvar, of fifty 
 sheep, five died after inoculation with vaccine No. 2 ; in Packisch, 
 three out of twenty-five ; in Salzduhlun, three out of eighty-two ; in 
 Dlonie, twenty-six out of 703 ; in Urmenyi, twelve out of seventy- 
 seven — in all, forty-three deaths out of 937 animals inoculated ; in 
 other words, four and a half per cent, of deaths. But the most 
 remarkable statistics are those furnished by Koch of results obtained 
 in Montpothier. Of 220 wethers, nine animals died after inoculation 
 with vaccine No. 1 ; later, seven more died after a repetition of the 
 same vaccine ; and later still, another animal after the use of vaccine 
 No. 2 — that is, seventeen in all out of 220 animals. This ought to 
 have been a sufficiently severe inoculation to ensure immunity. Yet a 
 short time after, six more animals died of natural infection. A further 
 inoculation was made with vaccine No. 2, and five more wethers 
 succumbed. As Koch exclaims, " At what a terrible cost was 
 immunity secured in these cases." To give one more striking record of 
 results obtained upon a small sheep farm. For some years, a farmer 
 had lost from three to ten per cent, of his sheep annually from anthrax. 
 He divided his sheep into two flocks of about 1800 each; one flock he 
 did not inoculate, the other flock of 1800 he inoculated by Pasteur's 
 method. Of these, twenty-one died as the result of inoculation, and 
 later, six by natural infection — that is, twenty-seven in all. Of the 
 uninoculated sheep, fifty-six died of natural infection. Let us suppose 
 the cost of inoculation to be 3d. per head, the cost of inocvilating 1800 
 at this rate would be ^£22 10s. It thus costs £22 10s. a year to save 
 about thirty sheep. This can scarcely be said to be any great jDecuniary 
 gain. 
 
 But Pasteur says that it is not necessary to use such a powerful 
 virus as will cause this great percentage of deaths, because the danger 
 from natural infection is less than by inoculation, and therefore, a 
 weaker virus is sufficient to protect against natural infection. In the 
 face of this statement, Koch has clearly proved the reverse to be the 
 case. Under natural conditions, infection is conveyed by the spores of 
 anthrax bacilli that are taken with the food into the stomach ; and this 
 mode of infection is more powerful, more dangerous, and more fatal 
 than infection caused by inoculation. This is admittedly the case in 
 cattle; and of seven sheep which, after proper vaccination, had resisted 
 infection by inoculation witli virulent material, two of the animals 
 died when they were fed with food containing anthrax spores. In 
 sheep therefore, also, this fact is quite at variance with Pasteur's view.
 
 president's address — SECTION OF PATHOLOGY. 607 
 
 It must also be remembered, that any protection secured lasts at most 
 only one year. Thus, with respect to Pasteur's scheme, as it applies to 
 sheep, we tind that the method of inoculation, to be effective, is 
 certainly dangerous, in some cases causing the death of five to ten 
 per cent, of the animals subjected to the treatment. The material, 
 even when it is supplied directly from Pasteur's own hands, varies in 
 strength. If it be weak, although it may not kill the animals, it may 
 artect their strength without protecting them. If it does not affect 
 them distinctly, it does not afford protection. In the most favourable 
 cases, protection lasts only for a limited time. The method, too, must 
 be costly. There is not only the original cost, but the method, if 
 applied at all, should only be applied in districts where the disease 
 assumes dangerous proportions, and then only under special regulations, 
 else the disease may be encoui'aged by the introduction of the method. 
 All the cost of such special regulations must also be taken into con- 
 sideration. On the other hand, it has been shown by practical results 
 in other countries that the disease among sheep can be greatly checked, 
 and its spread prevented, by the introduction of special sanitary regula- 
 tions in the infected districts. These sound sanitary regulations, 
 consisting in the main of the immediate notification of outbreaks when 
 they occur, and the prompt and thorough destruction by fire of all 
 the carcases of animals dying from the disease, have every year 
 produced better and better results ; and for the present — at least, until 
 we have some accurate scientific records upon which to base further 
 steps, we should do better to confine our action to the introduction of 
 such strict sanitary regulations in our efforts to limit the extent of the 
 disease, and perhaps banish it altogether from districts where it now 
 prevails, rather than hastily introduce a system, the wisdom of which 
 is, at any rate, disputed by those most competent to form an opinion. 
 
 "With respect to cattle, it would seem that Pasteur's method is less 
 dangerous, and naturally less costly, than in the case of sheep, and the 
 general conclusions with regard to its advantages are of a more hopeful 
 kind. The primary vaccination is not very dangerous, because in the 
 majority of cases cattle, even when subjected to inoculation with 
 virulent anthrax, suffer only from severe local reaction. For cattle, 
 the vaccines used and recommended by Pasteur, are much too weak to 
 give any protection. This is proved by the fact that, in those countries 
 where the method is applied to cattle, the vaccines in use are stronger 
 than Pasteur's — some of them, notably that of Perroncito, being little 
 weaker than virulent anthrax. Even these vaccines, while they afford 
 protection for a time against infection by further inoculation, do not 
 guarantee absolute immunity against infection by natural means, and 
 they may be a source of danger, not only to the animals themselves,
 
 60^ 
 
 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 but to other animals, especially sheep. We are, in fact, asked to use 
 a material which, while it may protect cattle to some extent, is highly 
 dangerous to sheep. It is strange that, although Pasteur's method is 
 stated to be more suitable to protect cattle than sheep against anthrax, 
 and although the mortality among cattle is much greater and more 
 serious than among sheep, Pasteur has applied his method to protect 
 sheep rather than cattle. Taking the statistics of Prussia, Austria 
 and Hungary, I find that 1113 out of 6 millions of horses, 1380 out of 
 27 millions of sheep, and nearly 8000 out of 23 millions of cattle, 
 died in one year from anthrax. Yet all the records of Pasteur show 
 that his system is specially advocated, and is mainly applied to save the 
 lives of sheep. It is mainly in Italy and Hungary that extensive 
 inoculations have been made to protect cattle from the disease. 
 
 What, then, are the general conclusions with regard to Pasteur's own 
 method of vaccination to protect cattle from anthrax ? Firstly, his 
 vaccine is not the best vaccine for the purpose, even when large doses 
 are given. Next, successful vaccination does not secure immunity 
 against infection by natural means. After such vaccination, five to ten 
 per cent, may fall victims to the disease, probably by the entrance of 
 spores into the stomach with food material. Further, a vaccine strong 
 enough to protect, may be a serious source of danger to sheep, and is 
 dangei'ous even to cattle. If any such animal dies, its carcase swarms 
 with organisms virulent enough to cause a wholesale destruction of 
 sheep. It therefore follows, that all animals that have been vaccinated 
 must be under strict supervision until the period of such risk is passed. 
 The effect of vaccination is generally to arrest the secretion of milk. 
 Any milk secreted is unfit for use, and even dangerous. This effect, 
 too, has a commercial disadvantage. It goes without saying, that the 
 flesh of no vaccinated animal is fit for food, till a certain interval of 
 time has elapsed after vaccination. And if the animal should die 
 during this interval from accident or other cause, apart from the specific 
 disease, it should be condemned as unfit for food, and destroyed by fire. 
 Thus, even if no other objections to the system existed, it is evident 
 that, with its introduction, it would be necessary to introduce most 
 stringent regulations, obedience to which could only be enforced by a 
 stafi' of competent officers. Thus one can imagine how expensive the 
 method would become, quite apart from the mere cost of preparation 
 and supply of the vaccine. The question then becomes an economic 
 one. What is the gain, if the method of protective inoculation, with 
 the attendant conditions, is so expensive as to counterbalance or, 
 perhaps, even outweigh the advantage gained by inoculation ? Since 
 the real nature of the disease has been understood, regulations have 
 been framed to minimise tlic danger of infection — and with good results
 
 president's address — SECTION OF PATHOLOGY. G09 
 
 — these regulations have reduced the number of cases of the disease in 
 those countries where they have been strictly administered, and 
 sufficient time has not yet elapsed for us to be able to gauge the full 
 value of these regulations. At any rate, until these simple methods 
 have been fully tested and found wanting, I can see no good grounds 
 for introducing a system which must always have an element of danger. 
 Quite lately we have learned that, by an accident, 3000 sheep were 
 sacrificed to this method. 
 
 These are the conclusions to which an impartial review of the whole 
 question forces us. Let our Governments — and it is a matter affecting 
 all the colonies — first take steps to find out the real extent of the 
 disease. • This could only be done by appointing an inspector possessing 
 the necessary scientific knowledge to visit the districts in which the 
 disease is said to prevail, and then to report. It is only in this way 
 that any satisfactory information and statistics could be obtained. 
 Owners of stations are not anxious to proclaim to the world that their 
 sheep or cattle are dying of Cumberland disease. 
 
 One is a little apt to discredit the view, that Cumberland disease is 
 causing a high rate of mortality among sheep. In New South Wales, 
 we have akiiost as many sheep as they have in the whole of Russia, 
 the great sheep farming country of Europe, and if the disease was 
 very common, one would expect to hear more of woolsorters' disease 
 among men, and more of the disease in cattle. In Europe, the mortality 
 among cattle is far greater than the mortality among sheep, both 
 absolutely and relatively. Until we have real and trustworthy statistics 
 of the extent of the disease, the Government should introduce proper 
 sanitary regulations that can be carried out by stock-owners, rather 
 than in a haphazard fashion and on no reasonable grounds, encoui'age 
 the introduction of Pasteur's system of vaccination for the prevention 
 of Cumberland disease in sheep. 
 
 But it must strike one with surprise that, in a country like Australia, 
 the prosperity of which is, to a large extent, bound up with the great 
 national industry — sheep and cattle farming — no effort is made to 
 establish scientific institutions for the investigation of the diseases of 
 animals. How long are we to depend entirely on the results of work 
 carried on in Europe? Surely we have here abundant opportunities 
 to contribute to those scientific investigations, which must be of 
 enormous practical value to our special industry. It is high time that 
 such an institution should be established for these investigations, 
 therefore it was that I wrote to the Minister for Lands: — "It seems to 
 me that some encouragement should be given in this colony to scientific 
 investigations that aim at discovering the essential cause of disease, 
 not in man only, but also in animals, with a view to checking, and 
 
 iR
 
 610 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 possibly eradicating, such disease. Such encouragement is given pre- 
 eminently in Germany, and Koch's splendid work flows from it. 
 France vies with Gei'many, and England is following the example. 
 There should be a bacteriological institution in connection with the 
 stock department, or at the University, or in connection with the Board 
 of Health, as I urged three years ago." If such an institution existed, 
 it would be of enormous value to our great industry, for upon any 
 outbreak of disease in stock, scientific investigations would rapidly 
 settle the nature of the disease, and this is the first step towards 
 checking and eradicating the disease. Such an institution is ready at 
 hand in Sydney, if only the Government will see fit to establish it. A 
 set of buildings, fitted up with all the necessary appliances for bacterio- 
 logical research, has been erected in order to test Pasteur's method for 
 the extermination of rabbits. The Government will do a great and 
 useful work in encouraging scientific research, and in assisting our 
 great national industry by establishing, on a permanent basis, the 
 present institution under the control of the Rabbit Commission, as a 
 scientific institution for the investigation of diseases of animals. 
 
 I trust that I have given no offence in alluding at some length to 
 this impoi'tant practical phase of a highly interesting scientific dis- 
 covery. It is well for us to learn from the teachings of science our 
 duties and responsibilities in this complex world of men and things. 
 I am glad, too, to have had the opportunity of expressing the opinion 
 that, in these young colonies. Government should bestow liberal patron- 
 age upon scientific investigations that have a great practical value in 
 special industries. Yet history tells us how slow Government may be 
 to recognise its duty. What a pathetic episode is presented us in the 
 answer given by a French Minister of Finance to M. Pasteur, when he 
 sought for some little assistance in his scientific researches — and that 
 but twenty years ago : — " There is no clause in the Budget to grant 
 you £50 to defray the expenses of experiments." This was the dis- 
 couraging reply. Did this refusal thwart him? Fortunately for 
 France, M. Pasteur followed science as a religion ; and, full of faith, 
 full of enthusiasm, lie bore himself, poor as he was, the expense of his 
 investigations — those very investigations which were the means of 
 saving from total ruin one of the great industries of France, the means 
 of preventing the loss of many millions a year to the people of France. 
 May we not ask, what statesman, what financier, what general, can 
 point to work so great, so useful ? Yet, while these public men receive 
 their decorations, their titles, their rich pensions, the votary to science, 
 who has lavished untold blessings upon the people, who is ever assisting 
 industry, who saves life instead of destroying it, who truly ministers to 
 the health and wealth and happiness of the people, receives scant,
 
 SIGNIFICAXCK OF AX EXCESS OF IXDICAX IX THE URIXE. (311 
 
 if ;iny, recognition, and his good and great deeds are the wonder of a 
 day. Let us all learn from the example of M. Pasteur, and follow our 
 special studies as a religion. Full of enthusiasm for the brilliant 
 achievements of the past, full of faith in the grand possibilities of the 
 future, let us study the nature and origin of disease, in season and out 
 of season, at all times and in all j)laces, so that some of the boundless 
 possibilities of the futui'e may become the real achievements of our own 
 lives. 
 
 THE PATHOLOGY AND CLINICAL SIGNIFICANCE OF 
 AN EXCESS OF INDICAN IN THE URINE. 
 
 By R. Humphrey Martbx, M.B., B.C. Cantab., M.R.C.S., 
 L.R.C.P. Lond. 
 
 Houorary Assi.staut Surgeon, Adelaide Hospital. 
 
 Although the cases illustrating this paper occurred at Addenbrooke's 
 Hospital, Cambridge, during the three years 1885-87, whilst I was 
 holding the post of house physician, I thought the subject might be of 
 interest to some members of the Congress. During my term of office, 
 I had to examine about fifteen hundi'ed specimens of urine, and in six 
 of these I found a marked excess of the substance called indican ; and 
 as most of these cases came under diseases of the alimentary canal, I 
 concluded there must be some connection between the two ; and on 
 searching the authorities on the subject, which are principally to lie 
 found in Hoppe-Seyler's "Chemistry," I found that their views generally 
 agreed with my researches. 
 
 Very little is to be found in English medical literature on the 
 subject. In Hilton Fagge's "Medicine" there are some i^emarks on 
 indican, but these appear to be simply an extract from the German 
 edition of Hoppe-Seyler's work. M'Munn, the author of the work on 
 the " Spectroscope in ^Medicine," has made a study of indican for years, 
 and to him I am indebted for much valuable information as to German 
 authorities. 
 
 The history of indican began with Schunk of Manchester, who 
 discovered it in the urine as a normal constituent, and it was at first 
 supposed that this product was identical with the indican found in the 
 vegetable kingdom ; but this has since been disproved, although they 
 differ in only a slight degree. 
 
 The presence of indican can be demonstrated by adding hydrochloric 
 acid to a large quantity of urine placed in a long glass vessel, and then 
 allowing the mixture to stand for about twenty-four hours, when a 
 dai'k bluish scum of indican appears on the surface of the urine. 
 
 iR 2
 
 G12 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 A second method of determininf? its presence is, by adding hydro- 
 chloric acid and chloride of lime to the urine, and then shaking the 
 mixture with chloroform, which becomes bluish from the presence of 
 indican ; and on being examined with tlie spectroscojDe, shows the 
 characteristic bands. 
 
 A third way for detecting indican in excess, and which is a very 
 useful one for clinical demonstration, simply requires the urine to be 
 warmed, and then nitric acid, yellow with nitrous, to be added ; when, 
 if the indican be present in any quantity above the normal, a dark- 
 brown colouration appears, which goes quite black on the further 
 addition of the acid. 
 
 The physiological causation of indican in the urine has been princi- 
 pally worked out by Jaffe, whose investigations are to be found in 
 Hoppe-Seyler's " Chemistry," as previously quoted. 
 
 It has been proved experimentally, that the final reduction of indigo 
 is a substance called indol. Now it has long been known that, during 
 the artificial pancreatic digestion of proteid material, two bodies, with 
 an offensive odour, to which the peculiar smell of fasces is due, are 
 formed — one being the body indol, the other a closely allied body skatol ; 
 and there is not the least doubt that the same two bodies make their 
 appearance in the small intestine of man, in exactly the same way as 
 they appear in the physiologist's laboratory. 
 
 The presence of indol and skatol does not appear to be due to the 
 action of the tryptic ferment of the pancreas, as at first supposed, but 
 rather due to a simultaneous putrefactive change taking place, under 
 the influence of bacteria. For if the laboratory digestion be conducted 
 with strict antiseptic precautions, with the pi'esence of salicylic acid, 
 no putrefaction occurs, no indol appears, and the products of digestion 
 have no characteristic smell of fasces. This of course might be due, 
 though very unlikely, to the destructive action on the ferment which 
 produced the bodies indol and skatol. 
 
 It is well known that bacteria are present, in the alimentary canal, 
 from end to end, in great qviantities in the small intestine, but increas- 
 ing in number towards the rectum. These would easily account for the 
 presence of the indol and skatol in the small intestine of man, where 
 the pancreatic digestion of proteid material is proceeding rapidly ; and 
 when from any cause there is some alteration in the amount of absorp- 
 tion from, or the onward movement of, the intestinal contents, or 
 change in the mucous lining of the canal, the excess of the body 
 indican, which in certain cases is found in the urine, has a ready 
 explanation. It has been proved by Jaffe that, by feeding dogs on 
 indol, obtained by the pancreatic digestion of proteids, or by injecting 
 the same substance under their skin, a large excess of indican could be 
 made to appear in the urine. Again, l^y simply feeding dogs on an 
 excess of proteid food, in which it is supposed that much indol would be 
 formed during the pancreative digestion in the alimentary canal, a large 
 (juantity of indican can ])e discovered conung away in their ui'ine. 
 Jndol being the final reduction product of indigo, it can be easily 
 imagined, that after its absorption from the intestine, and during 
 its sojourn in tlie blood, and its passing out by the urine, it can become 
 oxidized into tlie product, indican. No indican has ever been found in 
 the blood, but it has easily been detected in the renal epithelium, from
 
 SIGNIFICANCE OP AN EXCESS OF INDICAN IN THE URINE. 613 
 
 wliich it has been coiicludecl, that the final transformation takes place 
 during the very act of excretion, as is well known occurs with otlier 
 excretion products which are got rid of by the kidney. 
 
 Jatfe has found indican in excess in the urine, clinically in cases of 
 intestinal obstruction, and by experimentally obstructing the intestine 
 of dogs, especially the small intestines, he obtained indican in excess in 
 their ui'ine, thus proving that any obstruction to the onward flow of 
 the contents of the bowel, leads to an increase of the indican-forming 
 substances in the blood ; but it appears, from both clinical facts and 
 experimental investigation, that obstruction in the large bowel does not 
 produce the same excess of indican in the urine. This might be either 
 due to further changes having taken place in the contents of the bowels 
 in their onward progress along the canal, so that no longer any indol 
 is formed ; or else, from the peculiar construction of the large bowel, 
 absorption of indol is rendei'ed difficult. For if the change be simply a 
 putrefactive action, there is no reason why plenty of indol should not 
 be formed, as the large intestine contains many more organisms of 
 putrefaction than any other part of the canal. 
 
 But it has been shown, that the indol is formed during the digestion 
 of the proteid food ; and as this is mostly complete, and the products 
 absorbed before arriving at the great intestine, which only absorbs the 
 watery constituents of the contents, rendering the faeces drier, a ready 
 explanation is obtained. Obstruction of the bowel does not appear to 
 be the only cause of the presence of indican in excess in the urine, as 
 Senator (vide Fagge's " Medicine," Vol. II.) refers it to states of inani- 
 tion, as cancer of the stomach, gastric ulcer, and phthisis with diarrhcea. 
 Herringe, also quoted by the same authority, insists on its appearance 
 in wasting aftections of the canal, as well as its presence in cases of 
 diarrhoea and constipation ; but with regard to the latter, I shall have 
 more to say after quoting the cases which have come under my own 
 innnediate notice. I propose now to give a very short account of the 
 clinical cases which I have had the opportunity of personally examining. 
 
 The first case occurred in Addenbrooke's Hospital in October 1885, 
 and happened as follows: — Elizabeth T., a^t. 31, admitted from the 
 out-patients', with very obscure symptoms. There was a histoi-y of loss 
 of flesh, slight diarrhcea, with pain and tenderness in the left lumbar 
 and iliac regions of the abdomen, with a slight sensation of resistance, 
 but no evident tumour. Her temperature was found to rise each niglit 
 to 103° or 104^ Fah., and fall in the morning. The patient rapidly ran 
 down hill, no diagnosis being made, but an abscess connected with 
 eitlier the spleen or kidney thought of. Her urine from the first had 
 a peculiar dark colour, resembling urine in cases of carboluria, and this 
 colouration increased on standing for some hours. On heating a speci- 
 men, and then adding nitric acid, yellow with nitrous, it became 
 absolutely black, but at the time no importance was attached to this 
 fact. Dr. F. T. Allen, of the Cambridge Physiological Laboratory, 
 examined it for me, and was able to separate large quantities of indican, 
 and confirm my previous supposition that the colour produced by the 
 nitric acid was this body — indican. The patient soon died, and the 
 po.st-mortem showed well-marked tubercular ulceration of the bowel. 
 
 The second case was that of a man with a probable malignant ulcer 
 of the pylorus, with sickness and constipation ; but as the patient left
 
 614 INTEKCOLOMAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 the hospital somewhat improved in health, we never had an opportunity 
 of verifying our diagnosis. 
 
 The third case was that of a man, aged 66, who was admitted with 
 all the symptoms of acute intestinal obstruction coming on after a large 
 meal, in which a considerable amount of cucumber had been eaten. 
 The patient became so ill, that an operation was suggested ; but he 
 would not consent to this, and perhaps for him a good thing, as in a 
 few days all symptoms disappeai-ed under copious enemata. During 
 the wliole period of his acute obstruction, a great excess of indican 
 was present in liis urine. 
 
 Tlie fourth case was tliat of a drunkard who had no evidences of 
 intestinal obstruction, but had two epileptic fits after a big bout of 
 drinking, during which time his urine contained indican in great 
 excess. 
 
 The fifth case was that of a woman, aged 29, who was admitted with 
 acute intestinal obstruction, which came on after a violent exertion. 
 An operation was proposed, but declined by the patient. The urine 
 was always black with indican. The post-mortem showed a twisting 
 of the bowel, with an ulcer about eighteen inches above the ileo-ca'cal 
 valve, in the small intestine, with a recent perforation of the bowel 
 into the peritoneal cavity. 
 
 Tlie sixth case was tliat of a nurse who suffered from great abdominal 
 pain, accompanied by stools which only contained blood and slime ; no 
 motion. During tlie whole time of passing the blood and slime, indican 
 in great excess was present in the urine. 
 
 Since being in the colonies, I had an opportunity of seeing an 
 interesting case under Dr. Stirling, in the Adelaide Hospital, who 
 kindly allows me to make use of it. A young, strong, healthy man 
 was admitted with a crushed abdomen, and symptoms of obstruction 
 of the bowels. As he had a rupture, this was operated on, l)ut 
 without finding any strangulation, and was returned after removing 
 much omentum. As tlie symptoms continued, it was suggested that 
 abdominal section should be performed, with a view to finding if any 
 internal seat could be discovered. This was not carried out, owing to 
 the critical condition of the patient. I carefully examined his urine, 
 and could find no excess of indican, and from this concluded that 
 no obstruction existed, but only peritonitis, and this proved to be the 
 case post-mortem, when peritonitis was discovered, due to a rupture of 
 the bowel from the crush. Although this does not come under the head 
 of Indicanuria, it well illustrates its usefulness from a diagnostic point 
 of view. 
 
 In viewing the above cases, it will be seen that all but one, namely, 
 the drunkard with fits, had some intestinal trouble, thus closely 
 corroborating the previous observations of Jafte, Senator and Her- 
 ri nge. 
 
 T have also noticed an excess of indican in cases of strangulated 
 hoi'uia and prolonged constipation; but, strange to say, I have never, 
 either at home oi' out liere, lieen able to detect indican in typhoid 
 ievev, except in slight ti-aces where there is constipation. This may be 
 explained by the diarrlui-a carrying off' the intestinal contents before 
 any indol was formed, especially as from their diet, very little would be 
 present.
 
 UNILATERAL RENAL ATROPHY, WITH CASES. 615 
 
 In submitting tlii.s paper to the Congress, I have endeavoured to 
 show that the bhickening of the urine, on adding the nitric acid, may be 
 at times of great clinical importance ; and if my observations be correct 
 in typhoid and tubercular ulceration, it might help on some occasions 
 to ditierentiate between obscure cases of these diseases. 
 
 UNILATERAL RENAL ATROPHY, WITH CASES. 
 
 By T. Carson Fisher, A.B., M.D., M. Ch. 
 
 Kesident Medical Officer, Sydney Hospital. 
 
 From early times quite a number of cases have been collected, where 
 one kidney has been either absent or defective, from disease or 
 congenital abnormality. 
 
 Morris in his book on "Surgical Diseases of the Kidney," reviews 
 the literature of the subject. He shows that Morgagni, over a hundred 
 years ago, knew of cases of single kidney, and divided them into two 
 classes, namely: — (1) Fused kidney, where an organ was made up of 
 two; (2) Congenital single kidney, w^here one only had been formed. 
 Rayer and Rokitansky also studied the subject. The latter limited the 
 term "solitary" kidney to Morgagni's first class— the fused kidney; 
 while he gave the name " unsymmetrical " to the single oi'gan normal 
 in position, when its fellow is deficient. Morris dissents from these 
 somewhat confusing terms, and divides single kidneys into three great 
 classes : — 
 
 (1) Unsymmetrical kidneys, i.e., entire absence of one kidney. 
 
 (2) Atrophy, including congenital atrophy. 
 
 (3) Solitary kidney, i.e., fusion of the two kidneys into one mass. 
 This includes the horseshoe variety. 
 
 He then shows that several examples of absence of one kidney have 
 been recorded, and analyses those quoted by Rayer, who collected forty- 
 six cases ; of these, seventeen were unsymmetrical, and six were 
 examples of complete unilateral atrophy, due to defective development, 
 or disease. But Rayer's record, though it may show the proportion the 
 various forms of renal defect or atrophy bear to one another, does not 
 give the percentage of cases in which single kidneys may be expected. 
 
 Accordingly, Morris analyses the post-mortem records of four of the 
 great London hospitals, and shows forcibly the comparative rarity of 
 this defect. He found only three cases of absence, or extreme atrophy 
 of one kidney, out of 11,978 autopsies, and thus proves that congenital 
 absence of one kidney is a very rare event, occurring once in nearly 
 4000 cases. He quotes Dr. Weis in the New York Medical Journal, 
 who estimates that the single kidney is found about once in 5000 bodies. 
 These figures refer only to the proportion of cases of unsymmetrical 
 kidney, and of extreme congenital atrophy. They do not include the 
 proportion of fused kidneys, nor of those atrophied by disease ; nor 
 congenitally small kidneys, which weigh from one ounce to an ounce
 
 616 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 and a half. He found that 59 "atrophied " or "small" kidneys were 
 found in 8178 inspections. Morris then deduces the following 
 conclusions : — 
 
 (1) The probability of a person having one kidney, owing to 
 congenital absence or non-development of the other, is very small. 
 
 (2) There is a larger risk of meeting with one of the forms of fused 
 kidney, and a much greater risk of finding one of the kidneys wasted 
 by disease. 
 
 (3) Fused kidneys are usually situated in the median line, and so 
 their position prevents error. 
 
 Dr. W. Roberts also analyses the cases of single kidney recorded by 
 Mosler, Rayer, and others, and shows the I'arity of the atrophied kidney. 
 
 There are two great classes of atrophy of one kidney : — (1) The con- 
 genitally atrophied kidney ; (2) the kidney atrophied by disease. 
 
 The pathologist, finding one kidney very small, or almost absent, may 
 sometimes hardly decide between these two classes, but authors give the 
 following guiding signs : — 
 
 Ralfe says, that in congenital cases, the ureter or renal vessels are 
 defective or rudimentary ; whereas, in a kidney atrophied by disease, 
 the ureter usually remains, and frequently some trace of the organ itself. 
 In both cases, the other kidney is hypertrophied, and so long as it is 
 sound, does double duty. 
 
 Roberts says that, in congenital cases, other defects are usually found 
 either in the genito-urinary organs, as the ureter, bladder, or urethra ; 
 or shown in imperfect development of the body generally, as cleft palate, 
 malformation of limbs, ifec. 
 
 The causes of secondary atrophy, or atrophy due to disease, according 
 to Morris, are numerous, as Bright's disease, which usually afl:ects both 
 organs; obstruction of ureter, hydronephrosis, intei^stitial nephritis, due 
 to stricture of urethra, or stone in the bladder ; embolism, &c. Fagge 
 thinks calculus in kidney or ureter the most likely cause. The three 
 cases I have seen belong, I believe, to the last class, where the kidney is 
 destroyed or atrophied by disease. The rai-e condition of the congenital 
 atrophied kidney, I have never seen. 
 
 I. — Case of Absence op RiCxHT Kidney, Left Kidney Hypertrophied. 
 
 A man, named T. R., aged about 41, of well-nourished muscular 
 frame, fell from a scaffold, and died next day comatose, from intra- 
 cranial haemorrhage. 
 
 Autopsy, eighteen hours after death. — Left kidney abnormally large, in 
 usual situation, somewhat of horse-shoe shape, about six inches long; 
 weight, ten ounces. Capsule peeled easily, sui'face smooth. On section, 
 cortex was half an incli wide, pyramidal portion congested ; the organ 
 looked otherwise healtliy. A prolonged search revealed the fact that the 
 riglit kidney was absent. Its place was represented by a small mass of 
 fibrous tissue, embedded in fat, from which ran a ureter, smaller than 
 normal in the upper lialf, but the lower lialf of tlie tube was greatly 
 dilated and sacculated, resembling a portion of small intestine. Close 
 to tlie bladder was a cyst-like enlargement, the size of a liazel-nut; the 
 vesical opening was impervious. On slitting up this big ureter, it was 
 found to contain a dirty brown oily fluid, which contrasted with the 
 limpid urine which was in the bladder in small quantity.
 
 UNILATERAL RENAL ATROPHY, WITH CASKS. 617 
 
 In this case, I believe the right kidney was destroyed by pressure 
 eli'ects, due to the permanent and irremediable obstacle to the escape of 
 its secretion by way of the ureter. Some ulceration or adhesive intlam- 
 niation, or a calculus, probably blocked the vesical end of the ureter. The 
 sacculated condition of the duct, points to the long continuance of this 
 cause. Hydronephrosis, and consequent atrophy from pressure, was a 
 likely result. 
 
 It is possible too, that the affected organ may have been congenitally 
 small, and so the other kidney of partly horse-shoe shape, by doing 
 double work, gradually assumed its enormous size. 
 
 It is improbable, that the right kidney was congenitally absent, for 
 the reasons before given : — 
 
 (1) A very definite ureter was present. 
 
 (2) No other signs of congenital defect were found. 
 
 Fagge quotes a similar case in his work on " Medicine," vol. II., p. 674. 
 
 Case II. — Remarkable Atrophied and Cystic Condition op the 
 Right Kidney, Left Hypertrophied. 
 
 A stout elderly man named E. M., aged 63, was admitted into 
 hospital on the night of June 8, 1888. He was drunk, but not violent. 
 It was found that some hours previously he had fallen down an 
 embankment, and was brought six miles in a cart. He had a fracture 
 of the right humerus, just above the elbow. On the inner side of the 
 arm, a little above the fracture, was a small punctured wound, which 
 bled freely on removing a pad and bandage, one of the superficial veins 
 being pierced. A lacerated superficial wound, about two inches long, 
 was on the upper and inner side of the right thigh, and abrasions on 
 the right knee. The seventh rili, right side, was fractured in front of 
 the angle. 
 
 On June 14th, there was evidence of pulmonary congestion, with 
 noisy delirium, embarrassed respiration, etc. Urine was passed freely. 
 
 June 15th. He died, comatose, at 10 a.m. 
 
 Aiitopsy same rfa?/— Injuries as above. Slight pleuritic adhesions 
 right side. No wound of pleura or lung. Pulmonary congestion 
 affecting lower half of right lung. No true pneumonia. Lung weighs 
 twenty-eight ounces ; slighter congestion at base of left lung, which 
 weighs twenty-four ounces. Heart — much fat on surface ; right 
 chambers full of dark semi-clotted blood ; left empty. Slight fibroid 
 thickening in ring and cusps of mitral valve. Slight atheroma of aoi'ta. 
 Marked hypertrophy of left ventricle. Liver fatty, weighed eighty-six 
 ounces. Right kidney was embedded in perinepliritic fat, and was 
 hard to find. It measured two inches long, by one and a half inches 
 broad, and weighed only three-quarters of an ounce. On its surface 
 were three cysts, which lay near the convex border, and contained clear 
 fluid. The capsule was firmly adherent. On section, the oi'gan was 
 seen to be made up of cysts of various sizes, from that of a pea to a 
 pin's head. No distinction manifest between cortex and medulla. On 
 section, the larger cysts wei'e chiefly in the outer portion, and contained 
 clear fluid ; the smaller were full of caseous yellowisli-white mattei-, 
 limited by a fibrous-looking cyst wall. Between the cysts was the 
 cortical substance, or what remained of it, in wliich were yellowisli
 
 618 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 streaks, which ran in no definite direction through the dull-red hard 
 tissue. Numei'ous small caseous yellow nodules were scattered through 
 the organ. In the situation of the medullary portion, the condition was 
 very similar ; the pelvis of the kidney being occupied by fat, traversed 
 by fibrous bands. Renal vessels present, but small. Ureter was a 
 small shrunken bloodless tube, pervious ; no obstruction being found. 
 
 The cause of the atrophy in this case cannot, I think, be attributed 
 to congenital defect, hydronephrosis, interstitial nephritis, or primary 
 cystic formation. The shrunken organ, studded with cysts, was 
 probably the result of previous scrofulous disease; the other kidney, as 
 usual, doing douljle woi-k. 
 
 Similar cases have been recorded, where one oi'gan has been attacked, 
 the other being uiiaftected (cf. Lancet, 1885, Vol. I., pp. 142 and 699). 
 
 Case III.— -Hydatid Cyst in Site of Absent Right Kidney, and 
 
 IN Bladder. 
 
 An elderly badly nourislied man was seen on May 30, 1888. He 
 stated that lately he had been badly fed, had occasional nausea and 
 vomiting, difficulty in passing water, which was scanty. He did not 
 complain particularly of pain. His mental condition was peculiar. 
 He seemed hardly to understand questions, and did not answer 
 coherently. His articulation was defective, owing partly to total loss 
 of teeth. He had tremor of lips and lower jaw on trying to talk. 
 His skin felt cold and clammy, though the temperature in axilla was 
 99° F. Slight occasional rigors were noticed; tongue thickly coated 
 with brown fur, rather dry; pulse feeble and irregular. On percussion 
 over hypogastrium, no evidence of distended bladder. The passage of 
 a soft catheter was tried, but it set up such spasm, and distressed the 
 patient so, that the attempt was not continued. 
 
 May 31. — He slept badly, being at times delirious; temperature 
 subnormal ; mental condition worse ; speech incoherent ; has passed 
 turbid urine in small quantities. Stimulants and diaphoretics were 
 given. 
 
 During the next two days the prominent symptoms were delirium, 
 vomiting, occasional rigors, and passage of scanty urine; temperature 
 usually subnormal, with clammy skin. He gradually became comatose, 
 and died on June 2, at 7 p.m. 
 
 Autopsy, June 4. — Abdomen only examined. Intestines of livid red 
 colour, covered in parts with flakes of greyish lymph, and distended 
 with flatus. A few ounces of turbid bi'own foetid fluid wei'e found in 
 the pelvis. Left kidney large and congested ; on section, cortex large, 
 showing luemorrhagic infarctions, and congestion in boundary area. 
 Right kidney was absent, at least so far as any definite renal structure 
 is concerned ; its ureter in its upper half was degenerated into a narrow 
 cord, which, traced upwards, was found to spring from a mass of what 
 appeared to be perirenal fat; embedded in this fat was a cyst the size 
 of a walnut. This, on section, showed a firm fibrous capsule, containing 
 laminated layers of whitish-yellow membrane, and presented the appear- 
 ance of a degenerated hydatid cyst. On cutting into the bladder, 
 which contained little fluid, a clear grey translucent membrane was 
 exposed. It was drawn out, and was found to be a collapsed cyst, tiie 
 size of an orange wlien distended, and forming a lining to the interior of
 
 UXILATERAL RENAL ATROPHY, WITH CASES. G19 
 
 the viscus. It presented the usuul characteristics of a hydatid ecto- 
 cyst, by its colour, consistence, and separable layers. No daughter-cysts 
 were seen. ^licroscopically, the laminated layers were well seen, 
 crystals of amnionio-niagnesian phosphate being abundantly studded 
 over the tield. No booklets were seen, but as a low power was chiefly 
 used, they may easily have escaped observation. 
 
 This case is, I think, remarkable in many respects. It shows how 
 hydatid disease may destroy the kidney in adult life. The shrunken 
 condition of the ureter points to its previous existence, and the 
 functional i:)ower of the kidney, which gradually atrophied. The bladder 
 was affected by way of the ureter ; then followed the urinary symptoms, 
 which ultimately resulted in ursemic poisoning, peritonitis, and death. 
 
 Hydatids in the kidney are comparatively rare. According to 
 Morris, Cobbold, and others, they affect the renal organs only once for 
 every ti^•e or six times they are met with in the liver. They usually 
 form large tumours, instead of being withered and contracted as in this 
 case. 
 
 Dr. W. Roberts states that the ureter is a frequent route by which 
 renal hydatids discharge their contents, but I'ecorded case of hydatids 
 in the bladder having this origin, are certainly rare. ■ 
 
 In the Lancet, 1876, Yol. II., p. 176, is found a case of hydatid cyst 
 in the bladder, about four inches in diameter. Others were attached 
 to the liver and peritoneum ; none in the kidneys. 
 
 The fact tliat no I'enal structui'e was left in the affected kidney, 
 shows that hydatid disease must be put among the causes of secondary 
 renal atrophy, a statement generally not noted by authors on renal 
 disease. 
 
 These three cases, though they do not exemplify rare congenital 
 atrophy of one kidney, show some of the conditions which destroy one 
 of these important organs in adult life. However infrequent such 
 instances of disease may be, the possibility of their occurrence is worthy 
 of consideration in doubtful cases. The extirpation of a congenital 
 single kidney is recorded in the Lavcet, Vol. I., 1883, p. 514. 
 
 Surgeons in contemplating operations on the kidneys, have to bear 
 this in mind. The many ingenious methods for ascertaining the 
 presence and working power of a second kidney, such a"s catheterisation 
 of the ureters, Teichmann's ureter forceps, endoscope, itc, show that 
 modern surgery takes cognisance of these defects, however difficult the 
 diagnosis may he. during life. 
 
 The physician, too, may find the problem presented to him — how to 
 ascertain whether one kidney is absent, or at least inactive. He will 
 probably attend to the history and course of the case, and frequently 
 examine the daily quantity and quality of the urine. Ralfe, Thudicum, 
 and some German authors liave shown how valuable a guide it is, to 
 ascertain the pi'oportion which the amount of urea bears to the whole 
 amount of .solids passed. Barker in the Lancet, Vol. I., 1885, p. 143, 
 records how useful this line of research was in some cases. 
 
 Thus both in a clinical and pathological aspect, these degenerations 
 of one kidney are important.* And in regard to the victims who 
 
 Fagge states that a kidney enlarged by compensating hypertrophy, seems to be 
 unduly liable to Briglit's disease.
 
 620 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 possess only one useful kidney, which is doing double work, we must 
 bear in mind that their risk is intensified if any intei'-current malady 
 afflicts them, or if they meet with any of the accidents or thousand 
 natural shocks which flesh is heir to. 
 
 THE MICROBE OF GONORRHCEA. 
 By M. V. Crivelli, M.D. Paris. 
 
 I have just published in the Australian Medical Journal, an account 
 of the experiments made, to prove the existence of a gonorrhceal 
 microbe. I was fortunate enough to be able to carry on such experi- 
 ments under the best conditions, during the years I spent as resident 
 surgeon in the Venereal Hospital of Paris. I found there every facility 
 for examining and cultivating the microbe of gonorrhceal pus, in the 
 hospital laboratory ; such experiments having been carried on according 
 to the rigorous method of M. Pasteur, and submitted to the high appro- 
 bation of my friend and collaborator. Dr. Constantin Paul, a member of 
 the Academic de Medecin de Paris. The results I arrived at were so 
 conclusive, that they encouraged me to continue my experiments in 
 Melboui'ne. 
 
 A few years ago, it was thought that gonorrhoea was a special inflam- 
 matory catarrh of the urethral mucous membrane. The scientific study 
 of microbes, however, has now caused impox'tant modifications in our 
 views of the patliology of this disease, as well as of many others. The 
 pi'incipal chai-acter of gonorrhoea being the secretion of contagious pus, 
 after a certain period of incubation, the several phases — incubation, 
 purulence, and contagion, were sure to cavise this disease to be classed 
 amongst the parasitical maladies. So well was this recognised, that the 
 first researches in that way were made at an already distant date ; and 
 if results obtained from these have not been confirmed, we can, 
 however — thanks to the knowledge gained during the last few years — 
 affirm that there exists a gonorrhceal microbe. 
 
 If, at present, the different phases of evolution and development are 
 not formally ascertained, it is not premature to state that the few 
 missing links necessary to confirm the theory deduced from the patient 
 and the searching mode introduced to science by Pasteur, for the study 
 of each particular micro-organism, will be completed at an eai'ly date. 
 
 To carry out successfully this study, it is necessaiy above everything, 
 to be in a position to try reliable experiments on the microbe itself, as 
 well as on its method of destruction. It is necessary to procure it pure 
 and fresli, and to study closely exclusively acute cases, and the discharge 
 of the first few days, during wliicli the inflammation lias not reached 
 the posterior part of the uretlu'a, and the free evolution of disease has 
 not been modified nor interfered witli by any therapeutic agents. To 
 escape many errors, it is also necessary to experiment on male cases, 
 gonorrlueal disease in women not being so favoui-able; owing to the 
 anatomical disposition of the urethra, it is impossible to prevent the
 
 THE MICROBE OF GONOUKHCEA. 621 
 
 liquid of the urethral discharge being mixed with the vulvo-vaginal 
 discharge, thus rendering the search for the microbe difficult and 
 unsatisfactory. 
 
 I have always found gonococci in all cases I have examined, here as 
 well as in Paris. Taking the precaution to make the patient urinate, 
 I used a sterilised bougie for collecting the pus, introducing it to a 
 sufficient depth in the urethra. This pus, dried on glass, was stained 
 with a weak aqueous solution of gentian violet, according to Ehrlich's 
 method. 
 
 In these preparations, set either in Canada balsam or Dammar 
 resin, I have always ascertained the presence of microbes of one kind 
 only, whose morphological aspect was always the same. The outlines 
 of these micro-organisms come out very clear. They are rarely isolated, 
 especially when examining pus from acute gonorrhcea. They are mostly 
 found in couples, nearly approaching in shape the figure 8, or in fours, or 
 even joined in countless numbers, foi-ming large rounded heaps outside 
 of the cells. They generally correspond to each other, especially when 
 grouped in twos, by flattened surfaces, and it is often possible to 
 distinguish the edges of a capsule around each diplococcus. 
 
 These microbes are found in the epithelial cells, in the pus globules, 
 and also in a free state, but it is in the pus globules that they are to be 
 met with in greater numbers. 
 
 I have always found these gonococci in all my cases, even after a 
 lengthened anti-parasitical treatment, when only a faint and hardly 
 appreciable discharge remained. I have always found them, but in 
 lesser numbers, in the pus of chronic gonori-hceal urethritis. All these 
 examinations were made of pus taken from undoubted cases of gonorr- 
 hoea, that is to say, in cases where no other cause of contagion could be 
 found. On the other hand, I have examined pus derived from urethral 
 suppurations, caused by the use of the catheter and other traumatisms 
 of the canal, and have never found gonococci. 
 
 There are thus two kinds of urethritis. In the pus of the first, 
 nothing special is discovered, the suppuration is quite an accidental 
 one; it is simple urethritis. In the pus of the second, it is always easy 
 to ascertain the presence of micrococci, having always the same aspect, 
 ■■m(\. found exdusively in it. It is the true gonorrht^al urethritis, and the 
 only one vaorthy of this name. 
 
 The direct examination of gonorrhoeal pus has thus proved that gono- 
 cocci are always to be found in it ; and although many of the authors, 
 whose works I have quoted in my paper in the Au,stralian Medical 
 Journal, take it for granted that these micrococci are the pathogenical 
 microbes of gonorrhcea, it was indispensable to isolate and inoculate 
 tiiem for the purpose of showing their character. This has been done 
 by many observers, and it has proved the above contention. 
 
 I cannot give a better illustration of the careful and scientific method 
 of investigation introduced by Pasteur, than by quoting the experiments 
 carried on both by myself and my friend and teacher, Dr. Constantin 
 Paul, when I was a resident surgeon in the Venereal Hospital at Paris :— 
 
 On the 10th December, 1883, I had a case in the hospital of a 
 young girl of 1 6 suffering from recent gonorrhcea. The discharge from 
 tiie vagina was copious, especially so from the vulvo-vaginal glands; the 
 duct of Bartholini's gland also contained pus. I took a flask, which I
 
 €22 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA, 
 
 sterilised witli a spirit lamp, and having collected a few drops of pus 
 from these glands, I immediately sealed it up. I then hastened to 
 M. Pasteur's laboratory, who had kindly received me as a pupil, and 
 in less than an hour after collecting the pus, taking eveiy usual pre- 
 caution, and using a sterilised tube, 1 introduced one drop into a small 
 flask known as Pasteur's culture flask, which contained a sterilised 
 veal broth. The flask was placed in an oven ; two days later (on the 
 12th December), the liquid in the flask was muddy, and indicated a 
 multiplication of microbes. A corresponding flask (but purposely left 
 without pus), j)laced for compai'ison, was perfectly clear. On the 14th, 
 four days after the pus being added, I examined the liquid with a 
 microscope, enlarging about 750 diameters, and ascez"tained the presence 
 of a number of microbes, some isolated and some joined like the 
 figure 8, and agitated by the Brownian or oscillating movement. I 
 tried a second culture. On the 17th, seven days after the first addition 
 of the pus, the liquid of the first culture is more thick, and shows 
 chaplets of five or six articulations, some curved, some rectilinear. 
 The microbes are much more visible than at the end of the first four 
 days. On this same day, the liquid of the second culture, which is 
 three days old, is muddy, and the comparison flask is clear. I may 
 just as well state, once for all for the sake of lirevity, that no experiment 
 has been carried on without a comparison flask. The flask of the second 
 culture, examined by the microscope, shows a few isolated microbes, 
 proving that in twenty-four hours, microbes are already developed ; but 
 it takes from five to six days to arrive at a complete development. At 
 the fourth culture, the microbes thus sown at the expiration of every 
 four days were very numerous and active. 
 
 To inoculate active microbes, I prepared a new culture, and inocu- 
 lated it on the fifth day. It was not easy to find a person who would 
 agree to the operation. I procured, however, a young girl, not a 
 virgin, but who had never had any venereal disease, and was suflering 
 from headache with continuous vomiting, and paralysis of the bladder. 
 These symptoms had tlien lasted for six months without change, and 
 were of a hysterical nature. I did not inoculate the jous in the vagina, 
 as I wished to prevent the propagation in the uterus and the Fallopian 
 tubes. I made the inoculation at the entrance of the urethra, using a 
 small drop of liquid as it is done with the cultures. Thus I had no fear 
 of the consequences of the operation, and hoped that the irritation 
 caused by this process would have the eflect of exciting the conti'ac- 
 tility of tlie bladder. The inoculation was made on the 28th February, 
 liquid of the ninth culture l^eing used. No symptoms followed during 
 five days. On the sixth, the patient complained of a burning sensation 
 at the entrance of the urethra, and slight pain when urinating. The 
 examination, which gave no results during the preceding days, now 
 showed an evident urethritis, with a discliarge of sei'o-filDrinous pus, 
 which made the linen very stifl" wlien dry. I had thus all the signs of 
 gonorrhfta at its beginning, viz. : — First, an incubation lasting five 
 days ; secondly, a painful inflainmation at the enti'ance of the canal ; 
 tliirdly, a secretion of sero-fibrinous liquid, which stiffened the linen, 
 causing it to stick to the organs ; and lastly, pain during urination. 
 This inflannnation only lasted twenty-four hours ; next day, all symptoms 
 Jiad disappeared.
 
 THE -MICROBE OF GONORUHOEA. 623 
 
 I have succeeded in obtaining pure cultures of gonococci in broth, 
 slightly alkalised; in from eight to ten days, these granulations would 
 die and fall to the bottom, but the best medium for developing gonococci, 
 is a broth of extract of meat, solidified with agar agar. This broth is 
 prepared by mixing ten parts of Liebig's extract of meat, eiglit parts of 
 pepton, and one hundred parts of water, witli a small quantity of chloride 
 of sodium and phosphate of soda ; tlie broth then being completely neutra- 
 lised by potash, agar agar is added; a neutral jelly is thus obtained, 
 which being thoroughly sterilised, is kept in an oven at a temperature 
 of between 30'' and 35^ C. Tliree or four hours after the inoculation 
 in the agar agar, it is found that this substance is not more clear and 
 liquiiied, principally on the surface, hardly or not at all deeper down. 
 Tlie gonorrhoeal micrococcus is consequently an aerobial microbe. 
 
 When examining these cultures at this point, I have constantly 
 found mici^ococci presenting a very peculiar appearance, which I have 
 never seen described in any treatise on gonorrhcea. Small spherical 
 granulations attached to each other, are to be seen ; they form small 
 chains, in most cases rather short, which join together in the shape of 
 a star. The ramification of these stars, seem to be englobed in a hyalin 
 substance. 
 
 If one of these small chains be examined singly, it is found that the 
 granulations composing it, are not all of the same dimensions; here and 
 there one is seen rather larger, well coloured, and with well defined 
 outlines ; the others, whose contours are not so apparent, seem to 
 be smaller, this appearance is due to the colouring substance having 
 only reached their centre, these micrococci of the first hours of culture, 
 being indeed very difficult to stain. 
 
 If the same preparations are examined twenty-four hours after, one 
 may still sometimes recognise the special disposition, which I have just 
 described ; but in most cases, the ordinary micrococci and diplococci 
 only are to be found, such as they are described everywhere. 
 
 To me, the micrococcus of gonorrluieal pus shows, when cultivated, 
 two very different aspects During the first few hours, the micrococci 
 have a peculiar arrangement — they have a starry form easily seen, 
 especially from tlie third to the sixth hour. The following day this 
 has almost entirely disappeared, nothing is then found but spherical 
 granulations, isolated or joined in groups of from twos to fours, and 
 joined to each other by flat surfaces. 
 
 All the inoculations I have tried in Paris and in Melboui'ne with the 
 cultivated micrococcus, either on the intact conjunctiva, or on a small 
 wound produced on the conjunctiva, or on the urethral mucous membrane 
 of dogs and rabbits, and guinea pigs, in Paris, and in Melbourne, gave 
 an absolutely negative result. These inoculations however, notwith- 
 standing this result, still are not void of interest. They show that 
 the gonorrhceal microbe loses its virulent qualities by culture, or by 
 being transported to grounds which seem to l^e unfavourable to its 
 propagation. 
 
 The changes that occur in the cultivated microbe in the flask have a 
 striking analogy with those which take place in the urethra {althouyh 
 taking in the culture a shorter time), where we see the pus getting, in 
 time, less virulent, so much so, that discharge of long standing, where 
 the gonococcus certainly still exists, arc found to be non-contagious.
 
 624 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 Since this new interpretation of the disease, as being of parasitical 
 origin, is being given, it would hardly be pardonable in a medical man 
 to neglect prescribing a rational treatment, which is based on a patho- 
 genical conception of gonorrhoea. We know at present that gonorrhceal 
 pus is virulent and contains a microbe, and we know how and where it 
 is propagated. Notwithstanding the failures arrived at by a few 
 authors with the antiseptic method, which seemed useless in a few 
 cases, I am perfectly convinced that this method is the proper one to 
 be employed when treating venereal diseases, and that all researches 
 made in that rational direction will be found to be rich in results. It 
 should always be used in the first stages of acute gonorrhcea, having 
 generally an abortive effect on the disease, which is a sufficient reason 
 for it being preferred to the ordinary treatment by emollient and 
 inteAal medicines, generally prescribed in that first stage.
 
 SECTION OF OBSTETRICS AND 
 GYN^COLOG-Y. 
 
 PRESIDENT'S ADDRESS. 
 By Ferdinand C. Batciielok, M.D. (Durham) M.R.C.S.E. 
 
 Gentlemen, — My first duty is to thank you most sincerely for the 
 high honour you have conferred upon me by electing me your president 
 for this important section of your Congress, devoted as it is to a branch 
 of our profession, in which, during the last few years, progress has been 
 more rapid and startling than in any other in the domain of medicine 
 or surgery, and I cannot but feel that the post has devolved upon me 
 more from a graceful act of courtesy and good feeling on your part 
 towards a neighbouring colony and sister university, than from any 
 individual merit on mine. 
 
 With regard to the choice of a subject for this address, my first 
 difficulty was to make a selection from so vast a field, and then to 
 compress the topics to which I am desirous of drawing your attention 
 within reasonable limits. 
 
 ^lidwifery and Gynaecology, individually, offer such innnense fields 
 of observation, that there has arisen during the present day a 
 tendency to subdivide these subjects into distinct branches, a tendency 
 which has already resulted, as we see in England and America, in the 
 founding of distinct societies and journals, obstetric and gynaecological, 
 all of which have plentiful materials for observation and discussion. 
 
 To-day, I pi'opose to address you on subjects purely gynsecological, and 
 my reason for doing so is this, namely, that in midwifery I know that 
 there must be very many here whose opportunities for acquiring 
 knowledge, whose years of observation and field of practice are im- 
 measurably greater than anything I can offer for comparison. With 
 regard to gynaecology, however, I have somewhat less diffidence ; all 
 real, solid and fixed knowledge has been of such comparatively recent 
 growth, that within the compass of a few years of observation, it is 
 relatiAely easy to marshal some of the principal events, and to note the 
 striking changes and advances that have occurred in our reading of 
 symptoms and methods of treatment. During this period of probably 
 but little over a scoi-e of years, I would venture to make a .statement 
 which would be rash indeed to propound in any other branch of our 
 
 Is
 
 626 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 profession, viz., the whole literature of gynaecology, prior to this period, 
 might be obliterated and our loss would be comparatively small, so vast 
 and momentous have been the changes that have occurred within this 
 time. Hence, although far be it from me for one moment to pretend to 
 assume an authoritative tone, yet I feel it has been fairly within my 
 power to have kept myself abreast of the current opinions of the 
 day, and may therefore presume to review our progress, note some of 
 our errors, bring prominently before you certain innovations in our 
 practice which have hardly yet received the impress of authority, and 
 point out subjects on which we lack information with a freedom I should 
 be loth to assume with the sister-subject, midwifery. 
 
 Now, gentlemen, although from our attendance here to-day I judge 
 we all take some interest in the special work of this section, I well know 
 that the conditions of colonial practice are such that there are com- 
 paratively few amongst us who are able to devote ourselves wholly to 
 one special branch, and hence I feel that the remarks I make must be 
 addressed to a body of general practitioners, and if I touch upon what 
 may appear to some, well-worn or too elementary topics, I trust I may 
 on this plea be forgiven. 
 
 Before commencing the subject proper whicli I propose to treat, it will 
 be well to first call attention to the immense advance of late years in our 
 method of examination as compared with those in vogue twenty years 
 ago. Wliat in those days was considered by the bulk of the profession 
 a thorough investigation of the uterine organs consisted probably in a 
 mere digital examination, the patient at tlie time being attired in her 
 ordinary clothing, the condition of the cervix and os uteri being noted 
 almost solely, and the passage of the sound and speculum was probably 
 looked upon as exhausting all the resources of our art. Very few men 
 ever practiced the bi-manual method of examination systematically ; the 
 condition of the ovaries, pelvic peritoneum, or broad ligament were 
 rarely noted, and the existence of a pathological condition of the 
 Fallopian tube was practically altogether overlooked. The ease or 
 difficulty with which the uterine sound passed, its position and length 
 were considered as most important guides, and the appearance of tlie 
 cervix, as viewed through a speculum, probably formed the basis of tlie 
 diagnosis. What wonder then that deviations or presumed deviations 
 of the uterine axis formed such an important element in the pathology 
 of those days, and that from the appearance of the cervix uteri, as 
 viewed through the speculum, false conclusions were drawn leading to 
 treatment radically bad. Ulcerations, erosions and indurations of the 
 cervix uteri hence acquired such undue prominence, and were treated as 
 pathological entities instead of merely indicating, as is now generally 
 recognised, grounds for further investigations.
 
 PRESIDENTS ADDRESS^SECTION OF OHSTETKICS AND GVN/ECOLOGY. G27 
 
 But if we are to place any reliance in the statements of patients, in 
 ■\vliose case the seemingly all satisfying diagnosis of ulceration would 
 appear to have been made, I should judge there are a goodly number 
 of our profession hardly yet emancipated from the teachings of these 
 relics of the dark ;iges of gynjvcology ; nor so long as men are content to 
 found their diagnosis and formulate their treatment on the I'esults of 
 an examination conducted l)y sound and sj)eculum alone, are they likely 
 to discover their erroi-. 
 
 And although I fear it may seem like slaying the slain, I would say 
 a few more words upon this nmch mis-applied term — ulceration, the 
 popular bug-bear of a large portion of our patients. The conditions of 
 the cervix, with which we are all so familiar, has been incontestably 
 pi-OA'ed to be no true ulceration whatever. A mere change in the 
 character of the surface epithelium, a condition in itself, probably 
 totally incapable of evoking any symptom whatever. How and why is 
 it, that even in this day such an error in observation is permitted by so 
 many to still hold sway. Surely if the term is mis-applied, its use 
 should be abandoned, for not only does it lead the unfortunate woman 
 to fear she is sutiering from a more serious condition than there is any 
 justification for, but it has this worse tendency, of making a too 
 prominent impression on the mind of the practitioner himself, and 
 leading him to overlook what are really more serious conditions. 
 
 It is in consequence of a loose, superficial and thoughtless phraseology, 
 such as this, and lines of treatment or mal-treatment adapted thereto, 
 that a not altogether inideserved oj^probrium has in years past, attached 
 itself to gynaecology and gyn;ecologists. Without a sound pathology to 
 guide us, our practice has been too often conducted atterlyin the dark ; 
 eri'ors and fads of the most fantastic and preposterous description have 
 been allowed to hold sway, and systems of treatment carried out not 
 from a physiological and pathological basis, Init merely in accordance 
 witli the pai'ticular teacher or author with whose views the practitioner 
 has happened to be imbued. Thus, many an honest sceptic has ridiculed 
 the whole subject of gynaecology, looking upon the symptoms complained 
 of as merely whimsical or hysterical, and those who treated them as 
 only a shade removed fi'om the quack. 
 
 Hence, too great scope has been left for the unscrupulous practitioner, 
 who has not been slow to avail himself df his opportunity ; his results 
 equalled, or at any rate, were no worse than those of his moi'e 
 conscientious brethren, and by trading upon his patient's fears, he reaps 
 « rich harvest. Gynaecology in the past has been so over- ridden by 
 these pests, that for a time it began to acquire an unsa\ oury aspect, 
 even to the profession itself, and it almost seemed as though the 
 disorders of the generative organs in the female, were to ])e relegated to 
 
 Is 2
 
 628 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 a similar class of individuals to those who dri^e a lucratiAe trade by 
 means of tilthy advertisements, referring to diseases of tlie opposite sex. 
 And although quackery in gynaecology blazons itself less openly, I fear 
 it is an evil just as deeply rooted. The advertising quack is i*ecognised, 
 shunned, and avoided by his professional brethren, but the charlatan 
 who treats a young single girl for what he designates an ulceration of 
 the womb, throwing out vague hints that the condition may eventuate 
 in cancer, administers chloroform on the pretext of pei'forming some 
 imaginary operation for its cure, but in reality, to extort an exorbitant 
 fee ; or he who for some slight irregidarity of the cei'vical tissue, proceeds 
 to perform what he ostentatiously designates an Emmet's operation, 
 solely to impress his jDatient with the idea that she is suffering from 
 some terrible disease, the cure of which permits of his levying black- 
 mail. This type of sGOundrel is, I fear, by no means extinct, and he is 
 more dangerous to the public, being more difficult to convict, and is even 
 a greater disgrace to our 'profession than the self-assertive advertising- 
 quack. 
 
 From causes such as these, our branch has undoubtedly laboured 
 under a certain odium, Avliich at times honorable men have felt it hard 
 to struggle against. Most of us have proljably had cases which have 
 fallen into the hands of these Philistines, who often succeed in bleeding 
 their patient's purses proportionately to the discredit they can throw 
 on the previous diagnosis ; but I sincerely believe and trust that their 
 day is fast on the wane, and with an advancing knowledge of the 
 pathological changes in the uterine oi'gans, the fads and fashions which 
 seem to have ruled our practice in the past, must be swept away, and 
 diagnosis and treatment be as exact and scientific as in any other branch 
 of medicine. 
 
 I say, tlaerefore, that the first result of an increase in our pathological 
 knowledge has been an improvement in our method of examination, and 
 by this I do not mean that any startling addition has been made to our 
 stock of instruments, or new means de"\'ised whereby the generative 
 organs can be explored, but the improvement has been rather in doing 
 away with our instruments, and trusting more to our reasoning and to 
 the education of our special senses. Who, for instance, would diagnose 
 an oophoritis, a pelvic peritonitis, or a salpingitis from an examination 
 with the sound or speculum 1 No ! it is the finger, and the educated 
 finger, which gives us our information; and if I were asked what has. 
 been the greatest advance in I'ocent years in the practice of gyntecology, 
 I should say, undoubtedly, that it is tlie systematic adoption of the 
 l)i-manual method of examination. But I hear some of you say, " Oh ! 
 that is as old as the hills;" but I would reply, that the systematic 
 adoption of this metliod is not "as old as the hills," and more than
 
 president's address — SECTION OP OBSTETRICS AND GYNAECOLOGY. 629 
 
 that, I say without hesitation, tliat thoi'ough and systematic bi-naanual 
 examination is only carried out by a very small percentage of practi- 
 tioners even in the present day, and until it is adopted generally, until 
 the finger is efficiently educated, and its teachings properly appreciated, 
 the conmionest causes of diseases in the female generative organs will be 
 overlooked, and being overlooked, the majority of cases mis-treated. 
 
 Possibly some of you may think I have a hobby, and am riding it to 
 death, but when I see, as doubtless many of you see, cases of ooj)horitis, 
 and pelvic peritonitis, and salpingitis, which have been treated for 
 months, and sometimes years, by pessaries, applications to the cervix, 
 intra-uterine stems, and what not besides, and the true cause of the 
 patient's sufferings not even suspected; and when we remember that 
 until six or seven years ago, the most eminent leaders in gynaecology 
 tlu-ougliout the world had apparently altogether overlooked a disease, 
 viz., salpingitis and its complications, which we now recognise almost 
 daily by this method of examination alone, I feel I need make no 
 apology for dwelling thus at length on the absolute necessity there 
 exists for every one wlio attempts any gynaecological work whatever, 
 to perfect himself in tliis niost important method of investigation. 
 
 And now, leaving what I may term introductory matters, which, 
 however, seemed to lead up to my subject to day, and could not from 
 their importance be dismissed witli a passing word, I heg to bring 
 before your consideration some recent advances in our diagnosis of 
 iliseases of the uterine organs, and in our methods of treatment — 
 methods which seem to me in a measure to revolutionise the practice of 
 gynsecology, and to demand a re-consideration, alteration, and re- 
 arrangement of our popular text books. 
 
 If we refer to writings and articles published on subjects gynaeco- 
 logical, we find tliat during the last three or four years, there has been 
 a somewhat remarkaljle change in the class of cases published in our 
 journals, or discussed at the meetings of our societies ; until a very 
 recent date, uterine displacements, cervical lacerations and their repair, 
 menori'liagia, dysmenorrhtea, ha?matic and inflammatory effusions, were 
 the topics of discussion. Search where you will, until even as late as 
 the meeting of tlie International Medical Congress in London, in 
 1881, and you will fail to find the report of a single operation for 
 salpingitis; and althougli Battey had I'eported cases of removal of the 
 ovaries as early as 1872, it was not until fully ten years after this that 
 the frequency of morbid changes in the tubes and OA'aries (apart from 
 gross tmnour formations) acquired any practical importance. During 
 the last three or four years, however, you will find that reports on cases 
 of salpingitis, pyo-salpinx, hydro-salpinx, oophoritis, and peri-oophoritis, 
 <:onstitute a considerable bulk of gyiuecological literatux^e, and it is to
 
 630 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 these subjects that I wish to-day specially to de^-ote some attention,, 
 believing as I firmly do, that a new light has been shed on our practice^ 
 vastly surpassing any other recent innovation, and before which such 
 minor improvements as operation on the round ligament, or repair of 
 lacerated cervices, must pale indeed, so far reaching are the changes in 
 our views, so pregnant for practical application, so great the proportion 
 of cases brought from the region of the vague and indefinite, to within 
 the range of exact and certain diagnosis, so large a proportion of 
 suffering women may thereby be relieved from li\-es of misery. 
 
 To bi'ing this subject at all systematically before you, I must first 
 refer to a very remarkable essay, published by MM. Bernutz and Goupil 
 about 30 years ago, and translated by Dr. INIeadows for the Sydenham 
 Society, and published by them in the year 1866. Here are collected 
 a series of 99 cases of pelvic peritonitis, several of which were under 
 the immediate observation of M. Bernutz throughout their course, and 
 he reports on them fully, together with post-mortem appearances. The 
 cases presented these general features : — The Fallopian tube was in 
 every case the seat of morbid change, generally irregularly dilated or 
 pouched, containing purulent or caseating material, its extremity 
 adhei'ent to the ovary or surrounding pelvic peritoneum, and a general 
 matting together of the pehic viscera. 
 
 These observations, although at the time attracting considerable 
 attention and discussion, and subsequently occasionally referred to, 
 never apparently acquired any practical importance until within the 
 last ten years ; and it is a remarkable instance of the recognition of a 
 morbid condition which seemed for a number of years to be passed 
 over and forgotten, owing to the fact that no practical use was made of 
 the discovery at the time. It was not until the recent advances in 
 abdominal surgery — not until the peritoneal cavity had been demonstrated 
 to be so tolei"ant of manipulation, that these morbid conditions were 
 again brought to light, and their full importance as a factor in the 
 production of disease, realised. And, if to M. Bernutz is ascribed the 
 credit of first recognising tlie importance and freqviency of changes in 
 the Fallopian tube and sui'rounding peritoneum, to Lawson Tait must, 
 undoubtedly, be awarded due fame for first suggesting and putting into 
 practice methods of treatment for the relief of these conditions. Lawson 
 Tait it was wljo first published reports of the removal of diseased 
 appendages ; (l('nu)nsti'ated tlieir importance in the production of 
 pelvic peritonitis ; Ijoldly, and in tlie face of much factious and jealous 
 opposition, pressed upon the pi'ofession tlie frequency of morbid changes, 
 in the tubes, tlie method of their recognition, and the comparati^■e safety 
 of operative measures in those cases which demanded i-elief, otherwise 
 unobtainable. Reference to our ordinaiy text books for information
 
 president's address — SECTION OF OBSTETRICS AND GYNiECOLOGY. 631 
 
 concerning these diseases will give but little practical information ; a 
 chapter may be found in the more recent works de^•oted to morbid 
 changes in the Fallopian tubes, but any description adequate to the 
 importance of the subject is altogether wanting. 
 
 The accounts of chronic ovarian inflammations are, as a rule, brief, 
 fragmentary, and unsatisfactory ; and there are hardly two authors who 
 hold the same views on the subject of pelvic peritonitis and pelvic 
 cellulitis. The points I shall endeavour to prove to you to-day are 
 these : — 
 
 First. — That the most common causes of severe pain and chronic 
 suffering, in connection with the diseases peculiar to women, 
 are morbid conditions of the ovaries. Fallopian tubes, and 
 surrounding pelvic peritoneum. 
 
 Second. — That these changes have, relatively to their importance, 
 attracted but little attention; while diseases of the Fallopian 
 tubes have practically been altogether overlooked by the 
 whole profession. 
 
 Third. — That great confusion still exists as to the relative 
 frequency of inflammation of the pelvic, peritoneal and pelvic 
 cellular tissues, some even contending that they are clinically 
 inseparable ; whereas, pelvic peritonitis is a separate and 
 distinct disease, very frequently met with, and mostly due to 
 an extention of inflammation along the tul^e. Pelvic cellulitis 
 is an excessively rare disease, and almost unknown, except as 
 an accompaniment of acute general septicaemia. 
 
 Now, to consider my first proposition, that changes in the uterine 
 appendages are the most common cause of severe pain and chronic 
 suffering among the diseases of women. Those who have recognised 
 these conditions, and possibly in severe cases operated for their 
 relief, and observed the brilliant results following removal of diseased 
 appendages, will hardly think this proposition requires any proof 
 whatever ; others, whose attention has not been particulai-ly drawn to 
 the subject, will at once ask, how is it, if these affections have the 
 frequency, severity, and importance here ascribed to them, they should 
 be dismissed from our popular text-books with a brief consideration of 
 some fifteen or twenty pages? I would answer, that although 
 oophoritis, pehic peritonitis, and even salpingitis, have separately 
 received some Ijrief notice, the combination of these changes, as forming 
 a distinct type of disease clinically, has only been of such recent 
 recognition, that they ha\e not yet impressed the minds of gynaecolog- 
 ical writers with their importance. The whole of this subject will 
 require a thorough revision ; but with tlie unsettled and conflicting
 
 632 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 views still existing on some points, it is an extremely difficult matter to 
 dogmatically lay down any comprehensive and accurate scheme. 
 
 As regards diseases of the ovaries of the less gross type, such as 
 cystic and cirrhotic changes, I must say a few words, although it is not 
 with purely ovarian conditions that I wish to deal to day. Although 
 the ovary has long been recognised as the seat of severe pain, 
 pi'oducing pronounced and well-marked symptoms, we are still almost 
 entirely in the dark as to the pathological conditions on which these 
 symptoms depend. The late Professor Schrceder recently remarked, 
 that "the subject of ovarian pathology, apart from tumour formation, 
 is practically a blank." 
 
 Dr. Henry Coe, of New York, in an article in the recently published 
 American System of Gyncacology says, writing of the Anatomy of the 
 Ovary, " The boundary between the normal and pathological is not 
 a fixed one, and in spite of numerous careful studies of the subject, 
 there still remain many moot points. The microscopist who succeeds 
 in determining to what extent an ovary may contain cysts, without 
 being cystic, and how much fibrous tissue may exist in its stroma before 
 the diagnosis of cirrhosis is justifiable, will deserve no little praise." 
 And when the microscopist has decided as to what is a normal, and 
 what a diseased ovary, the clinician still finds a great gap to fill up. 
 namely, to decide why an ovary in one subject may be cystic, cirrhosed, 
 or atrophied, producing little or no discomfort ; while in another, an 
 even small amount of cystic change, fibrous deposit, moderate binding 
 down, or slight prolapse, will induce most severe and constant 
 suffering. 
 
 Here, we still grope in utter darkness. The mere fact of an ovary 
 containing a number of small cysts, or its stroma being abnormally 
 dense, does not at all preclude the possibility of its still retaining its 
 function sufficiently to produce healthy ova, capable of further full 
 development. The influence of the mind in modifying affection of the 
 generative organs is too well known to all to require more than a 
 passing reference on my part. No condition of physical suffering can 
 be more readily developed by injudicious attention. Given a neurotic 
 subject, some slight or passing derangement of the generative organs, 
 and an inquisitive solicitude on the part of tlie medical attendant, with 
 a pencliaiit for ovarian troubles, and you have the surest makings of an 
 inveterate form of ovarian invalidism. Pain, ^er se, is not a particularly 
 reliable symptom, nor one which we are apt to overrate in an hysterical 
 subject, in whatever part of the body occurring. Yet in the great 
 majority of affections of the female generative organs, that peculiar 
 condition of the nervous system whicli we designate hysteria, is more 
 or less a constant accompaniment.
 
 president's address — SECTION OF OBSTETIHCS AND GYNAECOLOGY. 633 
 
 Paget, in his lecture on the Nervous Mimicry of Disease, draws 
 attention to many points that have an application in the condition now 
 under consideration. In most cases of nervous mimicry, the patient 
 first receives her mental impression from seeing or hearing of some 
 foi'm of disease which her acquired ailment simulates more or less 
 closely ; and in these days when it would appear as if the various 
 affections of the female organs seem to be a not unfrequent and 
 engrossing topic of conversation at ladies' afternoon teas ; when 
 Mrs. A.'s displacement, or Mrs. B.'s ulceration is freely and fully 
 discussed ; wlien, as I liave reason to know, young girls yet in their 
 teens are present at conversations of this kind, I say it is not wonderful 
 tliat ovarian aches and jxrins are becoming alarmingly common, and it 
 behoves us as a profession, to be sharply alive to the fact that such a 
 condition of affairs may exist as a nervous mimicry of disease, even in 
 the ovary. 
 
 I take it as not a little remarkable, tliat of late years hysterical 
 knee-joints and hysterical spines, at one time fairly common, are now 
 excessively I'are, and wlien met with, as a rule it is in a country 
 patient from an out of the way district ; and I have seen more than 
 one instance when such a patient, having been removed to town, and 
 become cured of her joint trouble, has subsequently found out that she 
 has made a mistake, and that it was her uterine organs that were at fault. 
 
 Now-a-days, I believe our patients not rarely take on a nervous 
 mimicry of disease in the form of an ovarian pain, and when we are 
 dealing with an evidently neurotic subject, we must remember Paget's 
 dictum — "that our diagnosis must be founded, not on our patient's 
 sensation, but on our own." The fact of any ovary being the site of 
 some pain, somewhat abnormally sensitive, slightly altered in size or 
 consistence, or prolapsed, does not justify its removal ; and I hold that 
 tJie unnecessary removal of the ovaries is mo7-ally quite as culpable an 
 act as the amjnUation of a hysterical knee-joint. Althougli, in my own 
 mind, T am satisfied that severe pain and constant suffering is occasion- 
 ally met witli in connection with cystic and cirrhotic changes in the 
 ovaries, apparently uncomplicated by other conditions, I am convinced 
 that these cases are comparatively rare ; and there can, I fear, be little 
 doubt, that a number of oophorectomies liave been performed without 
 sutricient justification. Once the abdominal cavity is opened, it requires 
 a considerable amount of moral courage to stay one's liands, and few are 
 the ovaries which to tlie eye of the entliusiastic oophorectomist will not 
 present some flaw to justify their removal — it is a case of the horse-dealer 
 and the nag without a blemish. 
 
 With regard, however, to tubal disease, and alterations extending 
 therefrom to the neighljouring pelvic peritoneum, the case is far
 
 634 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 diffei'ent. The changes effected by disease are gross and characteristic. 
 Anyone who has watched even one well-marked case of this type, or 
 viewed the extensive alteration in the Fallopian tube and pelvic 
 peritoneum, noted the misery and ill-health induced thereby, and 
 the brilliant results following removal of the diseased organs, cannot 
 fail to recognise in such a condition the cause of severe local and 
 constitutional symptoms, beyond all possibility of doubt. Permit me 
 to read you the report of one such case which I specially select in 
 consequence of the severity of the symptoms, the characteristic pelvic 
 changes, and the striking results of treatment : — 
 
 E. P., fet. 27, married, seven children, admitted to Dunedin Hospital 
 August 8th, 1888. Confined in February last, labour difficult. During 
 pregnancy had suffered from pelvic and sacral pains; after confinement, 
 these had become more constant and severe. General health much 
 affected, losing flesh fast. Menstruation frequent, irregular, and 
 profuse ; copious leucorrhceal discharge. The patient is dull and 
 listless, and in a semi-typhoid state. Answers in a whisper ; gums and 
 tongue covered with sordes, breath offensive. In consequence of the 
 apathy and debilitated state of this patient, it was exceedingly difficult 
 to obtain any definite history of her previous condition, and it wa& 
 at first thought that she was suffering from typhoid or some cerebral 
 trouble, and was consequently placed under the care of one of the 
 physicians. As however the history of severe and constant pehic 
 pain, following confinement, was elicited, I was asked to make an 
 examination of the pehic organs. The abdomen was somewhat 
 distended, and excessively tender to the slightest pressure over the 
 pelvic region. 
 
 Vaginal examination. — Vagina patvilous ; cervix somewhat fibrous ; 
 OS points backward, and fissured. Body of uterus anti-flexed, and 
 somewhat enlarged. Bi-manually. — In the right lateral vaginal fornix 
 a hard, irregular infiltration was felt, spreading from the uterus 
 towards the posterior and lateral wall of the pelvis. In the left lateral 
 fornix a similar infiltration, but more posteriorly, and not so well defined. 
 Vaginal examination caused considerable pain, which was specially 
 marked in the region of the irregular infiltrations in the lateral fornices. 
 The patient was so excessively ill, and complained of such constant 
 and severe headache, that I was inclined to think at first there must 
 be some other trouble in addition to the condition of pelvic organs. 
 
 Dr. Lindo Ferguson kindly examined the eyes, as cerebral troul)le 
 was suspected. Motion of eyes normal ; pupils semi-dilated, sluggish ; 
 Aeins of fundus of both eyes full and slightly tortuous ; nasal edge of 
 disc rather ill-defined ; both discs redder and more irritable than normal. 
 It was determined to keep the patient under observation for some days.
 
 President's address — section op obstetrics and GYNi?:coLOGY. 635 
 
 The temperature averaged about 99-5°; pulse small, weak, 110 to 120. 
 No appetite ; no thirst. Pelvic pains and constant headache. Bowels 
 only acted by strong purgatives. No further symptoms developing, 
 and the patient's condition gradually deteriorating, on August 23, the 
 abdomen was opened in the usual manner. JNIy first impression on 
 passing the hand into the pelvis was, that it was almost blocked up by 
 hard irregular masses of exudation. The fundus uteri being identified, 
 the left tube was traced outward from it for a short distance, it was 
 then found to bend acutely backward and inward ; the portion of tube 
 beyond this flexion was considerably dilated, tliickened and irregularly 
 pouched, it was traced backward and downward into the pelvis, and its 
 extremity was found intimately adherent to a large ovary — ovary and 
 extremity of tube being matted to pelvic wall by fibrinous adhesions. 
 Ovary and tubes were freed, ligatured, and removed. On the right side, 
 the tube was similarly enlarged, pouched and dilated ; the tissues were 
 firmly matted together, rendering their identification and remo^'al 
 diflicult. The posterior surface of the dilated Fallopian tube had 
 formed firm adhesions to the ascending colon. The extremity of the 
 tube was adherent to the ovary. The ovary itself was small, lying- 
 deep in the pelvis, below and anterior to the extremity of the tube. 
 Considerable force was required to separate adhesions. Between the 
 posterior portion of the dilated Fallopian tube and ascending colon, the 
 adhesions were firm and well-organised, the walls of the bowels itself 
 being much thickened for a surface about the diameter of a shilling. 
 It was feared the tube might communicate with the bowel, and 
 consequently, was opened freely along its whole length. The lining- 
 membrane was thickened and rugose, and is some places broken down ; 
 semi-purulent and caseating material blocked the tube, but in no place 
 flid it communicate with the bowel ; it was carefully dissected off" 
 the colon, and removed. Hai'morrhage was free during separation of 
 adhesions, but was arrested spontaneously. 
 
 The day following tlie operation, the patient \olunteered the state- 
 ment that her head was clearer, and that she was freer from pain in 
 the abdomen than she had been for some months. )She made a ra2:)id 
 and uninterrupted recovery, and within eight weeks of the date of 
 operation, had taken a situation as a general ser\'ant, and was a1)le to 
 perforin all her duties to the satisfaction of her mistress. 
 
 This was a most striking case. Here was a poor woman who had 
 been confined to her bed for weeks, suffering constant pelvic and reflex 
 pains — so ill that her condition was, on admission, looked upon as due 
 to typhoid or meningitis — -and yet we see her restored to perfect health 
 within two months after the removal of the diseased uterine appendages. 
 This is but one out of a series of between tliirty and forty somewhat
 
 636 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 similar, though not so severe, cases that have come under my observation 
 dui'ing the last two years, in a small town, with a population of less 
 than 50,000 inhabitants. 
 
 Now let me refer you to text books of the clay, to seek an explanation 
 of those cases of severe and chronic suffering, which we all not rarely 
 meet with in our daily practice. Take Hart and Barbour's work, as 
 containing the best epitome of the most generally accepted views on 
 gynfecology. Clironic cervical catarrh, cervical erosion, or what in 
 the past has been wrongly termed ulceration, is described as "a 
 very common condition, and one of the most troublesome which 
 the practitioner has to treat." The symptoms given are four — 
 leucorrho?a, pain in the back and loins, irregular menstruation, 
 sterility. Pain in the back and loins, they say, are present in 
 all uterine diseases, and I say in probably a good many other 
 diseases ; so there is nothing distinct about this symptom. Irregular 
 menstruation is said to be due to an extension of the inflam- 
 matory change, to the endometrium, in fact, due to something else, 
 xiot to the cervical catarrh. Sterility is certainly not peculiar to 
 cervical catarrh. In fact, the only symptom which, on analysis, is in 
 any way pathognomonic of the condition, is the peculiar albuminous 
 discharge. This is exactly what we find in practice ; beyond a slight 
 occasional backache, a little general debility, probably as much a cause 
 as a sequence, and some slight albuminous discharge, we do not find 
 that tliis condition will produce symptoms by any means marked or 
 constant, and therefore, we may exclude it from our list of causes of 
 severer symptoms. 
 
 Then to refer briefly to various displacements : — 
 
 Ante-flexion. — The symptoms are, by the same authorities, dys- 
 menori'hwa, sterility, and in addition, sometimes leucorrhcea, and 
 menorrhagia. Nothing here to account for severe pain. 
 
 Then take retroflexion and version from the same authors. The 
 symptoms given ai-e — weakness in the back, painful deftecation, and 
 si/tiipto)tis of chronic pelvic peritonitis. Yes, it is in this last symptom, 
 you have the key to the true cause of tlie sufferings in retroflexion 
 and version, viz., the chronic pelvic peritonitis. Reduce the simply 
 displaced uterus, and the symptoms such as they be, disa2D2oear with 
 it ; but if the uterus is bound down by adhesions, the result of 
 chronic pelvic peritonitis, and if with the displaced and bound-down 
 uterus the ovary sliould also happen to be engaged, pessaries or any 
 other treatment of the kind will, I fear, avail little. 
 
 Lacerations, Hart and Barbour say, present no symtoms, but other 
 conditions may arise secondarily ; so we will dismiss lacerations. 
 Stenosis of the cervix — dysmenorrhea, sterility.
 
 president's address — SECTIOX OF OBSTETRICS AND GYN^'.COLOGY. G37 
 
 Endometritis. — Here Hart and Barbour gi\ e a goodly list of wliat 
 they call leading symptoms, nine in number. I will not detain you to 
 enumerate them, but will merely mention that so excellent an authority 
 as Dr. Matthews Duncan considers it an extremely rare disease, and he 
 tells us, in the last edition of his work on " Diseases of Women," tJiat 
 Dr. Godson of St. Bartholomew's Hospital failed to observe a single case 
 in the out-patient department of that hospital during a whole winter 
 season, although Dr. M. Duncan was evidently wanting one badly for 
 clinical observation. 
 
 Finally, after running through tlie list of the more conunon ati'ections, 
 we come to chronic metritis, and this disease Hart ;ind Barbour descrilie 
 as the most important of all diseases of women ; the sufferings of the 
 patients in cases of displacement of the uterus, they say, is due, not so 
 much directly to the displacement, as to the chronic inflammation 
 secondary to it. Well, I come across cases of clu'onic tliickenings and 
 enlargements of the uterine tissues fairly frequently, and in my experience 
 this condition lias been accompanied by a rather remarkable immunity 
 from any symptom whatever; but still, in a humble practitioner like my- 
 self, it might appear somewhat presumptuous to set up my own opinion in 
 opposition to that of Messrs. Hart and Barbour, were it not for the fact 
 that, after looking through Dr. M. Duncan's third edition of " Diseases 
 of Women," published in 1886, I fail to find any reference to chronic 
 metritis, and I can hardly imagine this eminent gynaecologist attaches 
 anything like the importance Messrs. Hart and Barbour do to this 
 condition, when, not only is there not a single chapter in the wliole 
 work devoted to it, but, as far as I can find, not even a passing reference. 
 Consequently, as a result of a somewhat cursory review of this well-known 
 work, if we exclude pelvic peritonitis and pelvic cellulitis, we are left in 
 the awkward predicament of finding no descri1:)ed diseases whatever that 
 shall account for the vast majority of the cases of severe and constant 
 suffering we meet with in actual practice. 
 
 Now, of pelvic cellulitis and pelvic peritonitis I shall speak later on, 
 and I think it is here that we shall find an explanation of our difficulty, 
 and so far, I tliink I may claim that amongst the diseases I have 
 considei'ed, there is nothing to account for the severer forms of 
 suffering. 
 
 And now to the consideration of my second point, viz., that diseases 
 of the uterine appendages have attracted but little attention relatively 
 to their importance, and that diseases of the Fallopian tube have 
 practically been altogether over-looked. 
 
 Until Lawson Tait published the remarkable results of his operations 
 for the removal of diseased uterine appendages, the general gyniecological 
 world would seem to have altogether failed to discover disease in these
 
 638 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 organs, if unaccompanied by gi'oss tumoui' ; while now, since our 
 attention lias been directed to the matter, we are every day becoming 
 more familiar with the morbid alterations in them produced by 
 inflammatory affections, changes often so ready of recognition that even 
 students with a very moderate amount of practice in examination, 
 rarely fail to identify them. When we remember that these changes 
 have been systematically passed over by men who must have been in 
 the habit of meeting them daily, I say it does more credit to our 
 profession for its fidelity to creed, than to its originality of observation ; 
 and I regret I must also add, that it would seem as if certain high 
 authorities, apparently disgusted with their oversight in the past, would 
 now bolster up their present false position, l^y ignoring or attempting 
 to ridicule the importance of this great advance. 
 
 The day for bowing to authorities is fast on the wane ; errors of 
 omission, such as tliese, shake men's faith in such leaders and make 
 them self-reliant, trusting more to their own experience and observation. 
 "Why, only three years ago, when I visited London, the subject of tubal 
 disease was just commencing to attract some little attention ; the 
 importance of the changes and pathological condition were entirely 
 mis-apprehended. Pyo-salpinx was then looked upon as the sole disease : 
 and the only conditions demanding operation were those where the tube 
 was distended with pus, giving rise to the sausage-like tumours described 
 by Tait. In fact, I remember one well-known teacher jesting at the 
 whole subject, and explaining to his class that the only symptoms were 
 a sausage-like tumour, pain preceding menstruation, and menorrhagia, 
 and consequently, it was a condition impossible to diagnose with any 
 certainty. But expressions of this kind only showed how entirely 
 ignorant the profession were at the time of the subject. Tubal diseases 
 demanding operation are by no means confined to pyo-salpinx, in fact, 
 in only a very small percentage of these cases requiring operation will 
 the tube be found distended, and forming a sausage-like tumour. In 
 only one case of a number in which I have operated, or seen operated 
 on by others, have I found the tube greatly distended with pus, and in 
 that case the symptoms were by no means so severe or urgent as in 
 several of tlie others. 
 
 From my comparatively small experience, I would say that the class 
 of cases in which operative measures are most demanded, ai'e those in 
 which the tube is sealed down on the ovary or pelvic wall, when the 
 walls of tlie tube itself are thickened, sacculated and pouched, and tlie 
 seat of chronic inflammation ; where the ovary is flxed down by adhesion, 
 tlie result of inflammatory changes in the neighbouring peritoneum ; 
 and where the patient is suffering constant and severe pain, or the 
 subject of recurrent attacks of pelvic peritonitis.
 
 president's address — SECTION OP OBSTETRICS AND GYNAECOLOGY. 639 
 
 Now let us proceed to tlie consideration of uiy tliird pi-oposition. I 
 believe there still exists amongst the profession, great confusion as to 
 the relative frequency of inflammation of the pelvic peritoneal tissue, 
 or pelvic peritonitis, and the pelvic cellular tissue, or pelvic cellulitis ; 
 and if I were to put the question to this meeting, I strongly suspect 
 the answer I should get would be, that these diseases were about of equal 
 frequency, possibly, that they ran one witli the other, and were clinically 
 inseparable, and it was practically a matter of little importance as their 
 treatment was tlie same. Up to within the last few years, the latter 
 portion of tlie reply might have been correct enougli ; recent experiences, 
 however, strongly point in an opposite direction, and show that the 
 treatment applicable to tliese conditions is fundamentally different. 
 
 I will quote from some authorities which support the views recently 
 entertained. 
 
 West considers the condition of pelvic inflammation as an acute 
 purulent redema, and thinks pelvic peritonitis a rare lesion. Graily 
 Hewitt maintains "the actual seat of the ett'usion is, in most cases, 
 in the meshes of the cellular tissue surrounding the uterus, between 
 the folds of the broad ligament, and extending thence in various 
 directions towards the pelvic wall ; but it is probable," he adds, " that 
 in some cases of pelvic inflammation, there is an inflammatory condition 
 of the pei'itoneum itself." Emmet, to whose observations I would 
 specially ask attention, writes thus, " the terms peri-metritis, and para- 
 metritis, are not applicable, as they express a theoretical distinction 
 only, and differences which cannot be recognised clinically, at least " he 
 says, " I must acknowledge my own inability to make any distinction at 
 the bed-side. It is inconceivable that inflammation of any portion of the 
 pelvic peritoneum can exist without involving the cellular tissue in 
 relation with it. Whatever the exciting cause, pelvic peritonitis 
 cannot exist alone, but must rapidly involve the cellular tissue in its 
 vicinity. I shall," he goes on to say, " employ the term cellulitis as 
 expressing the common condition of pelvic inflammation in connection 
 with the non-puerperal diseases of women. Pelvic peritonitis will not 
 be treated of as a distinct lesion, but as an accident rendering the case 
 of general cellulitis the more grave in character from the complication." 
 Further, he says, " I do not exaggerate when I assert that pelvic 
 cellulitis is by far the most important disease with which woman is 
 afflicted, it is the most common and becomes the most important, it 
 being comparatively seldom recognised when limited in extent;" then he 
 remarks " that many practitioners habitually neglect to recognise 
 forms of circumscribed cellulitis, and do not appreciate its importance 
 if accidentally they do recognise it." Then, describing the method of 
 recognition, he says, " when the finger is passed into the vagina, it
 
 640 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 should be passed first to one side then to the other of the uterus, to 
 detect any thickening in either broad ligament, which would indicate 
 the disease. With one hand on the abdomen, and the index finger of 
 the other in the vagina, it is easy to judge of the extent of the thickening, 
 and whether the disease is still smouldering, as it were, as evidenced by 
 the pain produced by pressure." 
 
 Now these views of Emmet's are most important in their bearings 
 on the subject we are now considering — " / do not exaggei'ate when I 
 assert that 2)elvic cellulitis is hy far the most important disease with 
 which woman is afflicted." With a great many of these views of 
 Emmet's I most thoroughly concur. I recognise fully the very 
 excellent work he has done in drawing attention to the frequency 
 and imjDortance of these thickenings and indurations in the region of 
 the broad ligaments. Emmet's description of their method of detection 
 is sound, but the inferences he has drawn from his observations are 
 radically and fundamentally wrong, and for this reason, Emmet made 
 these observations before the days of frequent laparotomies ; before 
 Lawson Tait and others had published their remarkable observations. 
 Had Emmet proceeded a step further, and cut down through the 
 abdominal walls, and examined some of these thickenings in the region 
 of. the broad ligament, as is now being done almost daily, he would 
 have found that these thickenings, puckerings and fibrinous infiltrations 
 ao'e not in the tissue of the broad ligament at all, hut behind and distinct 
 from it ; and that the masses which are detected by bi-manual examina- 
 tion, consist of thickened and dilated Fallopian tubes; adhesions 
 of fibrous exudation from peritonitis, binding together tubes and 
 ovary ; circumscribed exudation of lymph around ovaiy, or shut off" into 
 loculi ; all strictly peritoneal, or tubal, but the cellular tissue of the 
 broad ligament itself entirely unaffected. 
 
 Of this, I will offer for proof tlie result of a series of cases which have 
 passed under my own observation during a period of less than three 
 years. Some two years and a half ago, after reading Lawson Tait's 
 rej^orts on cases, I came across a poor woman, who for three years had 
 suffered severe and almost constant pelvic pain, totally incapacitating 
 her from attending to her household duties, and only obtaining temporary 
 relief from her sufferings by rest in bed. In her I detected what I had 
 often observed before in women with similar chronic symptoms, viz., 
 thickening about the posterior sui'face of either broad ligament, tending 
 to spread posteriorly and towards the lateral pelvic wall. Imbued with 
 the teachings of Emmet and others, these thickenings I had in the past 
 always ascribed to chronic pelvic cellulitis or infiltration into the cellular 
 tissues of the broad ligament. With some considerable trepidation, I 
 confess, I cut down and found that the exudation was not in the
 
 president's address — SECTION OF OBSTETRICS AND GYNiECOLOGY. 641 
 
 broad ligament, but consisted of peritoneal adhesions surrounding a 
 thickened tube and adherent ovary. With some difficulty these 
 diseased appendages were enucleated, freed, ligatured and removed. 
 The patient made a rapid recovery, was entirely relieved of her former 
 pain, and in a few months one would have hardly recognised in the 
 florid healthy-looking woman tlie inisei'able complaining invalid prior to 
 the operation. 
 
 Vei'y quickly other similar cases came under obseiwation, such cases 
 as so often pass from one doctor to another, until at last they give up 
 all hope of recei\ing any relief. All presented the same clinical 
 features — thickening in the lateral vaginal fornices, constant jDehic pain, 
 occasionally recurrent attacks of an inflammatory nature. When, after 
 a trial, ordinary measures had failed to give relief, I cut down through 
 tlie abdominal walls, at first fearing always to find the inflammatory 
 changes hi the broad ligament : Ijut as case after case came under 
 observation, and abdominal sections showed the same results — pelvic 
 peritoneal adhesions, thickened tubes, and adherent ovaries — I began 
 to recognise how in the past / had been led astray, svxtyed by a false 
 pojthology. 
 
 During the last two years I have operated upon fifteen of such cases, 
 and my friend and colleague, Dr. Maunsell, has during the same period 
 operated upon an almost equal number. By his kindness, courtesy 
 and professional zeal, I have had the opportunity of confirming my 
 obser\"ations. In every case operated upon, we liave found the conditions 
 described, never once an infiltration of the broad ligament ; rarely, when 
 the inflammatory changes have been intense and extreme, the Ijroad 
 ligament has been found tluck and fleshy, l)ut never a condition in 
 any way approaching an induration. These observations have been 
 sufficient to settle my views on the matter. Xo authority, however 
 eminent, could shake convictions drawn from the results of a series of 
 cases such as these. 
 
 Now I should like shortly to refer you to some authorities as to the 
 frequency of morbid changes in these appendages. 
 
 Winckel's recent work may, I think, be taken as containing sound 
 views on the pathology of the female generative organs. You will find 
 in this work a table of the different anomalies observed in the 
 Fallopian tube in a series of 575 subjects ; and, as the result of 
 tliese observations, he makes the following remarks : — " From this 
 table it is evident that the tubes show a remai'kably large number of 
 affections and anomalies during early life, and that they are predisposed 
 to a great variety of affections at all ages, almost one-third of all female 
 cadavers showing disease in these organs." Numerous observations, 
 confirming the frequency of tubal diseases, are now being made on all 
 
 It
 
 642 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 sides, and it is evident that this fruitful source of disease has, in the 
 past, altogether failed to attract clinically our attention. Winckel, I 
 would also ask you to note, as a pathologist, almost agrees with 
 Emmet, as a clinician, allowing for the latter's error in observation as 
 to the true reading of the masses of exudation felt in the region of the 
 broad ligament. Thus "Winckel states that '^pelvic peritonitis is of one 
 the most common and most important affections of the female sexual 
 oryans." He adds, " I have found it in more than 33 per cent. 
 of all my autopsies;" and regax'ding it he further remarks, " even in 
 those cases in which the symptoms do not liecome grave, and tlie 
 processes run apparently a favourable course, there are such frequent 
 recurrences, and the patient is so distressed by the distortion and 
 tension produced by the adhesions, that life is made a burden, and it 
 is only after the occurrence of the menopause, that some improvement 
 takes place." 
 
 Then referring to Bernutz and Goupil's works, as containing the 
 earliest recognition of these inflammatory processes, Bernutz says, " nor 
 do I consider I exalt its importance too much in saying, that the futui'e 
 knowledge of uterine pathology is as certainly subordinate to our 
 acquaintance with these affections as pulmonary pathology has been to 
 a complete knowledge of the thoracic serous membrane." Bernutz 
 proceeds to report on a series of thirteen cases, where careful clinical 
 observations were checked by very complete and exhaustive autopsies. 
 On these he remarks, " it was not until the unfortunately fatal termina- 
 tion of two cases, that I was able to prove incontrovertibly that the 
 peri-uterine tumour, which during life jjresented all the symptoms of the 
 so called perl-uterine 2^hleg7non (celhditis), loas oiot situate in the 
 cellidar tissue at all." His further post-mortem examinations showed, 
 in all cases, very similar conditions — pelvic viscera bound down 
 by false membranes ; uterus often adherent to the bladder or rectum ; 
 the Fallopian tube bent on itself, dilated, thickened, and in the majority 
 of cases containing pus ; the tube often .adherent to the ovary, and its 
 fimbriated extremity occluded. One constant condition, in all these 
 cases of pelvic peritonitis, was diseased Fallopian tubes. In none, any 
 infiltration of tlie cellular tissue of the broad ligament. As regards 
 then cellulitis, Bernutz remarks, " it would seem, from its anatomical 
 disposition, that inflammation of the cellular tissue almost necessarily 
 tends towards the abdominal wall, or else to the deep iliac fossa — hence 
 plilegmons of the broad ligament ought to be studied with phlegmons of 
 the iliac fossa, of which they are a very interesting variety." 
 
 Dr. Matthews Duncan, as early as 1869, writes: — "The adoption of 
 Bernutz's views is not founded on clinical observation merely, but on 
 several post-mortem investigations made by myself, or for me by able
 
 president's APDHESS — SECTION OF OBSTETRICS AND GYNAECOLOGY. 643 
 
 patliologists." It is, liowever, curious to note that this same autlioiity, 
 SO late as in 1S86, writes of salpingitis as a disease almost unknown, 
 our scanty knowledge being eliietly derived from the dissecting-room. 
 
 Dr. Gaillai'd Tliomas, in 1S68, writes: — "Since the publication of 
 tliese views, I liave directed my attention particularly to this point, and 
 from careful observation, both clinical and post-mortem, feel warranted 
 in recording the conclusions at which I have arrived — 
 
 First. — Cellulitis is rare in tlie non-puerperal state, while pelvic 
 
 peritonitis is connnon. 
 Second. — A large propoi'tion of cases, now regarded as cellulitis, are 
 
 really peritonitis. 
 Third. — The two afiections are distinct from eacli other. 
 Fourth. — They may be ditferentiated from each otlier. 
 
 But let us refer to more recent work — work performed with the object 
 of testing the accuracy of Lawson Tait's statements. 
 
 Professor Polk, in a very recent article on peri-utei'ine inflammation, 
 says : — " In a large number of post-mortem examinations made in the 
 dead-house of the Bellevue Hospital, nothing is more common than to 
 find evidence of peintonitis about the ends of the tube ;" and further on, 
 " the ovary may be always said to he implicated in these peritoneal 
 inflammations, the flmbria which attaches it to the tube forming a 
 ready transmitter of the process to the ovary." Polk also, as a result of 
 a large number of post-mortems, noticed that except in those patients 
 who had died of septicaemia, it was the rarest tiling to And cellulitis ; 
 and in a series of cases, he points out how tlie symptoms and signs 
 present were those of pelvic peritonitis and pelvic cellulitis, while the 
 abdominal section showed salpingitis, peri-oophoritis, and peritonitis. 
 
 Dr. H. C. Coe, pathologist to the Women's HosjDital, New York. 
 referring to the subject of peri-uterine inflammation, states : — 
 "Peritonitis is certainly the most prominent element in most of these cases, 
 as far as the post-mortem evidence aflfords any light. By far the greatest 
 number of these indurations are situated high up in the broad ligament, 
 and consist of cicatricial masses, mostly conflned to tlie peritoneum of 
 the tubes or ovaries, surrounded by old adhesions, or occasionally an 
 imprisoned knuckle of intestine. The thickenings of the sacro-uterine 
 ligament, so frequently alluded to in works on gynaecology, have, when 
 carefully dissected out, proved in my experience to be due, not so 
 much to a disease of tlie connective tissue of these ligaments, as to a 
 cicatricial condition of the peritoneum covering them." Then, "I confess, 
 that I ha\'e rarely found such thickening in the cadaver which could be 
 referred to a fair and straightforward cellulitis or inflammation of the 
 connective tissue, and this too vjhen I have recognised, by vaginal touch 
 before and after death, what seemed to he an induration, or distinct 
 
 It 2
 
 644 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 hand extending outwards from a deep laceration of the cervix, or a 
 condition of tension in or abovit one lateral cul de sac." The same patho- 
 logist, reporting on half-a-dozen fatal cases following Emmet's operation 
 and cervical incision, in which he had made post-mortems, says : — " In 
 every case the cause of death was acute diffuse peritonitis. The inflam- 
 mation could be traced straight up from the wound along the mucous 
 membrane of the uterus, along the tubes, and thence to the peritoneal 
 cavity." 
 
 Richard Maury, in an able article on Peri-uterine Inflammation in 
 the American System of Gyncecology and Obstetrics, after referring 
 to much evidence of the same natui'e, states : — " The evidence is 
 adduced here in full, in order to show that the common every-day form 
 of chronic pelvic inflammation which is met with in complication with 
 septicjemia, is pelvic peritonitis, associated witli diseased appendages, 
 and is not pelvic cellulitis." 
 
 Now, what is the practical outcome of these recent additions to our 
 knowledge 1 First, I say it is in the sweeping away of much of the 
 gyncBCologiccd luraher of the past. Where we And our patients com- 
 plaining of constant pelvic and reflex pains, aggravated by exertion 
 of any kind ; where we find her prematurely aged from constant 
 suffering, her life a burden, and not only her own happiness destroyed, 
 but that of the family circle around her, do not let us be content in 
 cases such as these to pass a speculum or sound, and finding some 
 erosion or displacement, rest our diagnosis upon such superficial 
 observation, and gloss over treatment by passing a pessary or making 
 an occasional application to the cervix. Where we find severe 
 symptoms, we should suspect, and strongly suspect, inflammatory 
 changes in or around the uterine appendages — changes which can only 
 be I'ecognised by a searching bi-manual examination, and are most 
 certainly overlooked by the superficial examinations even still too 
 much in vogue. Detecting these indurations, puckerings, and thicken- 
 ings in the region of the posterior surface of the broad ligament, and 
 recognising their import, there will be little fear of our treating these 
 cases by pessaries and applications. 
 
 It may be right to note the most recent suggestions for treatment, 
 emanating from Dr. Apostoli, by passing large currents of gahanism 
 through the indurated tissue. Whetlier this method of treatment has 
 any effect beyond the mere local cauterizing action is extremely 
 doubtful, and it is difficult to believe that the application of galvanism 
 in this region can have any more effect upon inflannnatory products 
 than upon inrtannnatory products elsewliere in the body. This is a 
 subject to which, possibly, attention may be drawn by some member 
 durin"' the meetings of this section. Emmet, whose clinical observations
 
 PREGNANCY COMPLICATED BY OVARIAN DISEASE. G45 
 
 are of extreme value, gives us tlie cue to treatment in his reconuncn- 
 dations of rest — not douclies, blisters, itc. — many cases being greatly 
 assisted by absorbent remedies, such as hydrarg. perch., potas. iodid., 
 and bromides. 
 
 We must not, liowever, for one moment be so carried away by 
 enthusiasm of our recent light, as to imagine that a large proportion of 
 these cases may not be relieved by suitable medical treatment ; but 
 after most cai'eful and systematic treatment, there will be a residuum in 
 whicli medical art will altogether fail to atlbrd relief, and here will come 
 in this great addition to our means of alleviating suffering. Previously, 
 looking on these conditions as due to chronic thickenings in the broad 
 ligament — old scars, in fact, wliich, for some unknown reason, took an 
 inflammatory action — we stayed our hands, and did nothing. Now we 
 perceive, that if we succeed in remo^"ing• diseased organs which are 
 functionally useless and only foci of inflammatory action, we shall surely 
 and certainly cure our patients. 
 
 Of the steps of the operation itself, the dithculties and complications 
 met with, and the means of overcoming them, I do not now propose to 
 speak ; doubtless we shall have some papers dealing with these matters 
 read before our section, when I hope to proflt by the experience of 
 many fellow'-workers. 
 
 And now, gentlemen, if I have succeeded in bringing prominently 
 before you a form of disease as common as it is overlooked ; if I have 
 succeeded in urging the necessity for more thorough and searching- 
 examinations than are at present generally adopted; if T have succeeded, 
 even in a small degree, in clearing away some of the confusion and 
 mystery that exists concerning the aflfections of the uterine appendages, 
 the objects of my address will be attained. 
 
 PEEGNANCY IX ITS VARIOUS STAGES COMPLICATED 
 
 BY, OR ASSOCIATED WITH, OVARIAN DISEASE. 
 
 By T. Rowan, M.D., F.R.C.S. Ed. 
 
 The subject standing in my name, and which I have the honour to 
 "bring under your notice, is both important and practical, and at the 
 same time hajjpens to be one which authors and writers seem to have 
 left very much in the background; not, I presume, because it has 
 appeared unworthy of minute attention and thought, but probably on 
 account of the fact that it is a condition of comparatively rare 
 occurrence. I may mention, that I have looked in most of the standard 
 works now in use for some information as to the proi)er line of 
 treatment in cases of the kind, and have failed to get anything reliable
 
 646 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 as a guide; and therefore, I trust that members of tliis branch of medical' 
 science may be able to contribute a degree of practical observation and 
 results, which will tend to lift the subject out of comparative obscurity, 
 and give it a prominent position amongst the numerous bodily troubles- 
 to which women are unfortunately liable. I have no desire to take up 
 the valuable time of this Section with a long theoretical paper, as I 
 consider such a course would be inexcusable; but I do wish to formulate 
 my subject so that we may get all possible information for future use, 
 without waste of time : — 
 
 (1) One of the lirst points to be considered when a case of advanced 
 
 disease in one or both ovaries is met with during pregnancy 
 is, whether the patient should, or should not, be left alone 1 
 
 (2) And whether surgical interference should be resorted to; and if 
 
 so, when 1 
 
 I presume there must be a medico-legal aspect surrounding the treat- 
 ment and management of cases of the kind. And as the law on the 
 subject, if there be a law in existence, should at least be known to 
 members of the profession, and not allowed to be unwritten as it seems 
 to be at present, I deem it my duty to have some expression of opinion 
 from this Section, concerning the proper course to be pursued by the 
 medical attendant when he meets with pregnancy associated with 
 ovarian disease. 
 
 I may mention, that I have only known of live instances of this 
 com])lication, and all of them were in Victoria. One was a patient 
 of Dr. Hillas ; another was a patient of my colleague at the Women's 
 Hospital, Dr. Balls-Headley ; and the remaining three cases occurred 
 in my own practice. In every instance but one, the patient was 
 operated upon before the end of utero-gestation, and in every instance 
 recovery followed ; therefore, it would seem that pregnancy does not 
 necessarily increase the rate of mortality in this class of ovariotomy. 
 The one exception above referred to, was in the case of a patient 
 who had a large dermoid cyst, which was not discovered until the first 
 stage of labour was well advanced, and then it filled the greater portion 
 of the pelvis, and by its presence prevented the head fiom coming below 
 the Inim. In the first two cases, one was a double ovarian, and the 
 other single; one had advanced between three and four months, and 
 the other about two months ; one Avas confined at full time of a healthy 
 female child, which weighed 7| lbs., and the other is not yet confined ; 
 in the one confined at full time, both ovaries were removed ; and in 
 the one not yet confined, only one was removed. In each case, the 
 condition was diagnosed before the operation. In the first of my cases 
 the right ovary was diseased throughout, and the left one nearly so ; 
 indeed, the wonder was as to how the patient ever managed to conceive, 
 and the point was only settled after a minute examination of both 
 ovaries, when it was found that a slender zone of healthy tissue still 
 remained on the extreme lower border of the left organ. The particular 
 kind of degeneration afifecting the ovaries in this case was very peculiar, 
 and I cannot recollect anything of a similar character in any of the 
 cases I have seen, either in my own i)ractice, or in the practice of any of 
 my friends or colleagues. The new formation, which took the ]ilace 
 of the ovarian tissue, can be likened to nothing which will more
 
 PREGNANCY COMPLICATED BY OVARIAX DISEASE. 647 
 
 accurately descrilie its appearance than frozen honey, and gave the 
 same rougli granular feel when rubbed to and fro between the forefinger 
 and thumb. The patient was sent to me by my friend, Dr. Kennedy, 
 of Hay ; and I am indebted to Dr. Anderson, of the Women's Hospital, 
 for the history and after-particulars of the case. 
 
 Case I. 
 
 Mrs. M., jet. 25, admitted March 9, 1888, married five months, 
 menses regular before marriage, with only a scanty flow and no pain, 
 have ceased now four and a half months. Felt well till Christmas 
 1887, when she began to feel weak and languid. About end of January, 
 noticed a small hard lump in the left inguinal region, which has been 
 enlarged ever since, but did not cause any inconvenience till three 
 weeks ago ; now complains of occasional vomiting for the last few 
 weeks, absence of menses, a round hard tumour in the left inguinal 
 region, about tlie size of a cocoanut, and tender — tumour is well defined, 
 extends upwards as far as a line drawn outwards at level of umbilicus ; 
 inwards, reaches to middle line ; and outwards, to the iliac crest — also a 
 small round mass in the right inguinal region, which is very tender. 
 From left anterior superior iliac spine, to umbilicus, is five and three- 
 quarter inches ; on right side, five inches. Per vaginam, a large hard 
 swelling is felt on left side, between uterus and bladder, which is very 
 tender ; os uteri looks downwards and forwards, lips very soft ; fundus 
 is large and heav}". 
 
 Operation of abdominal section March 13, 1888. Both ovaries, with 
 their Fallopian tubes, removed; non-adherent. The left was the size 
 of a small cocoanut, and the right about the size of an orange. After 
 the operation, the temperature never went above 100"2°. 
 
 March 18. — Bowels opened by enema. 
 
 March 19. — Deep sutures i-emoved. 
 
 March 23. — Superficial sutures removed. 
 
 Mai'ch 27. — Removed to general ward. 
 
 April 7. — Discliarged cured. The uterus now reaches to within two 
 lingers' breadth of the umbilicus; i)lacental bruit heard distinctly, but 
 fcetal heart sounds cannot be made out. 
 
 April 23. — Foetal heart heard to-day; rate 134. 
 
 August '2i. — Confined in the hospital, normal labour; female child, 
 alive, weight 7|lbs. ; uninterrupted recovery, and went out. Mother 
 and child both well on September 3. 
 
 Case IT. 
 
 Particulars of this case were also kindly supplied by Dr. Anderson. 
 
 Mrs. E. K., tet. 30, had three children ; last, December 30, 1887. 
 Quite well up to tliis accouchment, when, on admission to the hospital, 
 a firm tumour was felt in the pelvis, in front of the foetal head. Dr. 
 Kovvan attempted to push up the tumour, but failing this, under 
 chloroform, he performed podalic version, and then was able to push 
 up the tumour and deliver. After delivery, the patient was very low 
 and feverish at times, but is now improving. 
 
 Removed to the infirmary January 9, 1888. A tumour now is found 
 in the left side of the abdomen, which is tender to the touch, and 
 painful at times. It is situated in the ilio-ovarian region; is quite
 
 648 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA, 
 
 bai'd, no fluctuation. Tlie skin is quite movable over the tumour, 
 which itself is freely movable, being about the size of a small cocoanut. 
 On the right side of the abdomen a smaller tumour is felt; os uteii 
 transverse, very patulous; fundus enlarged, soft, heavy. Left lung is 
 dull at its base; sounds roughened, but dry, and the expansion on the 
 left side is deficient, this arising from an attack of low pneumonia 
 following delivery. 
 
 January 11. — Temperature, 99°. On 12th, 99-6° and 100°; thence 
 normal. 
 
 January 13. — Some jaundice appeared to-day, and cleared off in a week. 
 
 January 17. — Some cedema of left leg, which remained till operation. 
 
 Operation, January 25 ; methylene by Dr. Burke. Present — 
 Dr. Kennedy, of Hay, Dr. O'Brien, Drs. Anderson and Fetherston 
 Jun. Usual incision through abdominal wall and peritoneum ; left 
 ovary exposed and brought to the surface ; its pedicle was then trans- 
 fixed, and ligatured with carbolised silk, using the Stafl'ordshire knot ; 
 the ovary and Fallopian tube were then cut off, and the pedicle returned 
 to the abdomen. The right ovary and its tube were treated in a similar 
 manner. The left ovary was much enlarged, and on section was found 
 to contain dark brown hair (same colour as patient's), and also a bony 
 plate, but no teeth. The right ovary was also enlarged, but not so 
 much as the left, and had some large cysts on it ; section showed it to 
 contain fatty, soft, yellowish material. The wound was closed in the 
 usual manner, with deep silver and superficial horse-hair sutures ; 
 Keith's glass tube inserted between the fourth and fifth deep sutures ; 
 wound dusted with iodoform ; absorbent wool, strapping, and flannel 
 binders a|)plied ; i grain morphia suppository given, and patient placed 
 in bed with hot bottles to feet. 
 
 Next day (January 26), temperature was 100"6° ; after this, was never 
 over 100°, and fell to normal on the 30th, and remained so. The 
 drainage tube was removed on the 29th ; bowels acted on the 31st after 
 enema, and ol. ricini by mouth. 
 
 January 31. — Deep sutures removed ; good vmion, notwithstanding 
 the relaxed condition of abdominal wall through recent distension. 
 
 February 5. — Superficial sutures removed, and patient taken back to 
 general ward. 
 
 February 10. — Abdominal belt applied, and patient allowed to get up. 
 
 February 21. — Discharged cured, well and strong. 
 
 Notes after delivery on December 30, 1887 : — Temperature — 30th, 
 p.m., 103°; December 31, normal and 974°; January 1, 1888, 98° and 
 normal; January 2, normal; January 3, 99° and 100°; January 4, 99° 
 and 101°; January 5, 99-4° and 99-6°. 
 
 January 6. — Temjierature, 99-8° and 103°. Some herpes appeared on 
 face to-day ; left lung is uniformly dull, poultices applied, senega and 
 ammonia mixture given; no pain, cough, nor expectoration present, 
 although the whole of the left lung is consolidated. 
 
 January 12. — The lung sounds cleai'ing up very fast. 
 
 Child weighed G^lbs. wjien born. 
 
 Case III. 
 
 Mrs. L., jet. 28, married three and a half years, two children, last ten 
 months since, nursed it nine months and a week, consulted me on
 
 FIFTY CASES OP ABDOMINAL SECTION. 649 
 
 July 1 last, on account of a large tumour of the abdomen, whicli had 
 lieen steadily growing since the birth of her last child, and had given 
 rise to much j)ain during the month of June, and the latter part of 
 May. The tumour was about the size of the gravid uterus at the sixth 
 month. The growth was slightly tender upon pressure; and, at the 
 lower portion, presented a somewhat hard feel, and gave the impression 
 that the cyst contained a lump of solid tissue of some kind. The uterus 
 ■was enlarged and soft, and corresponded with the conditions usually met 
 with about the first month of utero-gestation. The diagnosis was, 
 ovarian tumour and pregnancy. 
 
 The operation was performed on August 2, and the cj^st, which was 
 dermoid, was removed. No douVjt existed regarding pregnancy, as the 
 ntei-us could be felt and seen tlu'ough the abdominal opening. The 
 patient made an excellent recovery, and is now expecting her continement. 
 
 FIFTY CASES OF ABDOMINAL SECTION. 
 By F. C. Batchelor, M.D., M.R.C.S.E. 
 
 President of the Section. 
 
 I propose to-day to give a short report of a series of 50 cases of 
 abdominal section, which com})rise all my oi^erations that have any 
 bearing on the special work of this Section. Althoiigli numerically 
 small, the series includes some cases of considerable interest and variety, 
 to which I shall briefly draw your attention, with the oltject of eliciting 
 discussion. The cases may be thus tabulated : — 
 
 Ovariotomies . . . . . . 18 with 3 deaths 
 
 Tail's operation . . . . . . 15 with 2 deaths 
 
 Oophorectomies — 
 
 For fibroids . . . , . . 4 — 
 
 For pain, cystic and cirrhosis 3 — 
 
 Hysterectomies . . . . . . 4 with 1 death 
 
 Laparotomy for pelvic abscess . . 1 — 
 
 Lapaiotomy during pregnancy . . 2 — 
 
 Caesarian Section . . . . . . 1 with 1 death 
 
 Extra nterine fcBtation . . . . 2 — 
 
 In all, !iO cases wdth 7 deaths. 
 
 In making reference to individual cases, I shall distinguish them by 
 their numbers in my case book. The corresponding numbers will be 
 found on the right side of the appended tables. 
 
 Amongst the ovariotomies, the first case of interest I would note was 
 Case 12. The patient doing well for some days, when symptoms of 
 obstruction of the bowels set in. A secondary operation was in conse- 
 cpience performed, and a portion of omentum, which had been stripped 
 otf the cyst-wall, was found to have formed a fresh connection, and in 
 80 doing, had tightly nij)ijed a portion of the small bowel. The patient
 
 650 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 never rallied from the collapse of the secondary operation. From this 
 mishap, I learnt two important lessons : — 
 
 (1) When dividing a large heavy band, to remove or else to fix it 
 
 somevN'here in the abdomen ont of harm's way. 
 
 (2) Not to trust blindly to opium. Had 1 given a free purgative 
 
 on the third or fourth day, the bowel might have freed 
 itself from the then soft adhesion. 
 
 Case 18. — The details of this operation were as simple as in any case 
 of abdominal section I have performed, and to the best of my belief, all 
 my antiseptic precautions were thorough and efficient ; yet, within a 
 few hours of the operation, the patient was attacked with septicaemia, 
 from which she died in a few days. I am at a loss to account for its 
 occurrence, except on the supposition that the operation was undertaken 
 too soon after delivery (on the thirty -seventh day) ; and I cannot but 
 think that the materies morbi were stored up ready for an outbreak, 
 and that the removal of the large ovai-ian tumour was but the exciting 
 cause. It has since made me chary of operating upon a patient while 
 still in the puerperal period. 
 
 Case 20 was an excessively i-are one. The patient was sent into the 
 hospital, supposed to be suffering from an ovarian tumour, which on 
 three occasions previously had been tapped of many gallons of fluid. 
 On admission, she was suffering from an enormous tumour, tilling the 
 abdomen, with usual lines of ovarian dulness. On oi)ening the 
 abdomen, a large white cyst-wall presented, which was tapped of several 
 gallons of darkish fluid. Tlie lower jiortion of the tumour was cleared 
 with much difficulty, and a large thick pedicle secured. On attempting 
 to free the ui)per portion of the tumour, it was traced deeply into the 
 abdomen, and was adherent loosely to the cellular tissue of the loin in 
 front, and at its upper portion it was covered by peritoneum. After 
 .separating most extensive adhesions, the whole sac was at length 
 I'emoved, and presented about its centre a constriction — apparently 
 dividingthe tumour into two large lobes, though both communicated freely. 
 Even after complete removal of growth, considerable doubt existed as- 
 to its true nature. From its deep pelvic connections ; from the absence 
 of the left ovary, which was searched for at operation, but could not be 
 found ; from the facts, that the lower poi'tion of the sac, which first 
 came into view on opening abdomen, had no peritoneal covering, and 
 the descending colon being displaced to the left, an ovarian origin was 
 indicated. But the tumour's deep connections in the loin, reaching up 
 to the diaphragm ; the situation of the upper part of the growth 
 beneath the ])eritoneum, and the absence of the left kidne}^ pointed 
 more to a condition of hydrone])hrosis. The patient never rallied from 
 the operation, but died collapsed on the fifth day. 
 
 Dr. Roberts, our pathologist, found the left kidney and left ovary 
 absent at post-mortem examination. The conclusion therefore arrived 
 at was, that the ovarian tumour being closely adherent to the pelvic 
 walls, in its earlier growth, had so pressed upon the ureter as to cause 
 its obsti'uction, and consequent hydronephrosis. By the two sacs 
 meeting and pressing together, the i>arty wall had become obliterated, 
 and resulted in the formation of one large cavity. I only remember 
 reading of one similar case, reported recently by Mr. K. Thornton.
 
 FIFTY CASES OF ABDOMINAL SECTIOX. 651 
 
 Case 50. — This patient was a woman,. who gave her age as 62 years, 
 but probabl}' older. On ojiening the peritoneum, the whole abdomen 
 was fjlled with layers of jelly-like material, which dipped between the 
 bowels and different viscera. On clearing away some of the surface 
 jelly, a white ovarian cyst was found, with a large rent, through which 
 the colloid material had esca})ed into the general peritoneal cavity. 
 
 In Case 65, a similar accident had occurred, the peritoneal cavity 
 being filled with colloid material, considerably modifying the ordinary 
 lines of resonance on examination prior to operation. 
 
 In both ■ these cases, the syphon trochar recommended by Lawson 
 Tait was employed, and acted most efficiently — gallons of hot water 
 were thus syphoned into the peritoneal cavity, block after block of 
 glutinous jelly-like material floated up out of the wound, until the 
 })eritoneal cavity was thoroughly cleared out. Both these patients made 
 most satisfactory recoveries. 
 
 Another point to which I would draw your attention in this list of 
 ovariotomies, is the frequency with which more or less abundant traces 
 of dermoid materials were observed — in seven of the eighteen cases was 
 dermoid matter distinctly present. 
 
 Those who are interested in the subject, and have not read an article 
 in the last number of the Gi/mecological .Tournal, by Bland Sutton, on 
 the "Origin of Ovarian Dermoid," will find it well worthy of careful 
 perusal. In it, he points out : — 
 
 (1) How multilocular, ovarian, and dermoids, originate in Graafian 
 
 follicles. 
 
 (2) How frequently dermoids are associated with multilocular 
 
 ovarian tumours. 
 
 (3) How transitional stages can be traced from the membrana 
 
 granulosa — the lining membrane of the follicle — to mucous 
 membrane; then to mucous glands, of which multilocular 
 ovarian are composed; then that skin and mucous membrane 
 are fundamentally identical. Skin covers the exterior of 
 the body, has sebaceous glands, and is furnished with hair; 
 and if a complex cyst, such as a multilocular ovarian, can 
 aiise from a Graafian follicle, surely we cannot deny the 
 origin of an ovarian from the same source. In this manner, 
 accounts for ovarian dermoids in a much more satisfactory 
 manner, than by the vague hypotheses formerly held. 
 
 Under the heading. " Tait's Operation," are classed cases where the 
 Fallopian tube pre.sented some marked inflammatory change, where this 
 iiiflaumiation had extended to the neighbouring peritoneum, and where 
 the ovary was more or less bound down by adhesions. The operation 
 for the removal of the.se diseased appendages has been by far the most 
 diflBcult I have performed within the abdomen. Throughout the 
 ojieration, one has to depend solely u|)on the sense of touch. The 
 relations of parts are often much altered, the structures themselves 
 olianged often beyond recognition, the ovary more than once entirely 
 >hut off by layers of exudation. 
 
 The i-esult of my cases has ])roved to me, what an immense amount of 
 manipulative interference the peritoneum will stand, provided no
 
 652 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 visceral injury is inflicted. The incision through the abdominal walls, 
 in these cases, must be made with much more care and deliberation than 
 where the abdomen is distended by a large cyst. More than once have 
 I found the peritoneum beneath the line of incision, thickened and 
 adherent to underlying structures. The fundus uteri, which is generally 
 taken as a guide to identify the tubes, was in Case 55 so surrounded by 
 adhesions to neighbouring bowel, that it was with difficulty reached; 
 the adhesions of the tubes and ovaries to surrounding structures are 
 often so dense, that considerable force has to be employed to separate 
 them; and more than once I have feared a rupture would occur into 
 the neighbouring viscera, or that some of the main vessels would be torn. 
 
 In Case 40, .such a ruptui'e into the bowel did occur ; and a 
 subsequent post-mortem showed several points of ulcerative com- 
 munication between an enlarged caseating cavity in the Fallopian tube 
 and the descending colon. 
 
 In both cases of this operation that terminated fatally, the disease in 
 the tube was tubercular. In Case 40, the general peritoneal cavity was 
 inoculated throughout ; the tubes were converted into large caseating 
 masses, and the left had formed adhesions so dense and extensive, that 
 the attempt to remove it had to be abandoned ; and even at post-mortem 
 it was found impossible to remove diseased portions, without actually 
 stripping the whole of the left and posterior part of the pelvic cavity of 
 its contents. Even here, however, the broad ligament could be 
 identified, displaced and covered by adhesions, but no thickening or 
 deposit existed between its layers. In my second fatal case. No. 56, 
 some rupture into the urinary passages must, I fear, liave occurred 
 during operation. The case was one of old standing ; the adhesions 
 were unusually tough and dense, their solid irregular feel having led 
 to a diagnosis of cancer by the gentleman who had forwarded tlie case 
 to me. Blood was drawn off with the urine ; following the operation, 
 peritonitis and collapse ensued ; the abdomen was drained, but no 
 improvement followed, the patient dying on the third day. Dr. 
 Roberts made sections from the diseased tissues, and found typical 
 giant-cells of tubercle. 
 
 In Case 54, the adhesions between the right Fallopian tube and 
 the bowel were most intimate, and required most careful dissection for 
 its removal ; and if it had been permitted to run on, a communication 
 between the two must shortly have occurred. 
 
 Ileviewing this class, I should say that the operation is severe 
 proportionately to the nature and extent of the adhesions. The 
 symptoms to which the disease gives rise are also severe, and often 
 render invalid, or eventually even cause death. Operative measures 
 give the only prospect of relief, especially to that class of patients 
 to whom the struggle for existence renders work imperative. The risks 
 of the operation itself should be by no means greater than other 
 operations performed for less serious conditions. It is an operation we 
 therefore hail as a great addition to our resources, and the greatest 
 advance in modern Gynaecology. 
 
 Oophorectomy has been performed for two different conditions : — 
 
 (1) To arrest growth of fibroid tumours. 
 
 (2) For severe ovarian pain, causing marked reflex disturbance.
 
 FIFTY CASES OF ABDOMINAL SKCTIOX. 653 
 
 Oo])hovpctoinv, for arresting; growtli of filiroids, is not so easy as 
 one might at first siglit imagine. The fibroid is often twisted on its 
 transverse axis ; the position of the ovary difficult to discover, especially 
 through a small abdominal incision ; the pedicle is very short, and 
 difficult to drag into the wound, and the veins of the broad ligament 
 enormously dilated ; although I have not lost a patient. 
 
 Case 25 had an attack of phlegmasia dolens following operation, 
 which i-etarded recovery. In all four cases, the growth of the tumour 
 has been arrested. 
 
 In Case 16, the lu^morrhage, a troublesome symiitom, continued as 
 severe as ever, when I last heard of the patient. 
 
 In Cases 25 and 33, the haemorrhage was arrested, and the tumours 
 decreased remarkably in size. In Case 25, although prior to operation 
 the summit of the tumour reached two inches above the umbilicus, eight 
 months subsequently, the outlines could only with difficulty be made 
 out immediately above the symphysis. 
 
 Case 28. — The fibroid was small, and tending to grow towards the 
 right side of the pelvis. The menorrhagia was effectually controlled, 
 liut the patient's condition has been rather aggravated than improved 
 by the operation, so severe have been the climacteric disturbances. For 
 twelve months, flushings, headache, and general debility were the chief 
 complaints. Latterly, })alpitation and polyuria, amounting to twenty 
 pints a day, and other sympathetic disturbances. 
 
 On the whole, I am not satisfied with the results of these operations 
 for arrest of fibroid ; and from a somewhat limited experience of the 
 Apostuli method, by large doses of galvanism, should certainly give it a 
 trial before resorting to oui)horectomy, or severer measures. 
 
 With regard to oophorectomies for persistent and severe ovarian 
 pain, I must honestly confess that, with these cases, I have always felt 
 myself treading on dangerous ground. I have avoided opei-ating in a 
 good many cases where some surgeons have considered the indications 
 sufficient to justify this radical measure. My difficulty has been in 
 determining where the subjective symptom (pain) is due to a change 
 which, by examination, gives no physical sign, and those cases where 
 pain is merely an indication of some general nervous condition, localised 
 specially in the ovary by some morbid concentratioii of the mind on the 
 generative organs ; or some slight local irritation which, with a more 
 healthy state of the nervous centres, would not cause any appreciable 
 disturbance. 
 
 In the few cases where I have removed ovaries on account of pain, I 
 have failed to find sufficient change to account for the symptoms. I 
 entertain the gravest doubts as to the role that slighter form of cystic 
 conditions play, as a factor in the production of symptoms. I have 
 more than once seen an ovary containing cysts in abnormal quantity 
 and size, without giving rise to any symptom whatever. In the early 
 stage, too, of the ordinary forms of cystoma, there is, more frequently 
 than not, an entire absence of pain. When we perform an operation 
 which mutilates and destroys one of the most important functions of 
 womanhood, I must admit, that I am materialistic enough to expect to 
 find some change marked, evident, and ready of recognition by the 
 naked eye ; and that the same rule must apply to the ovary, as to any 
 other imjiortant organ in the body, viz., that before removing it, it
 
 654 INTERCOLONIAL MEDICAL CONCxRESS OF AUSTRALASIA. 
 
 must be hopelessly diseased, and the changes gross and characteiistic. 
 Until, however, we obtain a closer insight into the histology and 
 pathology of the ovary, we must expect to find radical differences in 
 opinions and practices. 
 
 In Case 49, when I removed a prolapsed right ovary, which contained 
 cysts in excess, it would have been better practice to have fixed the 
 ovary in normal jjosition, and not removed it entirely, as I did. 
 
 In Cases 53 and 54, excessive cystic formations were present in the 
 ovaries. The pain, constant and jjersistent in one case, was entirely 
 removed; and in the other, the reflex ocular disturbance entirely 
 subsided, but the conjecture must ai'ise — had these patients' social 
 surrouiadings been different, had they been in a position to undergo a 
 course of Weir jMitchell's treatment, or had they become pregnant, 
 might not the results have been equally good, and at a less cost. The 
 operation for removal of cystic or cirrhosed ovaries is by far the simplest 
 in abdominal surgery; and it is hardly fair to class these cases with 
 Tait's operation, where one frequently meets difficult and dangerous 
 complications, and where there must be a much heavier mortality. The 
 mere fact of the operation being so easily performed, and being attended 
 by so little danger, renders it a measure specially liable to become 
 alaused. 
 
 The two cases of extra uterine fcetation, I have already repoi'ted in 
 full. 
 
 No. 14 was at the earlier month of pregnancy, and the cyst had 
 apparently ruptured between the layers of the broad ligament. 
 
 No. 19. — The pregnancy was probably originally tubal, and had 
 burst as usual about the third month into the general peritoneal cavity. 
 The foetus continued to develop till term ; its death occurred, and for 
 some twelve months it remained in the abdominal cavity, without causing 
 any disturbance. Communication then occurred between the sac 
 containing the foetus, and the bowel, and decomposition set in, with 
 symptoms of septic absorption. By operation, a decomposing foetus 
 was removed. Both these cases made satisfactory recoveries. 
 
 Laparotomy, during pregnancy, was twice performed : — 
 Case 4, was removal of a cyst (hydatid) from the under surface of the 
 liver, by an incision on the outside of the right rectus muscle. 
 
 Case 21, was a case of strangulation of the bowel, from bands; the 
 patient was almost moribund during operation — a most desperate case. 
 Both patients made most satisfactory recoveries. Pregnancy in each 
 case had advanced to between tlie third and fourth month; in neither 
 was its normal course interfered with. Both were delivered at full 
 term of healthy children. 
 
 Hysterectomy was performed in four cases : — 
 
 Case 15 was a moderate-sized tumour of slow growth, causing severe 
 menorrhagia. The fundus uteri reached to the cartilage of the ribs on 
 the right side ; the adhesions were numerous and tough. An interesting 
 point in connection with this case is that, when first admitted into the 
 hosi)ital, the tumour was diagnosed malignant, on account of oedema of 
 the legs, ascites, and a large effusion in the right pleural cavity. The 
 chest was tapped, and the patient left the hospital relieved. Six months
 
 FIFTY CASES OF A15D0MINAL SECTION. 655 
 
 subset) uently, slie was i-e-atlinitted, on account of the increasing size of 
 the abdomen ; and as her general health had in no way deteriorated, 
 and there was no reappearance of the pleuritic effusion, 1 determined to 
 make an attempt to remove the growth, which I succeeded in doing, 
 treating the stump by Kceberle's clamp. The })atient made a good 
 recovery. 
 
 Case 22. — An enormous fibroid, distending the whole abdomen, and 
 causing anajmia, from menorrhagia and constant irritating Avatery dis- 
 charge. Drugs had no effect, and intra-uterine dilatation and applications 
 failed to arrest haemorrhage. The entire uterus and appendages were 
 therefore removed, and the extra-])eritoneal stump clamped, as before. 
 The patient made a thorough recovery, though for many days her life 
 hung in tlie balance. A free purgation, finally, I think, determined 
 matters in her favour. 
 
 Case 35. — A ]:>articularly distressing one. A young woman, set. 2H, 
 only confined of her second child a few months previously, developed 
 malignant disease in the uterus, which must have rapidly involved the 
 whole organ. When I first visited her, she had only complained six 
 weeks, yet there was a large fungating mass protruding through the 
 cervix. The body of the mass was irregular and nodular, and infiltra- 
 tion was evidently extending in the broad ligaments. A microscopic 
 examination of a section from cervical tissue showed alveolar structure 
 of scirrhus, and consequently it was determined to make an attempt at 
 removal. In consequence of the broad ligament being involved, it was 
 determined to operate through the abdomen. The mischief was found 
 to be even more extensive than had been anticipated ; the whole uterus, 
 a great portion of the broad ligament, the Fallopian tubes, and ovaries, 
 requiring removal. The stump of the broad ligament was ligatured, 
 the abdominal wound closed, and a large drainage tube inserted through 
 the vagina. The patient for three days sviffered severely from shock, 
 but subsequently made a truly remarkable recovery in ten days, being 
 freer from pain and in better health than she had been prior to opera- 
 tion, there being an entire absence of any constitutional disturbance. 
 The disease, however, rapidly recurred ; and shortly she succumbed, 
 large masses of cancer blocking up the pelvis. It is somewhat remark- 
 able, that six months previously, I had removed an ovarian tumour 
 from this patient's sister. 
 
 Case 51. — One of the most interesting cases I have met with in 
 abdominal surgery. The patient, aged 22, a strong, muscular woman, 
 was admitted into the Dunedin Hospital with a history of a 
 miscarriage at the fourth month, two weeks pi-eviously. Since then, 
 she has been excessively ill, losing flesh, unable to take food, confined 
 to bed, and suffering heavy losses of blood. On admission, the 
 patient was blanched, suffering from metrorrhagic discharge, with an 
 irregular temperatui-e and quick pulse. The uterus was felt enlarged 
 to the level of the umbilicus, hard, and excessively tender. 
 
 In consequence of the history of miscarriage, it was considered 
 probable that there were some placental remains in the uterus ; and 
 consequently it was dilated and its cavity examined, but nothing was 
 discovered beyond the fact of its being too large, and though the whole 
 finger was introduced, it did not reach to within an inch or more of the 
 fundus. After this, the metrorrhagia ceased, but the abdominal
 
 656 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 tenderness, fever, and constitutional disturbance continued. The 
 anaemia became daily more marked, and it was suggested that we were 
 dealing with a case of pernicious anaemia. An examination of the 
 blood showed the red corpuscles irregular in outline, deficient, and 
 large quantities of granular matter, and small corpuscles. By 
 abdominal palpation, the tumour was found to be increasing 
 in size, the bulging being especially marked on the right side, 
 whereas the sound passed to its greatest depth towards the left. On 
 visiting, one day, it was found that the outlines of the tumour — which 
 had been carefully mapped out with aniline the day previously — had 
 made a very remarkable increase in all its dimensions, and the margins 
 were softer and less defined. The patient's condition was worse, being 
 more ansemic than ever ; it was thought that possibly there might 
 be some heematic effusion. A needle was passed on several occasions 
 for diagnostic purposes, but gave no further information. An 
 exploratory incision was therefore made. On getting through the 
 abdominal walls, the sub-peritoneal fat was cedematous ; the peritoneum 
 itself thickened ; on opening it, semi- opaque fluid spirted from the 
 opening, and a firm fleshy tumour came into view, part covered by 
 flakes of lymph, pai-t by a greyish exudation, and part black and 
 gangrenous-looking. To the summit and posterior portion of the 
 tumour were attached neighbouring bowel and omentum, in separating 
 which, several separate accumulations of fluid were opened — some 
 consisting of clear serous, some semi-purulent, and some purulent fluid. 
 After clearing the whole mass, we found that the portion to the left 
 consisted of a large sub-involuted uterus, while springing from its right 
 side was a sloughing semi-gangrenous fibroid, larger than a good-sized 
 cocoanut. 
 
 It was evident that the woman's only chance lay in removing the 
 sloughing fibroid, and with it the uterus. This condition not having 
 been anticipated, I was not prepared with the clamp I have previously 
 used in my hysterectomies; and therefore adopted the plan of clamping 
 the broad ligaments separately by long forceps, and then amputated the 
 uterus close to its neck by a circular flap, taking care to cut the exterior 
 layer of uterine tissue at a higher level than the inner. Smart bleeding 
 occurred from some vessels at the root of the broad ligament, which had 
 not been included in the clamp, but it was quickly arrested by application 
 of Spencer Wells' forceps. The tissues of the stump of the broad 
 ligament were then separately ligatured, and all bleeding controlled. 
 The uterine stump was united by double layers of suture — the deep 
 taking a good grip of the muscular wall, and the superficial including 
 only the peritoneal tissue — a very good stump was thus obtained. 
 After freely syphoning the ])eritoneal cavity, and inserting a glass 
 drainage tube, the abdominal wound was closed. 
 
 For the first week, all went well ; little discharge coming from the 
 drainage tube, and temperature and pulse improving. Then symptoms, 
 of intestinal disturbance arose — flatus, vomiting, and twisting pain in 
 the bowels. The upper part of the wound, two inches above opening for 
 drainage tuVje, became distended and hard, and here I had to make a 
 counter opening, evacuating pus in large quantities, and subsequently 
 bowel matter. A cavity formed here as large as a small orange, the 
 floor being formed by convolutions of the bowels, in one of which a
 
 FIFTY CASES OP ABDOMINAL SECTION, 657 
 
 circular opening existed, through wliich the intestinal contents 
 discharged. This oi)ening was evidently high in the intestinal canal, as 
 food escaped through it almost as taken by the mouth. Tlie patient 
 gradually sank. 
 
 At post-mortem, two feet of the small bowel was found to have 
 become invaginated ; the intussusception had started by a portion of 
 the bowel being constricted by adhesions, the result of the previous 
 purulent peritonitis, and sinking within and becoming strangulated by 
 a larger and more patulous portion. The sudden enlargement in the 
 outline of the tumour was probably due to the ojdematous state of the 
 peritoneal tissues surrounding it, and possibly also to exudation in the 
 tumour itself. 
 
 In this case, a purgative was administered on the fifth day, which I 
 have since regretted, as it may have had some influence in producing 
 the intussusception, and it was unnecessary, as the peritoneum was well 
 drained. 
 
 Case 43. —This case of Cfesarian section opens a very large subject. 
 The patient, a primipara, fet. 32, had been in labour three days ; the os 
 had been fully dilated, and the membrane ruptured many hours. 
 
 On visiting her, in consultation with Dr. Roberts, I found the patient 
 a stout muscular woman, who was evidently becoming exhausted. The 
 vagina was dry, rigid, and undilatable; the os was high, the pelvic cavity 
 being very deep; it was only by introducing part of the hand that the 
 presentation could be determined. Forceps had been applied, and 
 re-applied, and failed (brow and hand). The uterus was in a state of 
 tonic irritable contraction. An attempt was made to turn, but utterly 
 failed. It was impossible to convert the case into vertex. Chloroform 
 was administered to deep anaesthesia, but no relaxation of the uterine 
 walls ensued. Our choice lay between craniotomy, which with rigid 
 undilated vagina and deep pelvis would be aia exceedingly difficult and 
 prolonged operation; and in patient's weak state, dangerous, involving 
 much laceration of soft parts; or Caesarian section, which we considered 
 finally would give a little chance. 
 
 The operation was performed on a table, in as good a light as we 
 could command, in a small room. The uterine wall was freely incised, 
 keeping away from cervical portion. The child was so tightly grijDped 
 by the uterus, that in incising the uterine wall, we also scored the skin 
 of the child's back. The child (dead) was extracted with difficulty. 
 Haemorrhage from the placental site was quickly arrested, but a large 
 sinus from the lower part of the uterine wound bled pi'ofusely, and was 
 the cause of much delay in closing the wound. Deep muscular and 
 superficial peritoneal sutures closed the uterine incision. The patient 
 never rallied from the operation, but died shortly after removal to her 
 bed. 
 
 Now to make a few references to the steps of the operation itself, in 
 addition to the preliminary preparations usually recommended. In all 
 cases where I have to open the abdomen, and expect to find changes in 
 the pelvic organs, immediately prior to Operation the vagina is rendered 
 aseptic by thoi'oughly washing out with sti'ong tincture of iodine in 
 solution with hot water. In cases of difliculty, I have gained much by 
 passing one or two fingers into the vagina, while the fingers of the 
 other hand work in the abdominal cavity. When the tubes and ovaries 
 
 lu
 
 658 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 are much bound down by inflammatory products, the assistance thus 
 gained is immense, and but for this manoeuvre, I should have been 
 unable to complete several cases of Tait's operation. 
 
 In making my incision through the abdominal walls, I always avoid 
 dissecting the tissues as far as possible ; the first cut usually divides 
 skin and fat down the muscular walls, the second divides the sheaths of 
 the muscles for the length of the wound. On reaching the sub-peritoneal 
 fat, especially in cases where there has been peritonitis, I find it neces- 
 sary to be exceedingly careful, much more so for oophorectomies than 
 ■when dealing with large cysts. To divide the sub-peritoneal fat cleanly, 
 a very sharp kiaife is required, otherwise it slips under the blade, and 
 the fat is notched and jagged irregularly, which intei-feres with the subse- 
 quent kindly healing. As soon as I have opened the peritoneal cavity 
 sufiiciently to admit the finger, I trust to it rather than to directors 
 (from non-observance of this rule, I once saw an operator seriously 
 injure an adherent coil of bowel). 
 
 For emptying a cyst, I now always incise freely with a sharp-pointed 
 bistoury, turning the patient on her side before so doing, and directing 
 one of my assistants to seize the cut and gaping edge with strong catch 
 forceps. I prefer this infinitely to tapping with a trochar — the latter, 
 being often blunt, fails to penetrate a thick cyst-wall cleanly ; the cyst 
 often tears near the trochar, and permits an escape of fluid ; the tubing 
 is apt to kink, or get clogged, if contents of cyst are thick, if a multi- 
 locular cyst is being dealt with. To open secondai-y cysts satisfactorily, 
 one must eventually, in most cases, open cyst- wall sufiiciently to introduce 
 the finger and feel for projecting cysts. For ligature of stump, I employ 
 the Stafi"ordshire knot, as advised by Lawson Tait. If thick silk is 
 used, it should be well saturated with wax, or otherwise it will fail to 
 run freely, and causes trouble. 
 
 The syphon apparatus, recommended also by Lawson Tait, I have 
 found invaluable in several cases. Where colloid material has escaped 
 fi'eely into the peritoneum, it would have been simply impossible to 
 have cleaned that cavity effectually, without employing some such 
 measure. With a large tube, the pei'itoneum can be flushed with 
 gallons of water in a few minutes ; colloid matex'ial floats out of the 
 wound ; much time is thus saved. It avoids a large amount of sponging 
 and manipulating within the peritoneum, and one can do with far fewer 
 sponges. I have several times completed an ovariotomy, and employed 
 only two or three sponges throughout. It is a mistake to have too 
 many sponges in use ; they are apt to get mislaid amongst the patient's 
 coverings, or in dirty solutions, and at completion of operation cannot 
 be found. I always have a supply ready, but direct the assistant not 
 to use more than is absolutely required. 
 
 For sutures for abdominal walls, I use strong silkworm gut, and 
 include the whole of the tissues of abdominal walls; they are more 
 easily removed than silver wire, and are equally clean and strong, and 
 will remain for months in the wound without dissolving. 
 
 The necessity for carefully counting sponges and forceps, prior to closing 
 the wound, has more than once been xmpleasantly brought home to me. 
 Once, after a severe and difficult operation, I neglected this usual 
 precaution, and on getting my instruments home, found a forceps 
 missing. I had almost decided to return and open the wound, when
 
 FIFTY CASES OP ABDOMINAL SECTION. 659 
 
 •on enquiry of the gentleman who had administered the anaesthetic, 
 I found lie had inadvertently enclosed it in the bag with his anajsthetic 
 apparatus. 
 
 [ employ very simple dressing for the wound. After adjusting 
 sutures and drying surface, it is freely dusted with a powder, composed 
 of one part of finely powdered iodoform with four of amorphous boracic 
 acid. A light layer of absorbent or alembroth wool is laid on this; 
 a broad strip of straj)ping, which encircles the fourth of the body, keeps 
 this in place, and supports the wound in case of vomiting. A large pad 
 of absorbent tow covers the whole abdomen, and a many-tailed bandage 
 is applied over all. 
 
 When possible, I do without drainage tubes. The proper place for 
 draining of the peritoneum is, I consider, the posterior vaginal fornix. 
 In the majority of my cases, the jiatient is advised to pass her water 
 without the assistance of the catheter. 
 
 A few hours after o])eration, if the patient prefers it, she is allowed 
 "to lie partially over on her side, supported by a pillow along the spine. 
 On the third or fourth day following operation, a purgative is generally 
 administered, especially if there is a foul breath, furred tongue, vomiting, 
 persistent distension, or other sign of abdominal disturbances. Opium, 
 if possible, I carefully avoid ; some administer this drug as a mere 
 matter of routine; some immediately any symptoms of peritonitis are 
 apparent. There seems to me little likeliliood of this drug being of any 
 xise in the form of peritonitis we most dread after operation in the 
 abdominal cavity, viz., purulent peritonitis ; and my impression is, that 
 the strong recommendation of the administration of opium, in the 
 treatment of pure peritonitis, depends upon a confusion of ideas and 
 expressions. Peritonitis, as met with in general practice, almost 
 invariably depends upon ])re-existing visceral lesions, and for such 
 visceral lesions opium stands pre-eminent amongst drugs ; but it is 
 illogical to argue that it is of equal applicability in peritonitis, independent 
 of such visceral complications. In fact, in dealing with a pure peritonitis, 
 my belief is that opium does much harm by masking symptoms, and 
 rendering adhesions, when they do form, more dangerous. 
 
 Vomiting has always been my greatest trouble amongst minor 
 complications. I know of nothing that I can depend upon for its relief. 
 As a rule, for two days no food is administered by the mouth. A little 
 scalding water, sipped now and again, is all I generally allow. Ice is 
 avoided, as it induces thirst. Occasionally, when there is much shock, 
 an injection of morphia will temporarily allay sickness. 
 
 lu 2
 
 660 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
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 664 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 TWO CASES OF EXTRA-UTERINE PREGNANCY, SUC- 
 CESSFULLY TREATED BY ABDOMINAL SECTION. 
 
 By Ralph Worrall, M.D., M. Ch. 
 
 Hon. Assistant Sm-geon to the Department for Diseases of Women at the 
 Sydney Hospital. 
 
 At the present time, no subject in Gynaecology is more energetically 
 discussed than that of ectopic gestation. I have, therefore, thought 
 the record of two cases a not unworthy subject to bring before this 
 Congress. 
 
 The first case was that of Mrs. W., set. 33, married fifteen years, 
 four children, last in January 1887. This labour was diflicult, and 
 convalescence slow. A slight red discharge appeared off and on for 
 three months afterwards, and then completely ceased. About seven 
 months after confinement, she noticed a small lump in the right inguinal 
 region, which was painful on exertion. She felt queer, but did not 
 know whether to consider herself pregnant. She was nursing the baby, 
 and, therefore, was not surprised at the absence of her monthly periods. 
 
 On September 27, whilst washing, felt a sudden severe pain in the 
 small tumour, and spreading from there all over the abdomen, causing 
 her to faint. She was carried to bed, and revived by brandy. In 
 about two hours vomiting set in, and the faintness passed off; but the 
 pain continued to be very sevei-e. 
 
 The patient was first seen by me on the following day, September 28, 
 and then presented the local and general signs of acute peritonitis. 
 Bimanual examination disclosed a tender fluctuating swelling, 2)rojecting 
 into the right vaginal fornix, displacing the uterus forwards and to the 
 left, and reaching above nearly to the umbilicus. For the next five days 
 there was no change in her condition, except that the acuteness of the 
 attack passed off, and with it the vomiting. 
 
 On October 5, seven days after the sudden attack of pain, there was 
 a considerable discharge of blood from the uterus, containing shreds of 
 decidua-like membrane. This continuing, the following day, after 
 consultation with Dr. Chambers, I dilated the cervix with Hegar's 
 dilators, and curetted away a great quantity of decidua. The sound 
 passed 4^ inches. Haemorrhage followed this ])rocedure so profusely, 
 that it could only be controlled by injecting a solution of perchloiide 
 of iron (1 in 20). Collapse was marked, and for twenty hours the 
 pulse kept at 160. It gradually resiimed its previous rate of 120, the 
 temperature ranging about 101°. There was no more bleeding after 
 this, but the general condition remained unchanged. There was much 
 sweating, and progressive loss of flesh, but no pain nor shivering. The 
 tumour gradually increased in size, and on October 27 was noted to 
 have extended to two inches above the umbilicus, and to have crossed 
 the middle line for a like distance. 
 
 On November 2, ether was administered by Dr. Jenkins, and 
 assisted by Dr. Chambers, I performed abdominal section. The parietes 
 were highly vascular, and, to the right of the middle line, the cyst was
 
 TWO CASES OF EXTRA-UTERINE PREGNANCY. 665 
 
 found to be uuivei'sally adherent ; to the left, it was free. With the 
 aspirator I drew off about two pints of dai'k grumons-looking fluid, 
 which subsequent examination showed to have a specific gravity of 
 IOl'O, and to be highly albuminous. The microscope showed a few red 
 corpuscles ; others, which were similar to white or pus cells, and much 
 granular matter. The cyst was incised, and its margins stitched to 
 the edges of the abdominal wound. On exploring the interior with the 
 linger, a body the size of a small hen's egg was found engrafted on the 
 lower wall ; it fluctuated, and when incised appeared to contain similar 
 fluid to that in the cyst. A drainage tube was inserted, and the wound 
 closed in the usual manner. Recovery was very slow, the patient being 
 confined to her bed for two months. Sanious pus and necrosed 
 tissue continued to discharge from the cyst, so that I was unable 
 to remove the tube until the end of the third month. At the present 
 time she is in good health, and menstruates normally. 
 
 It will be noticed, that no foetus w'as found, and therefore it may be 
 contended that this was not an instance of extra-uterine pregnancy at all ; 
 if, however, the case be viewed as a whole, I think it will be admitted 
 tl)at tlie diagnosis was warranted by the facts. 
 
 I base my opinion, more particularly, on the detection by the patient 
 — who was very spare — of a small lump ; on her feeling so, that she was 
 led to suspect pregnancy ; on the sudden attack of agonising pain, 
 followed immediately by collajtse, and later on by peritonitis, with 
 discharge of blood and shreds of membrane ; and on the enlargement of 
 the uterus, with formation of decidua. 
 
 The second case (Mrs. H.), I saw in consultation with Dr. Power, 
 on January 11th, 1888. She gave the following history :— yEt. 28; 
 married nine years, two children (last seven years ago), no miscarriages, 
 menstruation had been regular and health good up to eight months 
 before ; she then missed a period, and thought herself pregnant ; the 
 flow, however, appeared a week later, and lasted two weeks. It was 
 regular every month after this until the last two months, during which 
 there was again a break, while for the last two weeks there had been a 
 profuse discharge. From the time the menses flrst ceased, she was 
 troubled with pains in the lower abdomen and occasional vomiting, 
 which culminated during a period, four months before I first saw 
 her, in an attack of agonising pain, followed by collapse. Her usual 
 medical attendant was hastily summoned, and administered morphine 
 hypodermic-ally. Repeated doses in the course of twenty-four hours 
 subdued the first violence of the pain; but sijice then, she had been more 
 or less confined to bed. About three months ago, she noticed " pieces 
 of flesh" coming away with the menstrual flow ; milk also appeared in 
 the breasts, and she felt what appeared to be movements. She con- 
 sulted one of the leading surgeons in Sydney, who told her she was 
 pregnant, and this assurance satisfied her for a time. Becoming 
 alarmed however at her increasing weakness, with occasional shivers 
 and profuse night sweats, she called in Dr. Power, who asked me to see 
 the case. We found her much emaciated. Temperature 101°, pulse 
 112. Tongue dry. Abdomen hard, distended, and moderately tender. 
 Id the hypochondriac and right inguinal regions, extending nearly to 
 the umbilicus, could be distinguished a tense cyst. Per vaginam, 
 the cervix had somewliat the soft feel of pregnancy, the uterus
 
 666 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA, 
 
 was firmly fixed, and the vaginal vault hard and tender ; the sound 
 passed to the left three and a quarter inches. Taking these physical 
 signs in conjunction with the foregoing history, there was little 
 difficulty in arriving at the conclusion, that we had to deal with a case 
 of ectopic gestation. The patient's means not allowing of home treat- 
 ment, she was admitted into the Sydney Hospital, and on January 19 
 I opened the abdomen in the middle line. On raising the omentum, 
 which was extremely vascular, the cyst, which had been felt thi'ough 
 the parietes, was found to be the right broad ligament distended with 
 fluid, and containing in addition some hard body. It was, to a large 
 extent, adherent to surrounding parts, and over its surface ramified 
 several enormous vessels. With the aspirator, I drew off" sufficient 
 stinking pus to relieve the tension ; I then incised, and extracted, in 
 j)ieces, a putrid foetus of about the fifth month. Every precaution was 
 taken to prevent contamination of the peritoneum, and all pus having 
 been removed from the cyst with the syringe, its edges were stitched in 
 the abdominal wound. The placenta was left undistui'bed. A large 
 drainage-tube was inserted, and the cyst syringed out with warm carbolic 
 lotion three times daily. From the third day, small pieces of placenta, 
 loosened by the syringing, were removed by forceps; and on the twelfth 
 day, the entire mass was found to have separated, and was removed in 
 the same way. The foetid discharge rapidly diminished after this, but 
 it was not until the thirtieth day that I was able to take away the 
 drainage-tube. The temperature, winch had ranged from 100° to 103° 
 before operation, fell to 99° afterwards, and never again exceeded 101° ; 
 it did not, however, become perfectly normal until the twentieth day. 
 On the thirty-seventh day, the patient was allowed up, and at the 
 present time is in perfect health. 
 
 In discussing this subject generally, it would be well if attention were 
 directed to some of the points most in dispute. What, for instance, is 
 the opinion of members on the doctrine of Lawson Tait, that all extra- 
 uterine pregnancies are at first tubal 1 For my own part, a close study 
 of the evidence has failed to convince me of its truth, and I agree with 
 Harris that such a theory is refuted by those cases in which the placenta 
 has been found attached to a remote part of the abdominal cavity. 
 Again, do cases of tubal pregnancy frequently, or ever, come under the 
 notice of the surgeon prior to rupture ? and, if they do, what are the 
 diagncstic points upon which reliance should be placed'? and what 
 treatment should be adopted? 
 
 In America, the diagnosis of such a condition appears to be by no 
 nieans infrequent ; and as regards treatment, the profession there are 
 j)retty equally divided into those who advocate abdominal section, and 
 those who rely on electricity. I give in my adhesion to the former, for 
 I cannot conceive how a mode of treatment can long continue to " hold 
 the field," which may prove immediately fatal by causing rupture of the 
 sac, and which, although it can kill the embryo, yet leaves it as a 
 sleeping danger, liable at any time to light up fatal inflammation. 
 
 Finally, we come to the most difficult question of all. What is to be 
 done in cases of advanced ectopic gestation 1 Are we to operate at once, 
 or wait until tlie child be viable ? or until after pseudo-labour and 
 cessation of circulation in the placenta 1 And when we do operate, how 
 should the placenta be dealt with 1 Four times it has been removed
 
 CONDITIONS AVARRANTING REMOVAL OF THE OVARIES AND TUBES. G67 
 
 with success at the time of operation, viz., by Martin, Lazyarewitch^ 
 Breisky, and Eastman — the two latter operators extirpating, in addition, 
 the entire sac. In this ex-section of one or both, as may be possible, 
 lies, I believe, our best hope of coping successfully with this great 
 ditHculty. 
 
 While I shall be glad to hear any criticisms of my own two cases, I 
 think it of much greater importance to endeavour to have recorded, for 
 the benefit of womankind, the matured opinions of Australian surgeons 
 upon the unsolved problems connected with this subject. 
 
 CONDITIONS WARRANTING REMOVAL OF THE OVARIES 
 
 AND TUBES. 
 
 By W. Balls-Headlev, M.A., M.D. Cantab., F.E.C.P. Lond. 
 
 Lecturer on Obstetrics and the Diseases of Women at the University of Melbourne. 
 Hon. Physician to the Women's Hospital. President of the Medical Society of 
 Victoria. Fellow of the Obstetrical and Gynaecological Societies of London, 
 d-c, &c. 
 
 When abdominal section was an operation which involved serious 
 risk to life from imperfection of details, it was natural it should be 
 delayed till the risk to life was immediately palpable and great; and 
 some vague rule existed that ovariotomy was justifiable, when tlie 
 patient could no longer walk half a mile. 
 
 Now, more happily placed by experience and a comparative immunity 
 from danger, the period of operative interference may be regulated and 
 defined more in accordance with science by our experience of the 
 comparative dangers of removal, and of non-interference or delay. 
 
 The diseased structures may be conveniently divided into :— 
 
 (1) Progressive ovarian cystic degeneration, and 
 
 (2) Other abnormal conditions of the ovaries and Fallo[)ian tubes. 
 Progressive ovarian cystic degeneration. — In regard to the first, I 
 
 would at once advance the necessity of immediate operation on the 
 discovery of the tumour, for the following reasons : — 
 
 (1) That the opei'ation in the earlier time is almost without danger, 
 
 (2) That the nature of the disease being progressive, removal will be 
 ultimately compulsory. 
 
 (3) That complications in the course of its development are liable to 
 occur, Avhich greatly enhance the subsequent risk to life, whether 
 uninterfered with, or in the operation. 
 
 That the operation in the earlier time may be almost without danger, in 
 the hands of the lapai'otomist of the present date, will probal^ly be 
 accepted as not requiring proof. The removal of a practically unilocular 
 cyst, without complication, is the easiest form of peritoneal removal
 
 "668 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 that can be found, and reports of sucli successful cases by general 
 practitioners, all over the country, are constantly recorded. The incision 
 may be but of two or three inches in length; the abdominal cavity need 
 not be touched ; no fluid need enter its cavity ; and it would appear 
 that, with the most ordinary abdominal knowledge, there is nothing to 
 cause death. But if in the earlier stages there be difficulties, there can 
 be little doubt that later they will have increased, and one cannot 
 suppose that they can be materially diminished by the progress of the 
 ■disease. 
 
 Nor is there a reasonable expectation but that the operation will 
 ultimately be recpdred. During the interval between the recognition of 
 the tumour and tlie time when the condition of the patient necessitates 
 its removal, the mind and health sufi"er, and danger is incurred of 
 complications presently to be mentioned. It is true that such term 
 may be long, yet it is rare that operation is not ultimately necessary. 
 In a case reported in the Lancet of November 1887, I tapped a cyst 
 ■occupying the pelvis in 1881, and removed a multilocular cyst in 1886. 
 During the interval, the patient had been constantly in the hands of 
 doctors, and was finally a complete invalid. By such delay, a period of 
 health was lost. The longest interval with which I am acquainted is 
 that of Mrs. L., fet. 73, who had, forty-four years previously, noticed a 
 tumour in the right abdomen, and for the last two months had been 
 incapacitated by pain in it. A dermoid cyst, tmiversally adherent, was 
 successfully removed. Thus, in a stationary tumour, as to size, even 
 where degeneration had, or perhaps in consequence of its having 
 proceeded to its utmost limit, removal was preferred by an old lady of 
 73, rather than suff'er the pain induced by its presence. 
 
 The effects of pressure on the abdominal organs and vessels require 
 to be only mentioned. This is not comparable to that of pregnancy, 
 which, however occasionally injurious, is but temporary. The capacity 
 for adaptation is frequently strongly exemplified, and we may wonder 
 at the apparently small inconvenience ; yet such pressure is often 
 evidenced by tlie partial obstruction of the rectum by a pelvic tumour, 
 producing constipation, flatulence, and indigestion, which promote 
 chronic blood jwisoning by absorption of ftecal matters, evidenced by 
 the muddy complexion and de[)ressed spirits. There is the annoyance 
 of frequent or painful micturition, by pressure on the bladder ; perhaps 
 disease of the kidneys with albuminuria, by direct pressure, or 
 more probably by partial obstruction of the ureters ; congestion or 
 disease of the liver, by pressure on it, or compression of the biliary duct ; 
 irritability of the heart, by its displacement upwards ; oedema of the 
 legs, by partial obstruction of the inferior vena cava or great veins ; as 
 well as ascites, from some one of these conditions. Some one or more of 
 these results of pressure are witnessed in most cases of tumour of any 
 size according to its site. 
 
 A complication which much creates new conditions of danger, is the 
 peritonitis resulting in adhesions, whether induced by injury, or by^ 
 inflanmiation extending from within the tumour, or by rupture of a 
 cyst into the abdominal cavity. In the case of a Mrs. M., from whom 
 I removed a large dermoid tumour, the intestine was thus firmly 
 adherent to the abdominal wall, and compressed between it and the 
 tumour, producing alternating obstruction and diarrhoea ; for its
 
 COXDITIONS WARRANTING REMOVAL OF THE OVARIES AND TUBES. 609 
 
 removal, an opening had to be made througli the omentum. In tlie 
 case of Mrs. L., the okl hxdy of seventy-three, similarly with a dermoid 
 tumour, the intestines were closely attached, while the sac was 
 calcareous and in sections, resembling the hydrocephalic skull of a 
 newly-born child. All her arteries were also densely atheromatous. 
 This case was also complicated by a fibroid of the uterus, which occupied 
 the whole pelvis. In a multilocular case of Dr. Hewlett's, in which 
 there was great pain and high alternating temperatures, some small 
 internal cysts of the tumour contained pus, others being of various 
 qualities, and there were most firm adhesions everywhere, especially to 
 the rectum and deep in the pelvis ; an injury was done to the intestine, 
 and she died. IVIrs. H. had a small ovarian tumour, wldch burst into 
 the peritoneal cavity without apparent cause, and death ensued from 
 acute pei'itonitis. 
 
 In a case on which I lately operated, the sac had dissected its way 
 under the broad ligament. She took a long coach journey, and a sudden 
 and large venous hfemorrhage occurred into the sac, so that the tumour 
 greatly and rapidly enlarged, and her temperature rose ; so great Avas 
 the pain, that she could neither lie nor sleej:). At the operation, the 
 sac was found partially mortified from pressure, the fluid being nearly 
 black and very ofiensive ; being aspirated, the gas did not enter the 
 peritoneal cavity ; the condition simulated that of a twisted pedicle. 
 The sac had to be enucleated from the peritoneal membrane ; and, 
 opei-atively, there appeared no reason why immediate recovery should 
 not ensue, but she sank from the effects of the absorbed septicaemia. 
 
 It is unnecessary to multiply such cases. It is certain that the longer 
 the existence of the tumour, the greater the probability of peritonitic 
 adhesions and of consequent difficulty and danger in the operation, 
 of mortification of the sac or its contents, of suppuration, or of 
 spontaneous rupture and fatal peritonitis. 
 
 One of the most frequent causes of immediate danger is the twisting 
 of the pedicle by rotation of the tumour. The size of the tumour, 
 within moderate limits, does not appear to materially affect such rotation, 
 which is rather influenced by its form, and the degree to which it may 
 be steadied by its occupation of the pelvis. The almost invariable result 
 of such rotation is peritonitis, from obstruction to the return of the venous 
 blood ; but the death of the sac will depend on the completeness of such 
 obstruction. In a highly unsatisfactory case, which I had some years 
 ago, a very stout woman, with fat abdominal walls, had a deep lacera- 
 tion of the cervix uteri, with such eversion and granulations as to 
 simulate malignant disease. I performed Emmet's operation on the 
 cervix ; but immediately afterwards her temperature became high, and 
 she got peritonitis, without apparent cause so far as the cervix was 
 concerned. She presently died, and at the post-mortem, an ovarian 
 tumour of the left side, of the size of the head of a six months' fostus, 
 was found to have twisted its pedicle, which induced the fatal inflam- 
 mation. The whole attention had been centred on the condition of the 
 uterus, and the examination of the abdomen of this thick-walled woman 
 had been incomplete prior to 0})eration, and impossible from distension 
 after the advent of inflammation. Probably the rotation of the 
 tumour had been effected by the laxation of the parietes imder the 
 anaesthetic, in conjunction with her being placed in Sims' position.
 
 670 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 A very severe case of this rotation occurred in a patient of Dr. 
 Scblesinger's, of St. Kilda, who had been putting up curtains. She had 
 not suspected a tumour, having had many children. Her peritonitis 
 induced a temperatui'e of 105°. Having thus diagnosed, I removed the 
 blackened gangrenous tumour, and she made an excellent recovery. 
 
 It is probable that the occurrence of pregnancy may tend to increase 
 the probability of such rotation, by the enlarging uterus raising the 
 ovarian tumour out of the pelvis. A patient of Dr. Barker's, of South 
 Melbourne, the mother of three children, got an acute peritonitis, her 
 catamenia having ceased for three months. On its partial subsidence, a 
 tumour was found. On opening the abdomen, the dusky tumour was 
 found full of dark blood, and the constriction of the veins was so great, 
 that an extensive venous rupture was found on the right broad ligament 
 with effusion of blood into the peritoneum, which conditions induced the 
 inflammation. The patient afterwards miscarried, from the healed 
 intestinal adhesions preventing the rise of the ])regnant uterus, but she 
 made a perfect recovery. This case was fully reported in the Lancet of 
 November 1887. 
 
 Yet the constrictions need not be so complete. In the case of a 
 tumour of the size of a child's head at term, the temperatures were 
 erratic, and, it being some eight years ago, I awaited for some weeks 
 their subsidence before operating. This not occurring, the abdomen 
 was opened and the tumour removed ; but a general phlebitis had 
 spread from the twisted compressed ovarian veins to those of the bladder 
 and pelvis, to which she finally succumbed. 
 
 In another case, under the care of Dr. Brownless, the tumour of the 
 size of a child's head had become so much twisted that she was seriously 
 ill with peritonitis, and Dr. Brownless tapped the tumour. The patient 
 continued ill, and was unable to perform her domestic duties ; on 
 operation, I found a dirty brown cyst loosely adherent, but not so 
 unnourished as to be actually gangrenous, yet sufficiently so to injure 
 the system by absorption ; but her recovery was complete. 
 
 These cases are sufficient to show that, whether in small or large 
 tumours, or in combination with pregnancy, rotation of the tumour 
 with dangerous constriction of the veins is liable to occur, whereby 
 greater danger is incurred. 
 
 That malignant disease is liable to be induced by persistent irritation, 
 is established ; and the principle applies not less in the case of ovarian 
 tumours than of other morbid conditions. In November last, I operated 
 on a woman in whom an ovarian tumour of the right side had acquired 
 extensive adhesions to the intestines, and had spread itself deeply under 
 the broad ligament. A second tumour of the left side filled the pelvis, 
 and from its upper edge sprouted epithelial growths, which were in 
 a stage of rapid progress. The cases are not infrequent in which 
 such cancer affects the mesentery and intestines, having apparently 
 originated from the external surface of the ovarian sac ; such additional 
 diseased growths form a further reason for an early removal of such 
 a source of irritation. I have thought it well to adduce so many fatal 
 cases, to show how serious simple cases are made by delay. 
 
 For the several consequences mentioned above, I think it cannot but 
 be our duty to .strongly recommend the removal of progressive ovarian 
 cystic tumours at the earliest date at which we become aware that
 
 CONDITIONS WARRANTING REMOVAL OF THE OVARIES AND TUBES. 671 
 
 they have risen out of the pelvis, or produce such pressure there as 
 to require that it be reduced. 
 
 (2) Of the abnormal conditions of the ovaries and Fallopian tubes. — 
 From the point of view of the desirability of removal, I would first 
 consider the simplest, and advance towards the more serious. 
 
 Thus, certainly the simplest condition is the misplacement of one 
 or both ovaries without adhesions, which so frequently occurs in the 
 parous woman, as the result of lacerated cervix, with its so common 
 sequelcB of sub-involution, retroflexion with dragging on the broad 
 ligaments, and the falling back of an ovary, tube, or of both. 
 Thus the ovary may become pressed between the fundus uteri and 
 the sacrum ; and on replacement, it may find its way to compression by 
 a pessary. Such conditions as this may be met by various modes 
 of treatment, and I have not seen the case which in my opinion 
 necessitated removal. 
 
 As a further com])lication in these cases, pelvic peritonitis may bind 
 down such misplaced ovary, when the case becomes identical in its 
 condition with that of adherent ovary, which so frequently occurs in 
 the nulliparous, next to be considered. 
 
 By far the greater number of cases of aSected ovary or tube, or both, 
 have their origin in the virgin or nullipara, though similar conditions occur 
 in tliose who have been pregnant. The friends of a suffering girl find 
 it necessary to take medical advice, and an examination is made. The 
 simplest condition found, leading in the direction of enlarged ovary or 
 tube, is perhaps a congested os, with evei-sion of cervical mucous 
 membrane, forming the state called "granular"; and there is endo- 
 metritis. Many of these cases simulate a laceration of the cervix, so 
 large appears the opening, caused, however, by the pressure of the 
 constant protrusion. A farther step may be, that the greater weight of 
 the heavy inflamed uterus has depressed the organ in the pelvis ; and, 
 its axes being followed, retroflexion has resulted ; or it may be 
 anteflexion. 
 
 The ovai-ies and tubes have followed such retroflexion, and may be 
 felt misj)laced, tender, and perhaps enlarged. In comparatively few 
 cases thus advanced can the uterus be replaced and retained in position, 
 pelvic peritonitis having bound down the parts. In such peritonitis, the 
 ovaries and tubes participate. 
 
 It appears to me, that the above states are oinginally caused by an 
 inflammatory state of the lining membrane of the uterus, whether 
 induced by a contracted outer or inner os ; by pressure on the canal, 
 from anteflexion ; by deficient development ; by flexion from accident ; 
 by unsatisfied desire ; by excessive develoj)ment and exudation of utei'ine 
 mucous membrane, as in fibrinous dysmenorrhcea ; or by the inflamma- 
 tion of gonorrhoea : that if such inflammatory thickening should exist 
 near the uterine openings of the Fallopian tubes, and be sufficient to 
 hinder or prevent escape of their secretions — a condition which a similar 
 progressive inflammation of the tissues of the tubes, with compression of 
 their proximal ends, serves to confirm — a bar to the escape of secretion is 
 formed, which secretion, now rendered muco-purulent by the inflammatory 
 action, ])asses oiit at the fimbriated extremities, whereby a pelvic 
 peritonitis is caused : that thus the tubes become bound down, and 
 unable to accommodate themselves to the surface of the ovaries : that
 
 672 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 the ovaries probably participate in such peritonitis : that the Graafian 
 follicles, as they develop in due course, can with difficulty burst through 
 the organised peritonitic lymph : that their fluid thus accumulates, and 
 compresses the ovarian tissue, producing pain, local inflammation, and 
 gi'adual absorption of ovarian tissue : and that thus such ovaries are 
 finally liable to become bags divided into a few small cysts, which cysts 
 have no relation to the true progressive ovarian tumour ; or, if such 
 follicles can burst, or the Fallopian distal extremities ai-e free, and can 
 continue to dischai-ge their contents into the peritoneal cavity, successive 
 attacks of more or less local peritonitis with progressive adhesions 
 occur ; but if the fimbriated extremities be occluded as well as the 
 uterine, accumulations in the tubes occur, forming muco-, hydro-, or 
 pyo-salpinx, some relief to which may occasionally be afforded under 
 varying conditions by escape of fluid into the uterine cavity. 
 
 I can adduce cases in every stage of the above-mentioned conditions, 
 from those of the endometritis with extensive granulations, gradually 
 advancing, as noted in the course of years, into the enlargement of the 
 tube or ovary with frequent intermediate pain or invalidism, up to a 
 case now under my care, in which there is extensive granular tissue at 
 the OS ; the uterus is enlarged and inflamed ; the left tube and ovary 
 are enlarged ; there is general peritonitis and pelvic cellulitis ; and the 
 temperatures vary from 99° to 103°. 
 
 From the consideration of the cause and progress of this class of 
 cases, must be derived our opinion as to the desirability or otherwise of 
 removing the ovaries and tubes ; and this will much depend on the 
 period at which we see the patient. Early, nothing may be found but 
 evidence of the inflammation of the lining membrane, with or without 
 some thickening of the tube or ovary ; and undoubtedly, treatment 
 adapted to the state of the uterus may be sufficient to restrain the 
 progress of the disease, at any rate for a considerable time ; yet in 
 several cases which I have watched for years, though the os and cervix 
 appeared to have been rendered quite normal, an attack of pelvic 
 peritonitis would occasionally occur, and a tube or ovary, at times 
 scarcely felt, would enlarge — at last to subside, and the whole genital 
 organs to become atrophic, or advance into permanently diseased bodies. 
 
 In view of the progressive character of the natural histoiy of the 
 disease ; of the formation of the adhesions, which, by lapse of time, 
 become exceedingly dense ; of the liability of fluid, mucus, pus, or cystic, 
 whether of the ovary or tube, escaping into the cavity of the peritoneum, 
 the bowel, or bladder ; any of which complications much increase the 
 danger of operation, I think it may be rightly determined to remove 
 the diseased organs as soon as it is found that the woman can no longer 
 satisfactorily [jerform the duties of her life ; or that frequent attacks of 
 local peritonitis occur ; or when, from one such peritonitis of consider- 
 able duration, it may be inferred that the condition is one of progressive 
 disease ; and that, in the presence of these conditions, the sooner the 
 operation is performed, the less the danger and the greater the expecta- 
 tion of complete recovery. 
 
 Of the numerous complications which may occur, pregnancy may first 
 be mentioned. In a fatal case of septicaemia after miscarriage, the 
 pregnancy had occurred by the healthy tube, the other being a bag of 
 pus. Had an operation successfully removed this tube and ovary, it
 
 CONDITIONS WARRANTING REMOVAL OF THE OVARIES AND TUBES. G73 
 
 may have been that the pregnancy would have continued ; certainly, 
 had the conditions been recognised, the operation should have been 
 performed. In view of the frequency of both tubes or ovaries being 
 affected, the condition of only one of which may have been ascertained 
 even in the case of considerable enlargements, as well as from other 
 considerations and difficulties, it is evident that it is unsafe to trust to 
 minor operations as aspiration, though several aspirated cases have 
 terminated temporarily successfully enough ; yet, in all but one, the 
 parts have continued to give trouble, which would not have been the 
 case had they been successfully removed. 
 
 Tlie dangers of delay were exemplified in a case of many years' 
 standing, in whom at length blood poisoning symptoms were acute, and 
 it was evident life could not long continue. On operation, there was 
 an exceedingly foetid abscess of the left tube, embedded in the lymph of 
 a chronic cellulitis and peritonitis, while the mesentery and omentum 
 were closely adherent in the right pelvic cavity, with general matting 
 and many points of gangrene. All was cleared away as far as possible, 
 but the patient sank. 
 
 No doubt in gonorrhceal extension, the disease of the tubes and 
 ovaries is usually double. In a case I lately read, among others, before 
 the Medical Society of Victoi'ia, a considerable abscess had formed in 
 each ovary, but the left was so large as to push the uterus to the right, 
 and the right abscess was not perceptible before operation on this 
 account, and through the peritonitic distension. She recovered. 
 
 While, then, in the more chronic cases with no immediate danger we 
 may calmly argue out the desirability of removal, such latitude is not 
 justifiable in the more serious cases of blood poisoning temperatures, 
 where, with some suppurative condition of tubes or ovaries, there may 
 be peritonitis, and, indeed, usually is. Here the main point is, not to 
 delay too long ; again, the earlier the operation in this condition, the 
 greater the success. 
 
 Yet of complications, there may well be great hesitation in those 
 cases in which an undesirable delay has permitted rupture into the 
 intestines. Such abscesses fill and empty, and thus alternate till the 
 patient may be worn out, or succumb in an acute attack of peritonitis ; 
 but I have known some cases, in which finally the sac appeared to have 
 closed or become quiescent. Yet this is not the usual result ; and such 
 has been the frequent discomfort and danger, that regret at neglect of 
 the early operation has frequently recurred. In operating with such a 
 ti*act, it is to be anticipated that the adhesion will so break down as to 
 leave a faecal fistula, the danger of which will mainly depend on the 
 extent of cohesion by previous peritonitis. Such cases, as a general 
 rule, are better left alone ; but they should have been removed early, 
 and in no case aspirated, which complicates removal. 
 
 And again, when pelvic cellulitis is a complication, the gravest doubts 
 of successful removal may well be entertained. The anticipated matting 
 of every tissue, coupled with the softening of a pelvic cellulitis, may 
 readily permit the stripping off" of the peritoneum with underlying 
 cellular tissue, leaving a raw cavity, instead of the mere separation of 
 adherent surfaces of peritoneum ; and as the whole contents of the 
 pelvis are intimately connected l)y inflammatory products, it is impossible 
 in such an operation carefully to dissect part from part. In such cases, 
 
 Ix
 
 674 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 it is a mattei' of anxious cai'e to decide whether to hope that tlie patient 
 will not die of her almost necessarily progressive disease, or to attempt 
 removal ; and again the rule holds good that, if it has to be done, the 
 earlier the better, before the feebleness of the patient shuts out all hope. 
 The conclusions thus arrived at are : — 
 
 (1) That in the earlier or more chronic stages, the rule may be, that 
 removal is desirable when a woman can no longer satisfactorily perform 
 the duties of her life ; or when attacks of local peritonitis are frequent, 
 or where such an attack is of considerable duration. 
 
 (2) That in the stages of blood poisoning from absorption or presence 
 of pus, without pelvic cellulitis or previous rupture into the intestine, 
 removal is essential. 
 
 (3) That in the late conditions with pelvic cellulitis, or rupture into 
 the intestine, such operation should only be entered upon as an alterna- 
 tive from the anticipation of eventual death, but be performed even 
 then as early as such fatal natural conclusion seems positive. 
 
 TWISTING OF PEDICLE IN OVARIA.N TUMOURS. 
 
 By Wm. Gardner, M.D., C.M. Glas. 
 
 Lecturer on Surgery, Adelaide University. Senior Surgeon to Adelaide Hospital. 
 
 The subject of this short paper is of great interest to all gynaecologists 
 and operating surgeons generally, both on account of the difficulties 
 involved in the diagnosis, and also because many important points in 
 treatment yet remain to be definitely answered. Personally, 1 had not 
 given any attention to this condition until the occurrence of two cases 
 in my practice, within three months, led me to study the literature of 
 the subject. Appended to this paper are short notes of the cases to 
 which I refer, and they are instructive because they furnish examples 
 of successful and unsuccessful terminations. In Case No. 1, it is evident 
 that rotation of the cyst took place with twisting of the pedicle, followed 
 by extravasation of blood into the cyst and peritonitis, with the 
 formation of adhesions as a conservative process, and designed to assist 
 in carrying blood to the tumour, the supply of which must have been to 
 a large extent cut oflf by the rotation of the pedicle. 
 
 The patient was not known at the onset of the symptoms to be the 
 bearer of an ovarian cyst, and the appearance of the pedicle, when cut, 
 was strongly suggestive of what one would regard in other parts as 
 gangrene. 
 
 Case No. 2 is an example of a patient not known to be suffering from 
 ovarian tumour, but in whose case rotation occurred during pregnancy, 
 followed by extravasation of blood into the cyst, and then finally 
 rupture into the abdominal cavity and peritonitis. 
 
 In both cases the symptoms, as interpreted by the medical attendants, 
 pointed to obstruction of the bowels; but in the first case, the discovery 
 and aspiration of a tumour, under ether, led to a correct diagnosis of 
 ovarian cyst. In the second case, however, no diagnosis was arrived at,
 
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 TWISTING OF PEDICLE IX OVARIAN TUMOURS. 675 
 
 as tlie tumour was small, and the patient was four months advanced in 
 pregnancy. It is noteworthy, that the direction of the twist in the 
 second case, which was a right ovarian cyst, was from ri^ht to left; and 
 in the former, it was from left to right, the left ovary being involved in 
 til is case. 
 
 The treatment adopted in tlie first case was to wait until the acute 
 symj)toiiis had passed off, and then perform laparotomy, which 
 fortunately was successful. In the second case, the })roblem presented 
 to us was a much easier one, as diagnosis, after rupture of an ovarian 
 cyst not known to be present, is impossible. We came to a decision to 
 perform laparotomy for some unknown abdominal condition, as the 
 patient was rapidly becoming worse, and it was a last, thougli not very 
 promising, chance. The result of the laparotomy was failure, and 
 al)ortion took place ; but, as cure could not have taken place by nature's 
 \inaided efforts, the operation was in my opinion fully justified, although 
 the duration of the illness (a week) militated against success. 
 
 In the International Journal of the Medical Sciences, October 188S, 
 Mr. Thornton, in an excellent paper from which I quote freely, states 
 that out of 600 cases of ovariotomy, fifty-seven had twisted pedicles, 
 i.e., more than 9 ]ier cent. ; and seven of these had ruptured at the 
 date of operation, i.e., 14 per cent., or about 1 per cent, of the whole 
 number of cases. Of the fifty-seven cases, four died after ovariotomy; 
 and of the seven cases of ruptured cyst, one only died. 
 
 History. — Thornton states that Patruben, in 1855, recorded a case of 
 rapidly fatal intra-cystic htemorrhage, from rotation of an ovarian 
 tumour. Rokitansky, in 18-41, first drew attention to the subject in his 
 "Handbook of Pathological Anatomy;" and in 1865, the same author 
 published a paper on " Strangulation of Ovarian Tumours by Rotation." 
 In making autopsies in fifty-eight cases of deaths from ovarian disease, 
 he found twisted pedicles in eight cases, Spencer Wells, at page 61 of 
 his work on " Ovarian and Uterine Tumours," says that he met with 
 this condition in from eighteen to twenty cases, and in two of the cases 
 it caused death before operation. 
 
 Wiltshire, in the " Transactions of the Pathological Society of 
 London, 1868," has published notes of a case in which he successfully 
 removed a strangulated ovarian tumour during ihe acute stage of axial 
 rotation. 
 
 Lawson Tait and Alban Doran have published a number of cases, and 
 have written in their resjjective works on " Diseases of the Ovaries " on 
 the subject, and to these works we shall later on refei". Scattered 
 through the medical literature of the last few years are a number of 
 single cases, illustrating more or less completely the various interesting 
 phenomena accompanying the condition of twisted pedicle. 
 
 Results of the Accident on the Tumour and Surrounding 
 
 Parts. 
 
 Spencer Wells says that, after rotation has occurred, " the great veins 
 are compressed, and blood continues to pour in by the arteries. Con- 
 gestion, exudation of serum, extravasation of blood into the cysts, and 
 nipture follow in rapid succession; antl unless timely relief is afforded 
 by ovariotomy, the patient soon sinks. If the rotations are so complete 
 and enduring as to strangulate the arteries of the pedicle, gangrene is 
 
 Ix 2
 
 676 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 inevitable. In other instances, the constriction of the vessels by the 
 change of ]iosition is so moderate, that the tumour itself is not much 
 affected, but it remains stationary, and contracts adhesions to some of 
 the viscera, and cannot be replaced." 
 
 Eokitansky mentions one case in which a strong cord-like band so 
 ligatured the sigmoid flexure of the bowel, that the slightest change of 
 position rendered it impermeable. The bowel has also got so entangled 
 with a long pedicle, during rotation, as to become strangulated. Even 
 after new vascular alliances have been formed between the rotated 
 tumour and the omentum and viscera, the pedicle has by some means, 
 either tension or pressure, been divided. In such a state of transplanta- 
 tion, the tumour has drawn its nutriment through the newly-formed 
 vessels of the plastic adhesions, and its ])arasitic existence has not been 
 much less vigorous than before. 
 
 Thornton expresses his views as to the results of rotation in the 
 following passage : — " First we have interference with the circulation ; 
 the firm arteries, resisting pressure, continue to pump in blood, which 
 the yielding veins cannot return quickly enough, so that congestion 
 with exudation of serum, rupture of vessels, and extravasation of blood 
 and rapid enlargement of the cyst, result. These ]H'ocesses are accom- 
 panied by acute pain, chiefly referred to the pedicle, and due to the 
 pressure to which its nerves are subjected, but also in extreme cases 
 extending over the whole surface of the tumour ; also by reflex symp- 
 toms, such as vomiting and collapse, and l)y fainting and pallor, the 
 result of internal hemorrhage. The strong fibrous covering of the 
 tumour prevents ru]iture of the external vessels, and in the majority of 
 cases confines the effused blood ; but if, as sometimes happens, previous 
 inflammatory changes in the cyst-wall have caused blocking of vessels 
 and deficient nutrition of portion of its substance, these, being soft and 
 lacerable, give way, and the mixture of ovarian fluid, serum, blood, and 
 clot, is poured into the peritoneum. This accident is, as we have seen, 
 often speedily fatal ; but in many cases, the pedicle vessels being closed 
 by clot, the haemorrhage ceases ; the effused matters, after causing more 
 or less peritonitis and fusion of parts, are absorbed, and the patient 
 slowly recovers, till the rent in the cyst heals, and the adhesions 
 affording a new blood-supply, the tumour starts growing again." 
 
 Theories as to Causation. 
 
 In 1880, Lawson Tait read a paper before the Obstetrical Society 
 founded on three cases of twisted pedicle in right-sided tumours, and 
 advanced the theory that the solid wedge of ft^ces passing down the 
 rectum was the cause of the rotation. This may be one of the causes, 
 but cannot be the only one, as Thornton's cases show an almost equal 
 number of twisted pedicles in right and left-sided tumours, and this 
 theory would not explain the latter. Thornton, in a paper published 
 in 1877, suggested " that the peristaltic action of the intestines may 
 start the process, and that the twist once started, the pulsations through 
 the cord tlius formed would tend to increase it." He also said, "If the 
 case is complicated with pregnancy, the foetal movements may play an 
 important part." 
 
 Doran, in describing a post-mortem on a case of ovarian tumour 
 complicated with cancer of the rectum, says : — " A little artificial
 
 TWISTING OF PEDICLE IN OVARIAN TUMOURS. G77 
 
 ilistension of the intestine caused it to press against the tumour so as to 
 push its left side backward, stretching and twisting the pedicle." Ther'e 
 was no twist in the pedicle, but its vessels were blocked with old clot, 
 and he considered it probable that the loading ot the rectum, caused by 
 the cancerous stricture, may have caused enough twist to set u]) clotting 
 in the vessels. Doran's opinion is that " as a rule the twisting of a 
 pedicle is to be explained by the simple doctrine that the tumour, 
 pressed u]>on by the viscera and even the costal cartilages above, and 
 by the i)elvic structures below, but comparatively free laterally and 
 anteriorly, rotates on its own axis every time that the })atient, after 
 walking or lying on her back, 'turns round and rests on her side.'" 
 
 There is a general consensus of opinion, that pregnancy predisposes to 
 rotation in ovarian tumours ; foui'teen out of Thornton's fifty-seven 
 cases were thus associated. 
 
 Tapping has also been suggested as a possible cause of rotation, and 
 in several recorded cases it certainly preceded the accident by a few 
 days. 
 
 Other causes too numerous to mention, and unfortunately, also, too 
 insusceptible of proof, have been suggested. They are mostly of the 
 2x>st hoc, propter hoc kind. Klob has suggested the alternate tilling and 
 emptying of the bladder as a cause. 
 
 Direction op the Twist. 
 
 For tumours of the right side, the twist is generally from right to left, 
 and the reverse in tumours of the left side. My two cases followed the 
 general rule, but there are a few undoubted instances on record in which 
 twisting in the reverse way took place. Dermoid and small tumours 
 are .specially liable to rotate. 
 
 PtEMARKS. 
 
 Looking back on my experiences in ovariotomy, I feel sure that I 
 have frequently passed by unnoticed minor degrees of rotation, but the 
 cases now recorded are the only ones in which I have met w-ith serious 
 pathological results. As far as my reading goes, the only contribution 
 in Australia to the interesting subject of rotation of ovarian tumours 
 was made by Dr. Balls-Headley, in the AvMralian Medical Journal of 
 November ].5th, 18S0 ; and although in the discussion which followed, 
 some of the speakers ventured to doubt whether the case was one 
 of axial rotation, I cannot help thinking, from the reported condition of 
 the cyst contents, and the recently-formed adhesions, that the operator 
 ■was correct in his interpretation of the facts. 
 
 Case I. 
 
 Mrs. C, a;t. 38, married, residing in Adelaide. Was delivered of 
 her last child eighteen months ago, and since has complained of i)ain in 
 the left ovarian region, and the last few ))eriods have been profuse for 
 tlie first and second days, and then stopped suddeidy. She was attended 
 four months ago for constijiation and pain in the left iliac region, 
 supposed to be due to colic, and relieved by enemata. 
 
 Present illness began on the morning of August 16, 1888, with acute 
 pain in the left iliac and lumbar regions, accompanied with nausea,
 
 678 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 vomiting, and constipation. Patient stated that the period had stopped 
 suddenly on the 14th. Temperature found to be normal ; pulse 84, full 
 and regular, features pinched, abdomen excessively tender in the above- 
 named regions, with an ill-defined sense of fulness. Ordered hot 
 fomentations, and a mixture containing morphia. 
 
 August 18. — Pain much more severe; vomiting continues; bowels 
 still unrelieved in spite of enemata ; pulse 84, temperature 99*8°. 
 
 August 19.- — Slight improvement; sickness has ceased; bowels not 
 yet opened ; pulse and temperature as before. 11 p.m. — Patient fainted 
 on getting out of bed to pass ui-ine, and remained unconscious for half 
 an hour. Takes nourishment badly. Rectum examined and found 
 normal. Vaginal examination shows no fulness. Uterus not fixed ; 
 painful on pressure. Abdomen much fuller on the lower left side, with 
 severe pain ; no sleep. 
 
 August 20, 8 a.m. — Much worse this morning. Face dusky, features 
 pinched. Pulse 120, feeble, regular. Breathing quick and shallow. 
 Ko sickness, and bowels have not acted. Tongue moist, but furred. 
 Abdomen still more swollen, and tender in left iliac and lumbar regions. 
 11 a.m. — Seen by Dr. Gardner in consultation with Dr. Marten, but 
 abdominal tenderness Avas so great that palpation could not be borne. 
 It was decided to try if the swelling was due to ftecal accumulation by 
 passing a long rectal tube, and administering an oil and gruel enema. 
 Flatus passed, but no motion ; Jq gr. of stvychnife sulj^h. was given 
 hypodermically every four hours. 6.15 p.m. — Pulse 120, feeble; no 
 sickness, and no action of bowels. Tongue moist, but furred. As there 
 was no improvement, it was determined to place the patient under the 
 influence of ether. The abdomen was thoroughly examined, and an 
 elastic and movable swelling was detected in the left lumbar and iliac 
 region, extending high up and well to the left of the mid-line. Vaginal 
 and rectal examination revealed nothing abnormal. Temperature 102°. 
 
 August 21. — Patient was again placed under ether, and the tumour 
 aspirated by Dr. Marten, and thirty ounces of red, glairy fluid removed. 
 Tlie operation gave great relief. Under the microscope were seen 
 numerous red and white blood-corpuscles, and some variable sized oily- 
 looking rounded masses. The fluid was sticky, and highly albuminous. 
 Ko Drysdale corpuscles found. 6 p.m. — No action of bowels. Ordered 
 calomel gr. iv., immediately, to be followed by ^j hst. sennje co. if 
 required. Temperature 99'8° ; pulse 116. Pain and fulness in the 
 left iliac and lumbar regions have almost disappeared. Retention of 
 urine relieved by catheter. 
 
 August 22. — Seen with Dr. Gardner. Swelling can still be detected, 
 but is not tender, and has a well-defined rounded liorder. 
 
 Septemljer 5.— Bowels have acted freely, and the patient continues to 
 make satisfactory progress as regards her general health, and there is 
 no increase in the size of the tumour. Temperature varies during each 
 day from 99' to 100°. 
 
 September 24. — Patient is in e.xcellent spirits, but has wasted slightly 
 and complains of pain in the left ovarian region, increased by movement. 
 Tongue clean ; appetite fair. The abdomen is iri'egularly distended and 
 ])rominent, especially over the lower left half where there is increased 
 resistance, dulness on percussion, and marked tenderness. No dulness 
 in either flank; measures forty-two inches at umbilicus, nine and a
 
 TWISTING OF PEDICLE IN OVARIAN TUMOURS. 679 
 
 (juarter from lower anterior superior spine to umbilicus, and eight and 
 tliree-cpiarters between the same j)oints on the right side. 
 
 September 27. — On this date, at 8.30 a.m., ovariotomy was performed 
 by Dr. Gardner in the Private Hospital, South Terrace, to which she 
 had been removed. Dr. Marten assisted, and Dr. Giles administered 
 ether. An incision was made three inches long in the linea alba, and 
 carried through an inch of fat, and the peritoneum was opened to the 
 full extent of the external incision. There were recent adhesions in 
 front, which were easily broken down. When the trocar was thrust 
 into the tumour, three pints of dark thin bloody fluid escaped, and ran 
 freely, also into the abdominal cavity by the side of the canula, as the 
 cyst-wall was so friable, that it gave way on the slightest touch. 
 Adhesions, which were numerous, were then dealt with, and the pedicle 
 was found to be rotated from left to right, and the tumour required to 
 be tui'ned completely round twice in the opposite way, to get rid of the 
 axial rotation. The pedicle was transfixed and tied with Spencer Wells' 
 silk, and the cyst removed. The stump was of a greenish black hue, 
 such as we associate with gangrene in other parts, and it was deemed 
 advisable to pare it down as closely as possible to the ligature. Tlie 
 right ovary was found to be slightly enlarged, and was removed. The 
 tumour was found to be almost gangrenous, owing to twisting of its 
 pedicle, and was full of old blood-clots. Its blackish-green surface was 
 covered with fairly recent lymph. The abdomen was then washed out 
 with warm boracic solution, until it was thoroughly clean. A glass 
 drainage tube was inserted into the lower angle of the wound, which 
 was closed with silk sutures in the usual way. Patient stood the 
 operation well, made a slow recovery, and is now perfectly Avell, except 
 that she is much troubled with flushes. 
 
 For the above notes, I am indebted to my friend. Dr. Marten, and I 
 have also to thank him for the opportunity of seeing this very interest- 
 ing case, and performing the operation, which resulted so successfully. 
 
 Case II 
 Mi's. C, set. 41, has had eight children, with post-partum hfemorrhage 
 on several occasions, and after the last child was born the haemorrhage 
 was severe, although the labour was in other respects easy. Recovery 
 was in each case good, exce])t after the first, when she was confined 
 to bed for eight months, owing to some unknown cause. Previous 
 health good, except occasional bilious attacks and flatulence. Present 
 attack began on October 26, 1888, by two sudden attacks of pain in the 
 right iliac region, which passed off in a few minutes. She was first seen 
 by Dr. AUwork, at 3 p.m. on October 28, when the face had an anxious 
 expression, and the skin was slightly tinged with bile. The legs were 
 drawn up on the abdomen; tem])erature normal, pulse 11-5, small and 
 feeble. Pregnancy had advanced to four months. She complained of 
 intense pain, which commenced two hours before, in the right iliac 
 region, with intermittent spasms of agonising pain eA-ery five or six 
 minutes, extending across the lower ]>art of the abdomen, and down the 
 inner side of the right thigh to the knee; and during the paroxysms, the 
 nght thigh became exquisitely tender. At the first onset of pain, 
 passed two normal stools at short intervals, giving temporary relief. 
 Vomiting followed immediately, the ejecta consisting at first of food and
 
 680 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 then mucus and bile. There was extreme tenderness over the right iliac 
 region, where an irregular, somewhat cylindrical mass could be felt 
 extending upwards towards the liver. There was dulness on deep 
 percussion ; no fluctuation ; swelling elastic, and exceedingly tender. 
 There was also some tenderness over the whole abdomen, and particularly 
 over the uterus. Examination per vaginam revealed no signs of 
 threatening abortion. Opiates were given internally, and soothing 
 fomentations applied to the abdomen. 
 
 October 29. — Very little relief; one attack of vomiting since last 
 night — not stercoraceous. No motion nor flatus passed, but intestines 
 distended. Aperients and copious enemata administered, without relief, 
 through a long rectal tube. Temperature normal; pulse 120, feeble. 
 
 October 30. — The paroxysms of pain are slightly less severe. 
 
 October 31. — Increasing distress, and abdomen gradually becoming 
 more tympanitic. Opiate treatment continued. 
 
 November 1. — Small amount of flatus passed once, but no motion. 
 Patient anaesthetised with chloroform, and insufiiation performed per 
 rectum without result. No blood passed per anum. 
 
 November 2, 7 a.m. — Small amount of flatus, and also faeces and mucus 
 passed. Dr. Gardner was telegraphed for from Adelaide, and saw the 
 patient with me. At the consultation it was decided, as a last hope, to 
 perform laymrotomy, and at noon the patient was placed under the influence 
 of ether by Dr. Yeatman. Dr. Gardner having emptied the bladder, 
 made the usual abdominal incision in thelinea alba; and on opening the 
 peritoneum, blood and clots escaped freely. The whole hand was then 
 passed into the abdomen in the direction of the right iliac fossa, 
 and a mass discovered which had some loose connections to the 
 ascending colon. These were easily separated, and tracing the tumour 
 back, it was found to be connected by the ovarian ligament with 
 the right horn of the uterus. It was then drawn out of the external 
 oi)ening, and found to be an ovarian tumour, which was rotated, and 
 had ruptured. The rotation was from right to left, and two complete 
 rotations of it had to be made in the opi)osite direction to prepare the 
 pedicle for ligature. The pedicle was long, and the opening in the cyst 
 admitted several fingers. The ligatiu-e was then applied in the usual 
 way, and the abdomen thoroughly washed out with boric acid lotion. 
 A drainage tube was inserted, and the abdomen closed with silk sutures. 
 7.30 ]).m. — Patient in a semi-comatose condition. Temperature 102°; 
 pulse 175, almost imperceptible; respirations 40, shallow. Administered 
 stimulant enemata and ether hypodermically, but condition did not 
 impx'ove, and the patient, after aborting, gradually sank, and died at 
 6 p.m. on November 3, the day after the operation. 
 
 For the above notes, I am deeply indebted to Dr. Allwork, who made 
 them at great personal inconvenience, as he was practising in a town 
 nine miles distant from the patient's residence, and I was not able to 
 see her after the operation— she was residing sixty-two miles out of 
 Adelaide. Not much was to l)e expected from an operation performed 
 so late in such a case, but we deemed it right to give the patient the 
 remote chance; however, the "unexpected," which so frequently 
 happens, unfortunately failed to do so in this case.
 
 PUERPERAL HYSTERECTOMY. 681 
 
 PUERPERAL HYSTERECTOMY; OR PORRO'S OPERATION 
 BY A NEW METHOD. 
 
 By H. WiDENiiAM Maunsell, M.D. 
 
 Honorary Surgeon, Dunedin Hospital. 
 
 Porro, of Pavia, was the first surgeon who successfully amputated the 
 pregnant uterus in a woman — Utero-ovarian amputation as a mode of 
 completing C;esarian section. The operation was performed twelve 
 years ago in the Maternity Hospital of Pavia, on a woman deformed 
 by rickets. Since then, the operation has been performed two hundred 
 times, with a mortality of nearly fifty per cent. 
 
 Instruments required. — Sti'ong scalpel, large sti'ong circular ampu- 
 tating knife, two pairs of strong scissors, eighteen pairs of Spencer 
 Wells' artery forceps, two strong slightly-curved needles, on handles ; 
 curved surgical needles, suitable sutures and ligatures, specially 
 prepared ; yaixl of strong rubber tubing, for tourniqi;et ; Tait's recent 
 modification of Kceberle's serre-nceud, with needle for transfixing 
 pedicle ; three large flat sponges, the bichloride antiseptic solution, 
 and large quantities of liot water. 
 
 In performing laparotomy in the median line, the incision should 
 be lower than for simple C?esarian section, as the stump of the 
 amputated uterus has to be brought out immediately above the pubes, 
 as in hysterectomy. A sound should be passed into the bladder, and 
 BAery care taken not to injure it, as it is often dragged up above the 
 pubes in these cases. 
 
 New Method of Treating the Stump. 
 
 (1) The incision should be long enough to permit of the gravid 
 uterus being taken out of the cavity of the abdomen. 
 
 (2) While an assistant takes charge of the gravid uterus, place a 
 large flat sponge, wrung out of hot water, over the bowels, to keep 
 them warm and out of sight ; and rapidly suture up the Avound Avith 
 strong salmon silkAvorm gut, as far as the neck of the uterus, Avhich 
 is pressed toAvards the pubic end of the Avound by an assistant. 
 
 (3) Open uterus by longitudinal incision in upper third, and remove 
 child, leaving placenta behind. 
 
 (•i) Transfix the neck of the uterus with a strong transfixion pin, 
 and apply the rubber tourniquet below it. 
 
 (5) Ligature the A-essels of the broad ligament en masse on both side.s, 
 immediately aboA-e the pin and torniquet. 
 
 (6) Pack round Avitli sponges. Make transverse incision through 
 peritoneum coA'ering the top of the uterus, and rapidly reflect it to 
 Avithin half an inch of the rubber tourniquet. If the peritoneum is 
 found to be A'ery adherent to the fundus, make a circular incision all 
 round the upper third of the uterus, and reflect it as above described. 
 
 (7) Apply Kuiberle's pin and wire ecraseur to the neck of tJie 
 deperitonised uterus. 
 
 (8) Amputate the uterus Avith a large circular amputating knife, 
 leaving a fair stump beyond the pin.
 
 682 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 (9) Apply torsion and ligature to any bleeding points, as the 
 assistant slowly and cautiously removes the rubber tourniquet and 
 transfixion pin immediately above it. 
 
 (10) Secure the lower end of the laparotomy wound, immediately 
 above the stump, Avith a strong acupuncture needle. 
 
 (11) Place a thin layer of iodoform wool under the reflected 
 peritoneum, which is spread out like a saucer round the stump. Secure 
 the edges of the reflected pei^itoneum loosely to the skin by five or six 
 horse-hair sutures. 
 
 (12) Screw up the wire clamp daily. Dress the stump night and 
 morning ^Aith a thick layer of iodoform and absorbent wool. 
 
 I have advocated this method of treating the stump in cases of 
 hysterectomy for fibroids. As far as I know, this method of treating 
 the stump has never been tried or suggested before. Its advantages 
 may be summed up as follows : — • 
 
 (a) The bladder and vxreters cannot be injured by the ecraseur. 
 
 (b) There is no tension of the peritoneum or broad ligaments. 
 
 (c) The stump cannot retract into the cavity of the peritoneum. 
 
 (d) The stump is effectually shut off from the cavity of the 
 peritoneum ; and as it shrinks and sloughs away, it is impossible for the 
 matter to drain on to the abdominal wound, or into the cavity of the 
 peritoneum. 
 
 Godson's Classification. 
 
 (1) True Porro operation — fcetus A'iable. 
 
 (2) Utero-ovarian amputation performed during pregnancy, before 
 ftetus is viable. 
 
 (3) Laparotomy for removal of fo?tus from abdominal cavity, followed 
 by amputation of ruptured uterus and ovaries. 
 
 The same treatment of the stump applies with equal force to all these 
 conditions. 
 
 In puerperal hysterectomy, experience is strongly in favour of the 
 extra-peritoneal method of treating the pedicle. According to Godson's 
 tables, eleven died out of fifteen cases treated by intra-peritoneal 
 methods. 
 
 DISCUSSION. 
 
 Dr. Jakins supplemented Dr. Rowan's experience with a case of 
 his own, in which an ovarian tumour had been diagnosed as a 
 complication of pregnancy in a single girl. Abdominal section was 
 successfully peiformed. He did not quite see the necessity for Dr. 
 Batchelor's ahdoniinal section if the pelvic diameters were normal. 
 
 Dr. Balls-Headley agreed tlioroughly with Dr. Batchelor, as to his 
 views on the treatnient of diseased tubes and ovaries. There could be 
 only one metliod of dealing with such conditions — viz., i-emoval. Dr. 
 Batchelor's Ccesarian section opened up the question as to whether, 
 witli our increasing knowledge of abdominal .surgery, we should do 
 craniotomy at all. He favoured the treatment adopted in this instance
 
 DISCUSSION. 683 
 
 by the President. In his recent experiences in an osteomalacia district 
 in Gei'many, lie had had numbers of women pointed out to him, the 
 subjects of Caesarian section- — as many as five times in the same woman. 
 Dr. Batchelor had not given the pelvic measurements. He agreed with 
 Dr. Eowan's views as to ovaiiotomy during pregnancy — a much safer 
 proceeding than the risk of twisting of the pedicle, with death of the 
 sac or prematui'e confinement. 
 
 Dr. WuRRALL agreed with Dr. Eowan, especially (as pointed out by 
 Dr. Balls-Headley) as the twisting of the pedicle increased the danger. 
 Like Dr. Batchelor, he thought that oophorectomy checked the growth 
 of fibroids ; but in cases of cancer, he pi-eferred the operation through 
 the vagina. He thought craniotomy, or even the removal of the uterus 
 altogether, applied to the obstetric case of Dr. Batchelor. He preferred 
 No. 2 silk for ligature. On one occasion, after operation, he re-opened 
 the abdomen on the eighth day ; found it full of pus, washed it out, 
 with good results. In his experience, ligatures often remained, and 
 came away after months, with pus in their track. 
 
 Dr. RowAX was quite in accord with Dr. Balls-Headley's views. He 
 believed that rest and other measures should be tried before resorting to 
 the heroic operation. He had had cases where rest had relieved 
 troublesome ovaries ; but where an ovary was encysted and bound down, 
 and laid a woman up, he felt himself justified in operating. He had 
 done so some sixty or seventy times, and had no cause for regret. 
 With regard to Dr. Batchelor's Caesarian section, he had seen only 
 one case. He had been consulted by a woman, two or three months 
 married, as to why she was not pregnant. He found the vagina 
 occluded, and thought she was not likely to become pregnant. The 
 next time he saw her, she had been in labour fifty-two hours, with no 
 possibility of delivery per vias naturales. He performed Caesarian 
 section, using catgut sutures for the uterine wall. The patient unfor- 
 tunately collapsed the second day, all the sutures having come undone. 
 In reply to Dr. Balls-Headley, he stated the sutures were ordinary 
 carbolised gut. The knots became untied. He would like to ask Dr. 
 Worrall if the absence of foetal consistence did not (in one of his two 
 ca.ses) point to something else 1 
 
 Dr. Meyer endorsed the views of the President, their soundness 
 being manifest from his practical and happy results. He begged, 
 however, to differ from the propriety of Caesarian section in the 
 obstetric case. He had met with a very similar case, where two medical 
 men advised section in a woman who had been some forty hours in 
 labour, and on whom forceps and version had been carefully tried in 
 vain. He performed craniotomy with a perfectly successful result. 
 The case read exactly like Dr. Batchelor's. He was not ready to discard 
 craniotomy from the list of obstetric operations. 
 
 The President said that he preferred Caesarian section in this case, 
 having in mind a similar one — a case of convulsions — where (after 
 weighing the value of a Porro) he delivered by vagina, with the result — ■ 
 death in twelve hours. He had no right to render the woman sterile. 
 Another ))oint was the absence of the husband. As to the propriety of 
 abdominal section in cases of cancer, he was opposed to Dr. Worrall, 
 who favoured the vaginal method. In this case, the broad ligaments 
 being involved, the only question was — Should operation be done at
 
 684 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 all? He thought if so, there was but one way. Although opposed to 
 all authorities, he would (unless with a very capacious vagina, an easily 
 prolapsed uterus, and all circumstances favourable) invariably make an 
 abdominal incision. He saw no reason why a small incision of two or 
 three inches should endanger the operation. You saw what you were 
 doing, and did not injure the ureters. Although statistics were in 
 favour of vaginal operation, it was probably because the worst cases had 
 been treated by abdominal section. He quite agreed with Dr. Eowan, 
 not to operate till other measures had been tried and failed. The 
 dangers of o]ieration at delivery, favoured operation on tumours during 
 pregnancy. Neglected tumours often sloughed. The doubt which Dr. 
 Ptowan had expressed as to the nature of one of Dr. Worrall's cases, 
 was removed by the fact that decidua came away. 
 
 SHOULD A MEDICAL MAN PRACTISE MIDWIFERY, 
 WHILE IN CHARGE OF A CASE OF PUERPERAL 
 FEVER ? 
 
 By Jos. C. Verco, M.D. Lond., F.R.C.S. Eng. 
 
 Joiut Lecturer on Medicine at the University of Adelaide. Honorary Physician at 
 the Adelaide Hospital. 
 
 There is an opinion current among the people and in medical circles, 
 that the occurrence of a case of puerperal fever in the practice of a 
 medical man demands the discontinuance of obstetric work, until such 
 time as he shall be cei'tainly free from the case and its contaminating 
 influence. This opinion, though somewhat indefinite in its application 
 and partial in its prevalence, is nevertheless a kind of lex non scrijita. 
 The more timid or the more conscientious among the profession ai'e 
 ruled by it. They sacrihce their immediate pecuniary interests by 
 cancelling every forward engagement as it falls due; and since by this 
 very means they gain an unenviable notoriety, they suffer loss, remote, 
 but no less certain. Bolder spirits, or less sincere, ignore this opinion, 
 and continue their work with a still tongue. But in so doing, they play 
 a pei'ilous game — one that, by an accident or a coincidence, may place 
 them in a serious position, where censure, swift and sharp, may be meted 
 out to them, both by the profession and the people; and where they may 
 be involved in the uncertain toils or ruinous processes of the law. 
 
 Now, if this opinion be valid, the reckless temerity of the bold must 
 be resisted ; but if, on the other hand, it be invalid, the timid must be 
 reasoned out of their fears, and the public must be educated out of their 
 populai- fancy. A full discussion of the question by the leaders of thought 
 amongst us is, therefore, of no little moment, and a plain expression of 
 opinion by tliose most competent to form one. 
 
 If the Conference unanimously negatives my question, then a practi- 
 tioner can honestly refuse to carry out his midwifery engagements, and
 
 PRACTISING MIDAVIFRKY WHILE IX CIIAUCK OF PrEKPKRAL CASES. 685 
 
 ran openly appeal to this consensus, in order to prevent the misconception 
 and misrepresentation which such refusal may provoke, and to obviate 
 the necessity for such petty frauds as a healthy right arm, borne for 
 weeks in a sling. 
 
 If, howevei', this Conference decides in the affirmative, then, while 
 continuing in his obstetric work, its moral svipport will be his, and he 
 will be free from the fear of foi-feitingthe respect of his medical brethren, 
 or ruining his public reputation. And if, to-day, opinions differ upon 
 the suliject, so as to l)e even equally divided, then the /ex non scripta 
 will l>e proven no law whatever, and the individual practitioner will 
 henceforth feel at liberty to follow the dictates of his own enlightened 
 reason and conscience in regard to the particular case, or the special 
 circumstances with which he may be concerned. 
 
 Whatever, therefore, may be the mind of the Conference upon the 
 issue raised, the result will be beneficial, and with this confidence, I 
 proceed to discuss it. 
 
 The consideration of the question, T propose to direct along three 
 chief lines, viz. : — 
 
 (1) What evidence exists, that the puerperal fever under our care 
 has ai'isen from previous cases of the same disease ? 
 
 (2) What evidence exists, that during the conduct of a puerperal 
 fever case, midwifery may be practised with impunity ? 
 
 (3) If puerperal fever preclude midwifery work, what shall be our 
 definition of that complaint 1 
 
 If the instances with which we ax'e acquainted are known to have 
 originated from similar ones, occurring just before them, this would be 
 a strong argument in favour of abandoning obstetric work in the 
 presence of puerperal fever ; but if they are ascertained to be almost 
 invariably sporadic, and to have generally no causal relation with 
 previous examples, then its continuance would be justified. So also 
 would it be, if we can demonstrate immunity from transmission of the 
 disease, in cases of puei'peral fever ti'eated by the accoucheur, while in 
 full oijsteti'ic practice. And lastly, before we decide upon the necessity 
 of relinquishing midwifery directly Ave are face to face with puerperal 
 fever, let us regard the difficulty of determining with precision which 
 of the post-partum pyrexias must be designated by so terrifying and so 
 binding a name. 
 
 Our first inquiry then is. What evidence have we, that puerperal fever 
 arises from previous cases of the same disease 1 During the past ten 
 and a half years in South Australia, I have attended 1255 cases of 
 parturition, and have lost four patients only, all of whom died of 
 fever : — 
 
 One, a primipara, was seen first at eleven o'clock p.m. ; and at 4.15 a.m., 
 as the head, with a large caput succedaneum, was somewhat delayed on 
 the pei'ineum, forceps were applied, and the delivery was easily effected 
 "without perineal rupture. At 5 p.m. of the same day, ?.e., about twelve 
 houi's afterwards, she had a long severe rigor, and after eight weeks 
 of illness, during which she had rigors almost daily, and on some days 
 more chills than one, she died, without developing any objective signs 
 of local disease, except towards the termination of the case, when some 
 albuminuria, anasarca and bed-sores appeared. Regarded clinically, 
 it was as well marked an instance of septicaemia as could be conceiAed.
 
 686 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 How did it arise ? The occurrence of the rigor, with a temperature of 
 102-6°, within twelve hours of delivery, tends to negative the explana- 
 tion of sapra^mia from decomposition of lochia, especially as it arose 
 during the cool month of August. So also the rigor within seventeen 
 hours of the first examination by the accoucheur, renders somewhat 
 improbable infection by him with an animal poison ; and as a fact, it 
 was learned that the patient had been "out of sorts" immediately prior 
 to delivery, and had had medicines prescribed by a chemist. But on 
 the supposition of contamination by the medical attendant (which in 
 many of these cases is, I think, somewhat gratuitous), whence came the 
 virus ? I had no puerperal fever under my cai'e, but for four days T 
 had had a boy with malignant scarlet fever, who subsequently died of 
 pleural effusion and pulmonary gangrene ; besides another child with 
 acute tibial periostitis (whose subpei-iosteal abscess had been opened 
 however, three weeks), and in wliose ailment there was some pypemic 
 element, as manifested by an abscess some months after in connection 
 with an exfoliation from the humerus. There was also a boil on my 
 own right arm, in the stage of suppuration, about two inches above the 
 wrist. Any one of these three may have been the source of the 
 septic?emic bacilli ; but no puerperal fever origin can be traced. 
 
 The second was a primipara, delivered with instruments, when the 
 head was at the lower end of the sacrum, without perineal rupture. 
 On the second day, the temperature was 104° F. She had had hardness 
 of hearing from before her delivery. On the fifth day, large diphtheritic 
 patches were discovered in the fauces ; then it appeared, that some 
 soreness of throat had been expei'ienced, though not complained of, ever 
 since the pai'turition. On the day following, the urine was smoky and 
 slightly albuminous. On the 14th day she died. This was evidently 
 post-partum diphtheria. I was not treating any patients with this 
 complaint at the time ; but it was learned, that the mother of the 
 deceased had sufiered from a serious attack of this affection three weeks 
 before. 
 
 The third was a multipara. The child was born, and the placenta 
 removed by the nurse before my arrival. There had been severe 
 alidominal pain some days before the confinement. She developed 
 symptoms of abdominal inflammation, and died on the eighth day. 
 
 The fourth was a primipara, whose left hip was fixed by old disease, 
 and who had been afflicted for many years with rectal strictui'e. Tiie 
 l)owel, from about two inches above the anus, was impermeable to the 
 finger, but per vaginam could be felt enlarged, thick, and hard, as 
 high as it could be reached. There were secondary fistuhe in ano, 
 always discharging sanious pus. After thirty-six hours of labour, with 
 the head still at the brim, she was etherised ; the forcejDS were applied, 
 and with great difficulty the head was brought through a pelvis, some- 
 what contracted to the very outlet. After a few days, fever supervened 
 with rigors, and these recurred at intervals for many weeks. There 
 developed in succession — swelling of the left sterno-clavicular articula- 
 tion, the right shoulder, the left temporo-maxillary joint, and the left 
 parotid gland— all without suppuration ; panophthalmitis of the left 
 eye, with collapse of the globe ; discharge of abundant fcetid pus per 
 rectum ; an abscess of the left gluteal region, apparently connected 
 with the bowel ; suppuration in the diseased hip-joint gradually wasted
 
 PRACTISING M1D\V1FERY AVHILE IN CHAKGE OF PUERPERAL CASES. 687 
 
 her, and she died eight months after delivery. Tliis was an evident 
 puerperal pyjvmia ; nor was the cause far to seek. The diseased 
 suppurating septic bowel, bruised by the passage of the head through 
 a pelvis diminished in its capacity by old morbus coxa?, became inflamed, 
 and provided a focus of infection for the system. 
 
 These are the only instances of death, or death from puerperal fever, 
 •which have come within my experience in South Australia, and from 
 them I conclude that, in its ordinary sporadic form, the disease can 
 very rarely be attributed to infection f i-om previous cases of a like kind. 
 It would lead me too far, and into too much detail, to enumerate and 
 discuss all the cases of post-partum pyrexia which have recovered, 
 amongst these many hundreds of deliveries. Suffice it to say, I have 
 been unable to trace any causal connexion between any two cases of 
 such feverishness under my care. 
 
 To what extent we can trace the instances I have given : — They may 
 have arisen from a scarlet fever patient under medical care, from a diph- 
 theria, from a surgical pyaemia, or from a surgical disease such as rectal 
 stricture and fistula? in ano. And does not this possibility press upon 
 our consideration another view of the matter 1 
 
 There is not room for doubt, that much of the puerperal fever 
 encountered does originate from such diseases as scax'let fever, measles, 
 diphtheria ; from such surgical aft'ections as erysipelas and pya?mia ; 
 and from the putrefactive matters of the post-mortem room. Hence, 
 to bring the lying-in woman into proximity with patients sutiering 
 from any of these complaints is reasonably regarded as eminently 
 dangerous and reckless. But do we therefore decide that the general 
 practitioner, who has under his care a case of scarlatina, of measles, of 
 diphtheria, of erysipelas, of pyaemia, must, during this period, and for a 
 week or a month afterwards, do no midwifery, lest he should communi- 
 cate puerperal fever? Do we forbid every man who is engaged iii 
 obstetrics admission to the post-mortem room ? To insist on this, would 
 practically exckide the general practitioner from the realm of obstetrics ; 
 for how seldom does he find himself entii-ely free from infecting patients ? 
 And yet if the attendant on a puerperal fever case is thereby forbidden 
 midwifery, because he may transmit the fever poison, for the same 
 reason and to the same extent should the Ijan apply during the 
 conduct of these other infectious and contagious complaints, unless it 
 can be proved that the parturient woman is more susceptible to the 
 influence of the poison of puerperal fever than of any other complaint. 
 No such evidence is, to my knowledge, forthcoming. On the other 
 hand, my own experience, and the usual sporadic nature of the com- 
 plaint, with only an exceptional and very limited epidemic, suggest an 
 origin, not from previous puerperal fever, but from other conditions 
 and complaints which are capable of exciting it. As, therefore, 
 midwifery is not precluded by attendance on these various poisonous 
 affections, neither should it be by the attendance on puerperal fever. 
 
 Of course, it would be folly to deny the communicability of puerperal 
 fever from a puerperal fever patient, or the communication of the 
 malady in its most virulent form by the accoucheur. For instances are 
 on record of medical men, in whose footsteps death has trodden relent- 
 lessly, and seized in succession every lying-in woman attended by them, 
 until they have relinquished their work. Here the transmissibility and
 
 688 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 the transmission were demonstrated. And here the line of duty is 
 plain. When a man has two or more cases in succession, and he 
 has reason to suspect himself the vehicle of the morbid virus, no 
 considerations of personal financial loss, of undesirable publicity, or 
 of boldness and independent action should be allowed to weigh; but 
 midwifery should be wholly and instantly abandoned. Now it has 
 become a question, not of possible transmissibility, but of certain 
 transmission ; not of a sick woman, who may supply a materies morbi, 
 but of an accoucheur who has a fatal supply about himself, and who 
 is as dangerous in his person, his clothing, his instruments, or his 
 methods, to every lying-in woman he attends, as if a puerperal fever 
 patient were placed beside her in the same bed. Midwifery under 
 such circumstances would be no less than murder. 
 
 To draw an analogy. Surgical pyaamia is very contagious. Does the 
 surgeon who has under his charge a pyjemic jaatient, therefore, and of 
 necessity, forljear to operate until this case is well or dead 1 Certainly 
 not ! He goes on with his work, and endeavours to prevent any 
 contagion; but should he discover in his operations a succession of 
 fatalities from this cause, would he not readily lay down his scalpel 
 for a while? So should it be with the accoucheur. 
 
 We proceed now to our second inquiry, viz.. What evidence exists 
 that, during the conduct of a case of puerperal fever, midwifery may be 
 practised Avith impunity 1 As narrated above, four lying-in women 
 have died in my obstetric experience, all fi'om puerperal fever. The 
 first, from septic?emia, lived 57 days, and received 118 visits, or an 
 average of two each day. During its protracted course, three women, 
 previously delivered, were seen 13 times; and 15 others were confined, 
 receiving 108 visits — so that on 121 occasions was I brought into 
 contact with parturient females. The second, from diphtheria, died 
 after 14 days, being seen 24 times. During this period, I paid seven 
 calls to two persons previously confined, and 49 to seven others whom 
 I delivei'ed, making a total of 56. , The third, from inflammation 
 (presumably peritonitis), succumbed in eight days, and was seen 15 
 times. Two antecedent deliveries were seen five times ; two confined 
 on the same day, 12 times ; one on the next day, six times ; and one on 
 the day following, five times — numbering altogether 28 visits. The 
 fourth, from pyasmia, lived for eight months. But after 10 weeks' 
 attendance vipon her, I was laid aside myself, and she Avas kindly taken 
 in chai-ge by a brother practitioner. During tliose ten weeks, on 63 
 days I paid 110 A'isits, and delivered no fewer than 22 other women, 
 seeing them 130 times, and two women, previously delivered, four times, 
 or altogether 134. 
 
 Combining the figures, we get the following reassuring I'esult : — At 
 the very lowest computation, I was at the bedside of those infective 
 patients 267 times; and simultaneously was brought, not into proximity, 
 but into contact, with 57 parturient and puerperal women on no fewer 
 than 337 occasions. And with what efTect 1 Not one of them showed 
 symptoms of contamination in any form, nor developed post-partuni 
 pyrexia sufficient to justify the term "puerperal fever," or to cause 
 danger or grave anxiety. 
 
 This succession of cases demonstrates the possibility of working 
 amidst these organic poisons without transmitting them. And if to
 
 PRACTISING MIDWIFERY WHILE IX CHARGE OF PUERPERAL CASES. 689 
 
 these we add the occasions on which I have seen in consultation, and 
 made complete examinations of, patients with serious puerperal fever 
 under the care of otlier medical gentlemen, we get some idea of the 
 impunity with which an indi\idual may move amongst the puerperal 
 miasmata, and handle the puerperal contagia, and yet do no hurt to the 
 healthy lying-in woman. In face of such facts, it is surely almost 
 puerile to ask the question — Was it demanded of me that I should not 
 attend those 57 women? The abandonment of my midwifery was 
 evidently not an obstetric necessity. With such a personal experience 
 in the past, am I required in the future, by any law, ethical or profes- 
 sional, to cancel all my obstetric engagements, should some one patient 
 have the misfortune to develop inflammatory or septiciemic or acute 
 specific febrile symptoms? Does consideration for the well-l)eing of a 
 woman, who trusts herself to my care in the critical time of her 
 delivery, if it be reasonable as well as conscientiovis, demand that she 
 should be transferi'ed by me to other hands ? Under such circumstances, 
 I have no hesitation in answering openly and honestly, " it does not ! " 
 Puerperal fever is I'egarded by some eminent authorities as an 
 excellent name, because it includes all the pyrexias which overtake 
 the lying-in woman, and because it involves no theories. For these 
 reasons, the designation certainly has its advantages for some purposes; 
 l)ut under other circumstances, they are evident disadvantages. If, for 
 instance, it be decided that a medical man, who has under his charge a 
 case of puerperal fever, must not practise midwifery — and puerperal 
 fever includes all post-partum pyrexias — obstetrics will be an impos- 
 sibility. Such a law will plainly demand a definition of puerperal 
 fever, not quite so general, nor quite so free from all theories. Here 
 arises a great difficulty. The term embraces not one specific entity, as 
 does scarlet fever for example, but a medley of diverse diseases. We have 
 seen from the four cases cited, how it may be a septictemia, a pyaemia, 
 a diphtheria, or a peritonitis ; and, without any doubt, it may be a 
 putrefactive sapr^emia, a scarlet fever, a measles, an erysipelas, a metritis, 
 a parametritis, a perimetritis, and probably several other complaints 
 besides. This is sure. The only evidences locally may be a pleurisy, 
 a pericarditis, a pneumonia, or a femoral phlebitis, a so-called white leg, 
 with attendant feverishness. And further, any one of these may exist 
 in any degree of severity, from the least even to the greatest. Are all 
 these puerperal fever ? Are all these infectious ? If not all, which of 
 tliem are ? With reference to some of them, the answer is easy enough 
 theoretically — tho.se derived from scarlet fever, from measles, from 
 diphtheria, from erysipelas. But, practically, it is very difficult, inas- 
 much as the origin is often involved in obscurity. Moreover, what 
 eA-idence have we even then that it is more dangerous than the primary 
 disease from which it was derived ? And if it be not, then scarlet fever 
 precludes obstetrics equally with scarlatinal puerperal fever. Again, 
 there is a floating idea to this effect — if the puerpera have high fever, 
 without local symptoms, it is of grave import to her, and serious as 
 regards contagion. But if there he found a collar of cellulitis round 
 the uterus, here is a local explanation of the continued elevation of 
 temperature. The prognosis is more favourable, and the transmissibility 
 of poison is improbable; in fact, there probably is no poison. But on 
 wliat foundation does such an opinion rest ? So far as I can gather, 
 
 lY
 
 690 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 not on that of fact, but of fancy. A pelvic cellulitis occurring in an 
 uncomplicated labour must be due to absorption of some sort of 
 poison; and that it should be less virulent, in respect of transmission, 
 than that of a puerperal peritonitis or a puerperal pericarditis, is not 
 quite manifest, though it may evidence a more localised absorption. 
 
 Frequently after delivery, there is pyrexia ; sometimes with a rigor, 
 at others without. We seek the cause, but cannot find it. In a day 
 or two it disappears, or it may last a full week, and range high, and 
 excite our apprehension, and then subside entirely without revealing- 
 its origin, or leaving any local sequela. In a few days perhaps it recurs, 
 may be continuous or remittent, may be ushered in by rigors, be 
 attended by variable shifting pains, lasting a fortnight, and after giving 
 the patient a shaking and the doctor a fright, terminate in a complete 
 recovery to both. Where shall we find our working rule, by Avhich to 
 measure the degree of infection in these cases? The directions by 
 which to sift the contagious from the innocent are still to seek. There 
 may be cases, such as the first cited by me, in which, after but two or 
 three days, recurrent rigors render a difignosis certain, and establish 
 the contagious nature of the complaint ; but on the contrary, it would 
 be no modesty in us to allow that, in nine out of ten instances of post- 
 partum pyrexia, we are unable to affirm, in the early stages at least, 
 whether we are dealing with an infectious malady or not. And yet, if 
 it ultimately develop positive symptoms, its virus was as dangerous in 
 our midwifery practice during the first few days of our doubt, as it is 
 now during the period of our certainty. One of my patients lived for 
 eight months ; during the last three of which, she was gradually 
 drained to death, by discharging abscesses in the pelvis and the hip-joint. 
 Now we must either insist that infection was present here from first 
 to last, or we must allow some arbitrary line to be drawn, on one side 
 of which is a malignant poison, and on the other side none. 
 
 The suggestion may arise in our minds, that these difficulties pro- 
 pounded are but captious quibblings. To me, they are far different. 
 They are pi'oblems demanding solution, if puerperal fever is to preclude 
 midwifery. We must know what we mean by the phrase ; otherwise 
 it means nothing, and the law cannot be interpreted ; or perhaps we 
 might say, can be interpreted anyhow. If, whenever a puerperal 
 pyrexia creates anxiety, we cease our obstetric work, this will be an 
 absurdly irregular department of our practice ; and if we defer our 
 decision as to the existence of puerpei'al fever until the case has become 
 critical or hopeless, and not until then take steps for self quarantine, 
 we shall have run the risks of transmitting the disease while the risks 
 were greatest, and have instituted our precautions when probably 
 these were the least requix'ed. 
 
 The conclusion at which I arrive is this :— A medical man should 
 recognise the special susceptibility of the lying-in woman to the 
 pernicious influence of all animal poisons. He should therefore in 
 every midwifery case exercise cai'e, lest these gain entrance to her 
 system, by adopting simple routine protective measures. Whenever he 
 has under his chai'ge a case of infectious or contagious disease, whether 
 this be medical, surgical, or obstetric, e.g., scarlatina, pyaemia, or 
 puerperal fever, he should regax'd himself as a possible vehicle of 
 transmission or contamination, and should consequently use extra care
 
 ON THE ADMINISTRATION OF AN.f:STHETIC.S DUKINfJ LABOUR. G91 
 
 in the einployineiit of precfiutioiiary means. But if in his midwifery, 
 a .succession of two or more cases of puerperal poisoning occur, between 
 which he is certainly or pi-obably tlie connecting link, since it is here 
 not a (piestion of pos.sible transmissibility of virus, but of its 
 transmission, not of an infective patient, but of an infecting 
 pi'actitioner, obstetric practice sliould be instantly and wliolly 
 abandoned. 
 
 By this course the fears and endeavours of the medical man will not 
 be focussed solely on puerperal fevei'. while he overlooks or too lightly 
 regards the equally grave and far more numerous dangers lurking in 
 the multitude of septic medical and surgical maladies with which he 
 is so f recjuently associated. The terror investing puerperal fever, which 
 is a foolish timidity, will be toned down ; and the apathy regarding 
 eminently poisonous common complaints, which is a foolish temerity, 
 will be corrected, and the life of the mother, which for so many reasons 
 should be specially sacred to us, will be pi'eserved. 
 
 ■SOME REMARKS ON THE ADMINISTRATION OP 
 ANESTHETICS DURING LABOUR. 
 
 By S. Mabekly Smith, M.R.C.S. Eng. 
 
 I propose to submit to your consideration a few points on this subject, 
 based on an experience of about 500 cases of midwifery, in which an. 
 anaesthetic has been gi^'en, either in small quantities to diminish pain, 
 or more fully to produce insensibility. 
 
 Most autliorities, who have written on the administration of anaes- 
 thetics in natural labour, speak of it as an unqualitied success in all 
 cases ; .some of the older writers have equally condemned it. My 
 experience has been, that the results of this practice vary in all degrees 
 from a brilliant success to a miserable failure, owing to the very different 
 effects produced on individuals. 
 
 As TO THE BEST ANESTHETIC TO BE EMPLOYED. 
 
 In most cases, the A.C.E. mixture acts admirably in stopping the 
 sensation of pain, and is then to be preferred from its safety. But 
 there are .some patients on whom, from various causes, the mixture is 
 not sufficiently quick in its effect to dull the pain, and in these cases 
 chloroform is preferable from its more rapid action. I have, on various 
 occasions, found the latter succeed, where the A.C.E. mixture has 
 given little relief. It is here presumed that the anaesthetic is given at 
 the beginning of each pain, and removed when it ceases. 
 
 Where complete insensibility is required, the A.C.E. mixture still 
 seems to be the best agent, or i-ather, I should say, the A.E.C., which 
 is the combination I use in midwifery. Of other narcotics, bichloride 
 of methylene does well. Ether is too slow in its action, and e.scapes 
 so much about the room ; there is also some risk of tire in these cases. 
 
 lY 2
 
 692 intekcolonial medical confjhkss ok australasia. 
 
 Of the Risk to Life. 
 
 Though there is undoubtedly much less danger in giving ansesthetics 
 to pregnant women than to others, from the position of the patient, the 
 small amount given at once, where it is administered only to deaden 
 pain, and the special immunity from heart failure enjoyed by persons 
 in this condition, still I believe that some risk does exist, and that this 
 risk is generally under-estimated. Though I do not personally know of 
 a death under these circumstances, several of my patients have exhibited 
 alarming symptoms, and medical friends ha\ e had the same unpleasant 
 experience. 
 
 In the British Jfedical Journal of 1878, Dr. Lusk, of New Yoi'k, 
 recoi'ds five cases in which an anaesthetic was given during labour. In 
 two of these, death took place immediately ; and in the other three, the 
 patients were saved with great difficulty. There are other cases 
 I'ecorded where death took place some hours after the labour, and there- 
 fore where it is doubtful whether tlie narcotic was answerable for the 
 fatal result. 
 
 I attended a patient in four consecutive confinements. On each 
 occasion she took the A.E.C. mixture to relieve pain only, and therefore 
 in small quantities. Twice she took it well ; the third time she 
 exhibited most alarming symptoms of heart failure ; on the fourth 
 occasion she insisted on having it again, and this time there was no 
 trouble. 
 
 I think this element of danger is an important point. In various 
 places, I have seen anaesthetics administered with the greatest careless- 
 ness, under the belief that a woman in labour cannot be so killed. 
 
 The Question of Patients Talking Whilst Under the 
 Influence of an Anaesthetic. 
 
 Writers on the subject seem to confine themselves to the discussion, 
 whether women in this state do or do not talk indecently. Some have 
 said that, where an anststhetic is given only to relieve pain, the amount 
 inhaled is so small that the talking stage is not reached. From my 
 oljservations, patients very seldom do make these remarks, though I 
 have not had qviite the same experience as Simpson, who says that they 
 never do. When they do so it is caused, I think, by the act of vaginal 
 examination ; and anything unpleasant in this way can be avoided by 
 always alloAving a full return to consciousness before an examination 
 is made. 
 
 As to the amount of vapour inhaled being too small to cause talking, 
 there are women who lose control of their speech with the least 
 inhalation. But, though women in this state seldom speak indecently, 
 they frequently say very foolish things, will tell the greatest secrets, 
 and will answer, generally truthfully, any question put to them. They 
 will quietly, and being apparently to non-professional by-standers in 
 their right senses, make statements damaging to themselves and others; 
 statements which huxe no foundation in fact, and which I am 
 convinced have no existence in their minds when conscious. 
 
 I am aware of two cases in which trouble arose in this way. In one, 
 there was the unfortunate combination of a woman who talked with the 
 smallest whifi" of an anaesthetic, a mischief-making nurse, and a jealous
 
 ON THE ADMINISTRATION OF ANiESTHETICS DURING LABOUR. 693 
 
 husband. The semi-conscious patient made some foolisli remark to the 
 doctor, this was duly carried to the husband, there was trouble, and the 
 doctor was never called in again. 
 
 Some years ago a well-known man was found drowned under 
 suspicious circumstances. Though great efforts were made by the 
 police, no one could be found who had seen the deceased after a certain 
 time at night, though he was believed to have been alive some hours 
 after. Some time after this occurred, I had to attend a woman, who 
 was a stranger to me, in her confinement, and as she was suffering 
 severely, I administei'ed small (juantities of chloroform. Undei* the 
 influence of this, she began to talk tjuietly and rationally about the man 
 who had been drowned. She gave a complete history of him from the 
 time that he was last seen by the witnesses at the inquest almost till 
 his death, stating that she had been with liim all the while. When 
 this patient was well, I told her what she had said. She was very 
 frightened, and was totally unconscious of having said anything, but 
 admitted that her statement was in every particular true. I mention 
 this case as an example of the revelations which may be made by a 
 narcotised patient. Certainly one should be most careful that a woman 
 in this condition does not damage herself or others by her statements. 
 
 Twice after administering the A. E.G. mixture, I have seen the 
 condition described by Dr. Tom Bird as a'ther mania — that is, that 
 long after tlie inhalation has ceased, perhaps for hours, tlie patient will 
 go on unconsciously saying anything that comes into her liead. 
 
 This matter of talking is so much more important in these cases of 
 anjvsthesia than in all others, because in these the patient is kept 
 constantly at the talking stage, whereas in others the state of silence is 
 soon reached. 
 
 Of the Effect of an Anaesthetic on Others in the LviNfi-iN 
 
 Room. 
 
 A drawback to the administration of an anaesthetic in some cases 
 seems to me to be this : — Where it is given for a pi-olonged period to 
 deaden the pains, and when tinally some operative measure has to be 
 resorted to, the effect of the vapour on the medical attendant may be 
 sucli that he is not in the best condition, mentally and pliysically, to 
 undertake a critical deliveiy. He is to a certain extent unnerved, his 
 head is not thoroughly clear, and muscularly he is rendered weaker. 
 At all events, I have expei'ienced this condition personally so often that 
 I think there must be others who have been similarly affected. In 
 some rooms, and under some circumstances, it is impossible to ventilate 
 so that the fumes of the anaesthetic are all carried away. Others may 
 be also affected. 
 
 I attended a lady in a severe labour where cliloroform was used. 
 During its progress, her husband came into the room several times. 
 He became A^ery curious in his manner, and after the case terminated, 
 I found him in another room (juite hysterical. Though a perfectly 
 sober man, he was suspected of being drunk at this time. In another 
 case, I had to get the assistance of the husband in a chloroform case. 
 He was a very strong able-bodied man, but after l^eing in the room a 
 short time, he began to cry, and Ijehave much as the man in the other 
 •case. Both these men were aware of being affected by the anfesthetic
 
 694 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 vapour. I have never seen mother or child aftectecl after the confine- 
 ment. Women in labour must have an exceptional freedom from the 
 sequela? of anjesthesia, though some cases of vomiting are recorded. 
 
 Do ANiESTHETICS TeND TO PRODUCE PoST-PaRTUM HAEMORRHAGE? 
 
 There is much difference of opinion on this question ; some authoritie 
 go so far as to say that they prevent it. My belief is, that they have 
 this tendency to cause bleeding. In looking over a record of about 
 4000 cases, the constant relation between the use of ana;sthetics and 
 haemorrhage is striking. To any woman who has a predisposition to 
 bleed, the smallest amount of any of these agents adds to her danger. 
 Unfortunately in first cases, and often in others, one cannot usually 
 foretell this predisposition. There is however one guide, I think, that 
 is, that there is a pretty frequent relation between those who sufi'er 
 from menorrhagia and those who fiood, though it is by no means 
 constant. If I know that a woman has habitually menstruated 
 excessively, I never, if possible, give her an ana'sthetic. The chance o 
 post-partum ha'morrhage occurring increases with each laljour, and that 
 risk is proportionately made greater by an;esthesia. If I can avoid it, 
 I do not give inhalations simply to relieve pain after the first case, 
 specially as there is usually less need. But here there arises one of the 
 drawbacks of this pi'actice. After once having a narcotic, patients often 
 insist on a repetition of the practice on all future occasions, yet some 
 special risk may have been disclosed from a former experience. If a 
 woman knows she has to bear the pains of labour, and thinks there is 
 no way of escape, she will bear them bravely ; whereas, if she has once 
 had an anaesthetic, she is a coward without it in many cases. 
 
 Of this I am sure, that whether there is post-partum ha'morrhage or 
 not, after-pains are very frequently caused by anjesthesia, even in first 
 cases ; that is, that though relaxation of the uterus, sufficient to cause 
 severe bleeding, may not occur, yet there is enough to allow oozing into 
 the uterus, causing clots. 
 
 Of the Effect of this Form of Narcosis in Relaxing the Soft 
 
 Parts. 
 
 As a general rule, ana'sthetics have ;i powerful and rapid effect in 
 relaxing the os, but not always. I have seen the deepest anaesthesia 
 fail to do this. I think that the thick rigid ps withstands the effect 
 more than the thin rigid one, and primijiarous cases than multiparous. 
 In cases where the rigidity will yield to nothing else, I have found 
 hypodermic injection of morphia succeed. Inhalation always relaxes 
 and moistens the rigid perina>um to some extent, and generally in a 
 very marked mannei-. 
 
 The Use of Chloral in Labour. 
 On the whole, my experience of chloral has not been satisfactory. In 
 some cases, doubtless, it relaxes a rigid os ; in many, it fails. In a large 
 number it causes vomiting, and, I belie\e, sometimes relaxes the rigid 
 OS by its emetic action. It is, in my opinion, more dangerous, given in 
 repeated doses, than a general anjesthetic. I have seen two deaths 
 from moderate doses, but not in parturient women. I attended a
 
 DISCUSSION. 695 
 
 patient in labour with a rigid os ; twenty grains of chloral were given 
 in Liebreich's Syrup. Twenty minutes after, the os not having yielded, 
 the dose was repeated. The woman then got into the most alarming 
 condition with the symptoms of chloi'al poisoning, and was with 
 difficulty saved. 
 
 Patients made semi-unconscious, sometimes become very noisy and 
 unmanageable ; in this case, it is better to stop the inhalation, however 
 much they object. Giving an anaesthetic for natural labour is often a 
 severe tax on the medical attendant. However tired he may be, he has 
 to sit perhaps for hours watcliing for the commencement of each pain, 
 to give the looked-for whiti' — the more tempting process being to go to 
 sleep in anotlier room. 
 
 The cases above all others in which anaesthesia gives relief, and does 
 direct good, are those in which there is one continual pain without 
 cessation, pain peculiarly hai'd to bear and nearly useless, caused by 
 irregular contraction of the uterus. A few inhalations make a complete 
 change, the pains become bearable and defined, there is the regular rise 
 and fall with an interval, and the labour progresses. 
 
 In conclusion, I would advocate the use of aniesthetics in operative 
 midwifery, and in natural labour, where it is required, and where it is 
 practicable. I say, whei'e practicable, because there is a vast difference 
 between giving them where there is the assistance of another medical 
 man, or of a skilled nurse in a town, and being away in the bush with 
 practically no help, and where the proceeding may be strongly objected 
 to by the friends. In such cases, it is often better to do without them. 
 
 In natural first confinements, I would administer an anaesthetic for 
 any of the following reasons : — Either that the patient desired it, or 
 that the pain was excessive, or to relax the soft parts. In natural 
 multiparous cases, I would not give it if I could avoid doing so. In 
 all operative cases I would give it, except where forceps are used with 
 the head on the perina?um, when it is not required, unless the perinaami 
 be rigid and dry, then the practice is invaluable. 
 
 DISCUSSION. 
 
 Dr Balls-Headley agreed ^\ith Dr. Verco's conclusions, but pointed 
 out the necessity of practitioners taking every precaution to protect 
 themselves against dangers of transmission. He recommended even so 
 strong an antiseptic as a solution of corrosive sublimate of ten grains 
 to the pint. It must be noticed that Dr. Verco's statistics were those 
 of private practice, and so were different from those of hospital practice. 
 The common cause of so-called puerperal fever was the transmission 
 from one septictemic patient to another. Antiseptic midwifery 
 prevented septic;emia. The lines of temperature in hospital charts 
 i)efore and since the introduction of antiseptic treatment, undoubtedly 
 proved this. 
 
 Dr. Bkummitt had had a fairly wide experience in the country, 
 having attended 1000 cases of midwifery during the period covered by
 
 696 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 Dr. Verco's paper. He had seen only one case of true puerperal feve)-, 
 a fatal one, in a house which contained a case of malignant diphtheria. 
 The degree, with which lying-in women sufiered from proximity to 
 contagion, varied. He rememl^ered finding a child with typhoid lying 
 in bed alongside its recently confined mother. The woman escaped 
 scot-free with a straight line temperature. Another child (in a 
 different case) had scarlatina, without in any way affecting the mother. 
 In his district, he had known no year free from zymotic disease ; but as 
 far as he knew, it had not affected lying-in women. 
 
 Dr. Eugene Anderson, Resident Medical Officer of the Women's 
 Hospital, Melbourne, pointed out that from May 1877 to August 1888, 
 there had been 688 women confined in the institution; and that of the 
 four deaths that had occurred among them, only one was due to 
 puerperal fever. This, he thought, proved that he himself, combining 
 as he did the dual duties of infirmary and midwifery departments, had 
 conveyed no puerperal fever to his lying-in patients. The strictest 
 antiseptic precautions were observed. He laid great stress on 
 thoroughly cleaning the nails with a nail brush. He mentioned the 
 case of a woman who had been brought to the hospital with scarlatina, 
 and though she was seen (necessarily) in the first instance by nurses, 
 no harm had ensued. 
 
 Dr. WoRRALL agreed with the conclusions of Dr. Verco, provided 
 rigoi'ous antiseptic measures were adopted, as indicated by Dr. Balls- 
 Headley. He thought that Dr. Verco had proved that other forms of 
 blood-poisoning than puerperal fever may occur from contagion. 
 
 Dr. J. W. Dunbar Hooper could speak from his experience as a 
 previous Resident Medical Officer of the Women's Hospital for two 
 years, and a member of the present Honorary Staff of the Midwifery 
 Department. He agi-eed with Dr. Verco, provided antiseptic pre- 
 cautions were employed. He had seen a woman affected with puerperal 
 fever lying in the same ward as another not so affected, without 
 conmmnicating puerperal fever to the latter. He thought a good deal 
 of liarm was done by ignorant midwives, who should be made to pass 
 examinations, and show their knowledge of the use of antiseptics. 
 
 Mr. E. M. James agreed with Dr. Hooper, and approved of tlie 
 registration of midwives, and of cases also. Puerperal fever cases 
 should be traced. He believed that lacerations of the cervix, by 
 presenting a solution of continuity, were a cause of feAer by absorption. 
 
 Dr. Nyulasy asked if Dr. Verco believed that bad drainage was a 
 cause of puerperal fever. 
 
 Dr. Meyer, as one of the pi'esent Honorary Staff of the Midwifery 
 Department of the Women's Hospital, and a previous Resident Medical 
 Officer of over four years' standing to that institution, could agree 
 thorouglily with Dr. Verco. 
 
 Dr. Bright, of Hobart, differed from the voice of the meeting. He 
 thought that where a medical man had a case of puerperal fever, he 
 sliould give up attendance on liis other patients for at least a month, 
 especially in towns. 
 
 Dr. Batciielor pointed out that we must not overlook the possibility 
 of mischief existing in a pati(!nt before the onset of puerperal fever. 
 In Dr. Verco's first case, the mischief might have been tubal. In the 
 second case, the unilateral pain pointed to tubal mischief. These causes
 
 UTERINE PREGNANCY SUPERVENING ON ECTOPIC GESTATION. G97 
 
 might account for a good many sporadic cases. He wished to correct 
 an erroneous impression in Dr. Verco's mind, that he (Dr. Batchelor) 
 did not believe in the existence of pelvic cellulitis. He did say such a 
 condition was excessively rare, except as an accompaniment of acute 
 general septic conditions. He thought the term, " puerperal fevers," 
 was better than " fever." 
 
 Dr. Verco, in reply, was very thankful to the members for their 
 cordial support of his views. He had feared opposition. He wished 
 it to be understood, that he did not say that puerperal fever cannot be 
 conveyed from one patient to another. He never attended a case 
 without previous disinfection ; even if the child had been born before 
 his arrival, he used antiseptic measures before commencing treatment. 
 We might for our own peace of mind (in the face of puerperal fever 
 developing in a patient), hand over our cases to a brother practitioner. 
 Such a proceeding would be all right, if we knew that he had nothing 
 likely to be a source of contagion ; on this point, we could not be sui'e. 
 In reply to Dr. Nyulasy, he thought bad drainage a likely cause of 
 puerperal fever. 
 
 A CASE OF UTERINE PREGNANCY SUPERVENING ON 
 
 ECTOPIC GESTATION, WHICH HAD PERSISTED 
 
 FOUR YEARS. 
 
 By Thomas Chambers. 
 
 Lectiu'er on Midwifery and Diseases of Women at the Sydney University. Senior 
 Physician to the Department for Diseases of Women at tlie Sydney Hospital. 
 
 Mrs. ^I., a^t. 32, mother of three living children, youngest two years 
 old ; always had lingering labours. She engaged Dr. Jones, of Ashfield, 
 to attend her fourth confinement, which was expected in March 1884. 
 When two months pregnant, she had a severe attack of pain in the 
 right iliac region, which passed off in about a week without any special 
 treatment beyond rest and sedatives. When four months gone, she 
 went to Grafton by sea, and soon after her arrival there she was seized 
 with very severe crampy pains in the right side, and urgent vomiting, 
 which kept her in bed about a month, fixed on her right side — this 
 being the only position compatible with anything short of the severest 
 agony. 
 
 In the early part of the sixth month, when preparing to return home, 
 another attack of severe pain and vomiting came on, which prevented 
 her return. From this time the attacks were frequently repeated, 
 with more or less severity, until the full term of gestation was 
 completed, when strong pains, similar in all respects to her former 
 labour pains, came on, and continued for forty-eight hours. She 
 herself believed, and the doctors (three) who attended lier believed her 
 to be in labour.
 
 698 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 At the end of forty-eight liours she had a severe attack of faintness, 
 with loss of vision and a sense of approaching death, with a very 
 peculiar fluttering, as if something was loosely moving about in the 
 abdomen. At this time sevei'al attempts were made to deliver her, 
 but, I need scarcely add, without success. These unpleasant symptoms 
 gradually subsided, when a discharge of blood from the vagina appeared, 
 much in the same way, and in about the same quantity, as had followed 
 her former confinements. Several clots were passed, one being specially 
 noticed from its peculiar formation and density, having the length and 
 outline of a child's forearm. 
 
 By the end of the tenth week she had I'ecovered sufficiently to enable 
 her to return home, when she again came under Dr. Jones's observation, 
 and shortly after her return I had an opportunity of seeing her with 
 him. She could now get about her house, and attend to her family 
 affairs without pain or discomfort. 
 
 The lower zone of the abdomen was occupied with a globular tumour, 
 resting on the pelvic brim, inclining decidedly to the left side. It was 
 s})herical in outline, perfectly smooth on its surface, with a boggy feel 
 closely resembling a dense colloid tumour, but by deep pressure the 
 fcetal outline could be cleai-ly traced. The tumour, which had a 
 diameter of seven and a half inches, was to some extent movable — ■ 
 that is, it moved like a body anchored to a fixed point. 
 
 The inference was, that it had formed attachments to the antero- 
 lateral aspect of the abdominal peritoneum. The uterus was normal in 
 size, but the fundus was less movable than the cervix and body. 
 
 As she felt herself to be in good general health, and able to attend to 
 her domestic afiairs, she absolutely declined to submit to any surgical 
 interference ; and although she was warned as to the risk's involved in 
 delay, she stoutly resisted any operative procedure. 
 
 The patient continued to enjoy excellent health up to the end of the 
 year 1887, when she again consulted Dr. Jones, believing herself to be 
 pregnant. This belief was confirmed by Dr. Jones, and she continued 
 pretty well until the early pai*t of June 1888, when she had an 
 exhausting attack of diarrhoea and vomiting, accompanied by severe 
 abdominal pain. The abdomen was greatly distended and veiy painful, 
 with great mental depression ; and her sufierings were so acute and 
 exhausting, that she earnestly desired something might be done to 
 relieve the painful distension. 
 
 I saw her in consultation with Dr. Jones on June 21, and found the 
 aspect of afiairs greatly changed since my last visit. The severe attack 
 of diarrluea and vomiting had much exhausted her, the abdomen was 
 distended to an extreme degree, and exquisitely sensitive, even to the 
 most careful manipulation. The uterus was placed obliquely across the 
 alxlomen, with its fundus directed towards the spleen ; the dorsum of 
 the child lying immediately under the median line, with its head resting 
 against the right ilio-pectineal ridge. The tumour was lifted com- 
 pletely out of its original position, and relegated to the right 
 hypochondriac region, immediately under the liver. Per ^■aginam, the 
 cervix utei'i could be easily reached by tlie examining fingei", the os 
 uteri was sufficiently patent to admit the finger, and the cranial arch 
 could be felt resting against the right half of the pelvic brim. Ifo 
 trace of the tumour could be felt within the pelvic area.
 
 UTERINE PREGNANCY SUPERVENING ON ECTOPIC GESTATION. 69^ 
 
 The important question now to be determined was — What was best to 
 he done in the interests both of mother and child? That something 
 must be done was clearly manifest. Upon which factor should we act? 
 I'pon the tumour, leaving the uterus and its contents intact ; upon 
 the uterus, leaving tlie tumour for a future occasion ; or should we 
 leave both alone, and let nature take her own course ? If these 
 important questions could have been discussed under less urgent and 
 nwre favourable circumstances, the difficulty would have been reduced 
 considerably. 
 
 Having carefully considered the unfavourable circumstances surround- 
 ing the case, the condition and position of the uterus and its contents 
 (the evident indications that nature had already detei"mined the 
 question as to which factor she intended to act upon, in order to relieve 
 herself of an insupportable burden), the changed position of the tumour, 
 the great uncertainty as to its attachments, as well as the difficulty of 
 dealing with it under existing circumstances ; having, I say, carefully 
 balanced these several risks, we came to the conclusion that, if one 
 course offered fewer risks than another, it was to follow the manifest 
 indications of nature, viz., to empty the uterus by the induction of 
 premature labour. The fcetus having passed the seventh month of 
 utero-gestation, and as its heart sounds counted 144, a female was 
 diagiiosed, which was regarded as a favourable element in the case. 
 
 On June 23, Dr. Jones passed a soft gum elastic catheter up between 
 the uterine wall and the membranes ; labour pains came on with 
 increasing regularity and force in about twenty hours, and a living 
 female child was born twenty-four hours after the introduction of. 
 the catheter. Post-partum haemorrhage necessitated the mechanical 
 removal of the placenta, after which the uterus contracted pretty 
 lirmly. I saw the patient four hours after the child's birth ; the uterus 
 had relaxed considerably, and its cavity was distended with coagula, 
 which were removed by gentle compression, and the uterus and the 
 vagina were well irrigated with vinegar and water, after which tlie 
 uterus contracted fairly well. 
 
 The abdomen was a good deal distended and painful : pulse 1 20, 
 lessened in volume; temperature 101 "4°, and respirations 28. The 
 face was pinched and anxious, and the skin covered with perspiration. 
 These early symptoms pointed to peritoneal iri-itation of an asthenic 
 type, and to a doubtful prognosis. Next day, the symptoms which 
 usually characterise asthenic puerperal peritonitis were in full force — • 
 viz., abdominal distension, acute pain, urgent vomiting (green vomit), 
 exhausting diarrfuea, dry tongue, urgent thirst, high temperature 
 103"5°), quickened pulse without power (132), shallow respirations (36 
 to 38), great facial anxiety, and fixity in the dorsal decubitus, with flexed 
 lower extremities. 
 
 Tn this condition she continued, fluctuating from day to day, until 
 Saturday, June 30, when she quietly succumbed, just a week from the 
 introduction of the catheter. 
 
 A post-mortem examination was made about eighteen hours after 
 death by Dr. Wilson, Pathologist to Prince Alfred Hospital, and 
 Demonstrator of Anatomy at the Sydney University. The peritoneal 
 cavity contained a quantity of dark grumous fluid, mixed with lymph 
 shreds and pus. The peritoneum around the ca?cum was much congested^
 
 700 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 and studded with dark patches of effused blood. The uterus was well 
 contracted, and liad descended well into the pelvis, although its sinuses 
 contained pus. The tumour extended upwards to the ninth rib (right 
 side), overlapping the ascending colon, to whicli it was attached by 
 recent adhesions; it was also connected by tibrous bands, of old standing, 
 to tlie meso-colon and small intestines. In the immediate vicinity of 
 the tumour, the coils of the small intestines were matted together by 
 recently eS'used lymph, at a point where the sac containing the foetus 
 had given way, apparently from ulceration, and the cranial bones 
 were protruding through the opening. The tumour was anchored to a 
 long pedicle, which appeared to have undergone gradvial elongation, by 
 the enlarging uterus exercising continuous upward pressure upon it. 
 The pedicle was triangular, having a very bi"oad base, which involved 
 the right broad and round ligaments, the right Fallopian tube and ovary, 
 the round ligament forming its right free border. The sac, uterus, 
 and appendages were removed, and cai-efully examined by Dr. Wilson, 
 who, in answer to a list of questions, kindly replied as follows: — 
 (1) Character of cyst and its site — originally tubal, now in the folds 
 of right broad ligament. (2) The containing sac is too much condensed 
 to say whether it consists of the original membranes ; but the lining- 
 membrane is, in part at least, original. (3) Right ovary is intact, and 
 appears to be atrophied; the right tube is intact from the cyst to the 
 fimbriated extremity; the proximal uterine part is ati'ophied and 
 closed. (4) I am of opinion that puerperal peritonitis, together with 
 septicfemia, were the causes of death, and think it probable that the 
 peritonitis preceded tlie septicaemia, though it may have been otherwise. 
 
 (5) 1 do not believe that, apart from the subsequent septic infection, 
 the cyst contents which escaped into the peritoneal cavity were the 
 causes of the peritonitis; but they may have been predisposing causes. 
 
 (6) The ftetus belongs to the macerated variety. (7) Tlie left ovary 
 contained a coi'pus luteum. 
 
 Having already occupied more of your time than I originally 
 intended, I will not trespass much longer; but I cannot refrain from 
 offering a remark or two. In the first place, it may be asked — 
 "What were the causes of the severe pains at the end of the second 
 month ? I am inclined to the opinion that pai'tial rupture of the 
 muscular wall of the tube occurred, while the ovum remained intact, 
 and if the true cause had been recognised, it would have been good 
 practice to have performed laparotomy, and cleared out the peritoneal 
 cavity. Then, with respect to the formidable array of symptoms 
 which presented themselves at the end of the fourth month, it may be 
 fairly inferred that a second and more extended rupture occurred, 
 but did not involve the amniotic coat on the placental site, at any rate 
 to any considerable extent. Laparotomy would, at this juncture, have 
 been in accord with modern views, if tlie nature of the case had been 
 made out; but extra-uterine gestation does not appear to have been 
 suspected, notwithstanding tlie presence of a chai-acteristic symptom, 
 viz., a sanguineous discharge from the vagina, more or less continuous. 
 
 What were the precise changes wliicli took place after tlie cessation 
 of the labour pains, when the faintness, loss of vision, and a sense of 
 impending death — witli a feeling as if something was moving loosely 
 in the aVjdomen — occurred, it is difficult to conjecture? The patient
 
 UTEIUNK PUEGNANCY SUFEKVKXING 0\ iiCTOfIC (iKSTATIOX. 701 
 
 was satisfied tliatthe child was alive previous to this attack, but did not 
 feel its movements after the urgent symptoms had passed away. It is, 
 however, within the range of possibility that the membranes were more 
 completely ruptured than heretofore, permitting the escape of the 
 liquor amnii, and perhaps tlie child, in part, into the al)dominal cavity ; 
 that the child died ; and the ruptured cyst was repaired by the 
 inflammatory changes that supervened. AVith respect to the clot 
 passed per ^"aginaln, of peculiar formation, size, and density, having 
 the length and outline of a child's forearm, we may fairly assume this 
 to have been the uterine decidua, although it does not appear to ha\'e 
 l)een recognised by the medical men in chai-ge of the case. 
 
 When the patient returned from the countiy, her general health had 
 so much improved, and her personal inconvenience was comparatively 
 so little, that slie positively declined to permit of any surgical inter- 
 ference, although it was represented to her that the retention of the 
 tumour might eventually prove to be a source of danger. While, in some 
 cases, toleration of a gestation sac may be established after the sac 
 and its membranes have become calcified, and may be retained, as an 
 inert body, for a long series of years, — (Sappey met with a case where 
 a foetus had been thus retained, in this way, for more than half a 
 century) — nevertheless, it is well-known that tliis process of calci- 
 fication, even when established, is often impei-fect, and the sac may 
 rupture inopportunely, and prove disastrous to the interests of the 
 unfortunate patient. Hence, it is a wise precaution to remove the 
 tumour when a favourable opportunity offers. It is quite possible that 
 rupture would not have taken place in this case had irot uterine 
 pregnancy supervened. 
 
 But the most important questions yet remain to be noticed, viz. : — ■ 
 What was the best course to adopt when interference became a 
 necessity ? Upon which factor ought we to have acted 1 Upon the 
 tumour, or upon the uterus? These are important questions, upon 
 which I should be glad to hear an expression of professional opinion, 
 especially as we possess so little information as to the best method of 
 dealing with cases of this kind ; indeed, I have not been able to find a 
 similar case on record. 
 
 Looking at the case from an after-event point of view, it may be 
 said that, to have removed the tumour, as we should an ovarian tumour 
 complicating pregnancy, would have been the best mode of treatment. 
 I was not of this opinion before the event, nor am I now, and for the 
 following reasons : — 
 
 (1) Because the uterus had evidently made preparation for relieving 
 
 itself of its contents, as indicated by the conditions already 
 mentioned, and I am one of those who hold the opinion 
 that in cases of perplexity we should, if possible, ascertain 
 nature's plan of dealing with her difficulties ; and if her 
 method is practical and reasonable, we should, as far as 
 possible, aid her in carrying out her conservative designs. 
 
 (2) Because Ave liave the fact on record, that toleration of an 
 
 abdominal gestation sac may have become so well 
 established, that labour, even at full term, may be completed 
 without injuiy to the sac or its contents, even if the uterine 
 gestation is several times repeated
 
 702 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 (3) Because I Ijelieved the patient's general condition and 
 surroundings were exceedingly unfavourable for abdominal 
 section — a belief which was well sustained by the after- 
 death examination, which revealed the facts that the fcetus 
 belonged to the macerated variety ; that the sac had given 
 way, and its Huid contents had escaped into the peritoneal 
 cavity. How long the cyst had been ruptured could not be 
 ascertained ; but it may reasonably be inferred, that the 
 escape of the fluid contents of the cyst into the abdominal 
 cavity was the exciting cause of the exhausting attack of 
 diarrhoea and subsequent peritonitis, which contributed so 
 materially to the disastrous i-esult. 
 If rupture of the sac could have been diagnosed, then abdominal 
 
 section should have been undertaken immediately, notwithstanding the 
 
 unfavourable circumstances surroundinc: the case. 
 
 A MODIFICATION OF MARION SIMS' OPERATION FOR 
 
 METROTOMY. 
 
 By George Rotiiwell Adam, M.B., Ch. M. Edin. 
 
 Hon. Physician, Midwifery Department, Women's Hospital, Melbourne. 
 
 It is not within the scope of this paper to enter upon a discussion on 
 the merits of metrotomy ; suftice it to say, that the operation has now 
 been thirty years or more before the profession, and is still extensively 
 practised in some form or other. My aim is rather to bring tlie 
 operation up to the scientific requirements of the day, and thereliy 
 reduce its possible dangers to a minimum. 
 
 The patient is directed to have the pudenda, including the inside of 
 the thighs and each groin, thoroughly well washed with soft soap a}id 
 hot water, the vagina to be syringed out with water as hot as can 
 conveniently be borne, the night before, and the morning of the 
 operation. 
 
 The patient is placed in Sims' position on a stout table. The 
 pudenda, insides of thighs and groins, are then well washed with a 
 1 — 1600 solution of perchloi'ide of mercuiy, diluting the solution to 
 about half this strength to syringe out the vagina. The instruments 
 and sponges are kept in a 1 — 20 solution of carbolic acid. A Sims' 
 speculum, or wliat I prefer for vaginal surgery, Semon's perineal 
 retractor, is then introduced, the cervix brought into view, and seized 
 with a vulsellum, which is steadied by an assistant. 
 
 An attempt is then made to introduce a sound tlii'ough the cervical 
 canal into the utei'us, in order to ascertain the lie of the viterus, the 
 condition of the cervical canal :ind internal os. If the external os is 
 so narrow that a sound cannot enter, its posterior lip may be incised by 
 a curved sharp-pointed bistoury.
 
 MODIFICATION OF MARION SIMS' OPEKATION FOli METROTOMY. 703 
 
 The posterior wall of the cervix is then divided at one cut with a 
 pair of Hart's scissors, nearly up to the vaginal roof. The hjemorrhage 
 is usually slight, but after sponging, bleeding points are easily seen and 
 secured by pressure forceps. General oozing is readily controlled by a 
 strea^m of liot corrosive solution. The tip of the left forefinger is now 
 pushed up the canal as close to the internal os as possible, and a curved 
 probe-pointed bistouiy is slipped along it through the internal os, and 
 its superficial fibres lightly notched, anteriorly and posteriorly. I the}i 
 enlarge tlie internal os, by stretching it with a four-bladed dilator with 
 spring handles, which enables the operator to accurately gauge the 
 amount of tension used. The vagina is again washed out, and all clots 
 removed by careful sponging. Three or four sutures are noAV 
 introduced into each half of the divided cervix, so that the endo-cervical 
 mucous membrane is united to the mucous membrane on the vaginal 
 aspect of the neck of the uterus, thus practically covering in the cut 
 surfaces of eacli half of the divided cervix. For this purpose, I use 
 curved needles on long handles, similar in pattern to those employed in 
 the operation of cleft palate. No. 3 silver wire makes a good suture, 
 being pliable and sufficiently strong, as there is little strain on it. It 
 is well to leave the ends long enough to reach to just within the vaginal 
 outlet, taking care to bend up the points in order that the vagina may 
 be uninjured. In this way, the removal of the suture is more easily 
 •effected. The vagina is now thoroughly washed out with corrosive 
 solution, carefully sponged dry, and packed with absorbent iodoform 
 wool. The whole operation need not occupy more than twenty or 
 twenty-five minutes. The after-treatment consists in keeping the 
 patient in bed for seven or eight days, after which she may be allowed 
 to get on to a sofa, and on the fourteenth day she is usually convalescent. 
 
 I remove the vaginal packing on the second day, and have the vagina 
 then daily washed out with hot carbolised water until after the sutures 
 are taken out, which is done on the sixth or seventh day. The 
 advantages of this method of j^erforming metrotomy are: — (1) It is 
 aseptic, in so far that the vagina is thoroughly cleansed, and the cut 
 sui*f aces are closed in and encouraged to heal rapidly. (2) Ha?moi'rhage 
 is effectually controlled by the fact, that those parts from which any 
 considerable bleeding can occur are bi'ought within easy view, and 
 secondary hiemorrhage is obviated by the closing in of the cut edges. 
 
 (3) The object of the operation is more effectually carried out, inasmuch 
 as closure of the cervical canal is abundantly provided against by the 
 forcible teai'ing of the superficial muscular fibres of the internal os (wliich 
 act as a sphincter) and the suturing of each half of the divided cervix. 
 
 (4) It is in accordance with modern scientific requirements, whereby 
 tlie sense of touch is not alone unnecessarily relied on, but a precision 
 is given to the can-ying out of details which other methods in vogue do 
 not possess. 
 
 The homely adage, " the proof of the pudding is in the eating," is 
 axiomatic; so in surgery, an operation must be known by its results. 
 Of five cases I have done by this method, two were where steiility 
 was the prominent trouble, and in both instances the result justified 
 the procedure. The other three were for dysmenorrhoea. In two, the 
 relief was all that could be desired ; in the third, the result was a failure, 
 probably due to want of care in selecting it as a suitable case for
 
 704 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 operation, as there was a fibroid gi'owth in the posterior wall of the 
 uterus, on which I now think the dysmenorrhcea depended. Not one 
 of these cases gave me the least anxiety during convalescence. The 
 temperature and pulse, after the reaction from the operation subsided, 
 continued normal throughout, and the patients suffered no incovenience 
 beyond the confinement to bed. In contra-distinction to this, within 
 the past year I have seen thi^ee cases, in which the metrotome was 
 used, do very badly. One had alarming hfemorrhage; the other two 
 were confined to bed for many weeks with a sharp attack of peri-uterine 
 inflammation. 
 
 In conclusion, I would say that any who may try this method of 
 doing meti'otomy will find it a distinct advance on the ordinary 
 methods in vogue. 
 
 THE MENSTRUAL FUNCTION— ITS INCEPTION, DURA- 
 TION, AND CESSATION, COMPARATIVELY CONSIDERED. 
 
 By Eugene Anderson, M.D., B.S. Melb.; L.R.C.P. et S. Ed. 
 
 For two years Senior Resident Surgeon, Women's Hospital, Melbourne. 
 
 In casting round for a subject worthy the attention of so important 
 a meeting of the medical profession as this, it occurred to me that a 
 consideration of some points connected with menstruation might be of 
 interest, especially if those points we)-e particularly worked up from an 
 examination of the suiTOundings of that function as exhibited by those 
 born in the colonies, as compared with those born in the United 
 Kingdom. For this purpose, I have taken the records of the Women's 
 Hospital, Melbourne, and from over 1200 cases I have drawn out the 
 following results and conclusions. 
 
 Comparatively, I have also considered throughout the differences which 
 exist in the perfoi'mance of this function, when it is first established, 
 and later, in more mature years, when marriage and child-bearing have 
 in most cases brought their influences (if any) to bear. 
 
 I have taken particular note of the following points, viz. : — The age 
 at which menstruation is established, its regularity or otherwise, the 
 number of days which the flow lasts, the amount of accompanying pain, 
 the age at which menstruation ceases, and the duration of menstrual 
 life. 
 
 These points I desire to now shortly bring before this Congress, 
 hoping that this paper may shed some few rays of light on this important 
 function : — 
 
 The Average Age at which Menstruation begins. 
 
 In 1220 cases, the average is 14-71. The whole of these were born 
 in the colonies, with the exception of 132 cases, in which the age 
 was 14*73. The average mean temperature of Melbourne is 57° F., 
 and of the capitals of all the colonies it is G0'5°, while that of
 
 THE MENSTRUAL FUNCTION. 705 
 
 Great Britain and Ireland is 45'4° ; thus a difference of 15"^ 
 in temperature is accompanied by an earlier onset of the flow of 
 only '02, or one week less than is, I think, ordinarily supposed to be the 
 case. Hart and Barbour give from 13 to 15 as the usual age for the 
 home country; while Playfair states that, in temperate climates, it 
 generally commences between the fourteenth and sixteenth years, and is 
 somewhat earlier in tropical, and later in very cold countries. My 
 number of cases is certainly not large, but, as far as they go, tend to 
 show that the difference is not so great, according to tem[)erature, as is 
 often ascribed to this influence. 
 
 A few particulars are given of the most notable cases met with in my 
 examination of our records. Thus the earliest age at which men- 
 struation commenced was 8}, years. This woman was regular from the 
 start; married at 19, had one child, is 30 now, and is irregular, with a 
 7 to 8 weeks interval. In another case, pet. 25, the menses have never 
 appeared ; married at 1 8 ; has never been pregnant ; no treatment was 
 considered necessary ; uterus and ovaries present. Another, jet. 34 now; 
 is married; never has been pregnant; menses have never appeared, 
 though there is no pathological condition to acconnt for their absence. 
 Another, set. 18 now; no menses have appeared; was married at 16, 
 and has had two children, the last very recently. This is a curious 
 case, and it would be interesting, if her history could be followed, to 
 see if they appear later. 
 
 Of 1160 cases— 1 began at 8.1,, 7 at 10, 20 at 11, 91 at 12, 154 at 13, 
 267 at 14, 254 at 15, 164 at 16^ 109 at 17, 54 at 18, 13 at 19, 12 at 20, 
 3 at 21, and 2 at 23. 
 
 (a) Question of Regularity, or otherioise, at Incejyfion of Menstruation. 
 In 1170 cases, 308 or 26 per cent, were irregular then, while 862 or 74 
 j)er cent, were regular. The average age at which menstruation began 
 in those who were irregular was 14'82, or "11 higher than the general 
 average — a slight indication that late appearance rather predisposes to 
 irregularity. I find that in 1177 cases, the average number of days 
 which early menstruation lasts is 4*42 days. 
 
 (h) Amount of Pain with Early Menstruation has been considered as 
 
 None, Some, Great, and Very Great. 
 Out of 1144 cases : — 
 
 No pain occurred in 484, or 42 per cent. 
 
 Some ,, ,, 352, „ 31 ,, 
 
 Great „ „ 289, „ 25 „ 
 
 Very great „ 19, „ 2 „ 
 
 (c) Amount of Floio in Early Menstruation is Grouped under the Heads 
 of Very Scanty, Scanty, Usual, Free, and Very Free. 
 In 1109 cases:— 
 
 Very scanty in 34, or 3 per cent. 
 Scanty „ 235, „ 21 „ 
 Usual „ 450, „ 41 „ 
 Free „ 346, „ 31 ,, 
 
 Very free „ 44, „ 4 
 
 While working out these results, I thought it advisable to enquire if 
 scanty or very scanty flow is associate*.! with more pain than when the 
 
 Iz
 
 706 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 amount is usual or free, and found, from a consideration of 228 cases, 
 that scanty flow is associated with more pain in 9 per cent., 
 while very scanty flow is accompanied by veiy great pain in 21 per cent, 
 more (33 cases) than the average. 
 
 Later Menstruation. 
 
 The average age (of 940 cases) at which this is taken is 31, and the 
 percentage of married to single women is 80 per cent, to 20 per cent. 
 
 (1) Its Regularity, or Otherwise. 
 
 In this, I have taken every woman as regular who menstruates 
 every 2, 3, 4, 5, or 6 weeks habitually. 
 
 In these 940 cases, 65 per cent, are regular, and 35 per cent, 
 irregular. Comparing this return with the results obtained in early 
 menstruation, it will be found that 9 per cent, more are regular in 
 their early, than in their late performance of the function ; tending to 
 show that, in later life, menstruation is a good deal more likely to 
 be irregular, than at its onset. 
 
 Hart and Barbour state that it is regular in 87 per cent, when 
 once established. I suppose the discrepancy in these returns is due 
 to the fact, that Hospital patients are so often affected with various 
 uterine and ovarian troubles, which tend to cause irregularity. 
 
 (2) The Frequency of Later 3fenstruation. 
 In 621 cases who are regular : — 
 
 29 menstruate every 2 weeks, or 5 per cent. 
 
 88 „ „ 3 „ 14 „ 
 
 471 „ „ 4 „ 76 
 
 OK (\ 1 
 
 ■^" >> 5J " >> ■* 5) 
 
 Thus, three-quarters of all those who have any regular interval are 
 unwell every 4 weeks, while every 3 weeks is by far the next in 
 frequency. Seventy-one per cent, of all women are stated to menstruate 
 every 28 days. 
 
 (3) The Number of Days tohich Later Menstruation lasts. 
 
 Hart and Barbour consider it abnormal if the flow last less than 
 2 days, or more than 8. In 848 cases, I obtained an avei-age of 5 days, 
 closely agreeing with Playfair (who gives 4 or 5 days for the Home 
 Country, while some French writers give 8 days for that country), 
 and being an excess of rather more than half a day over the duration of 
 its continuance in early life. 
 
 (4) Amou7U of Pain in Later Menstruation. 
 In 853 cases : — 
 No pain in 212, or 25 p.c. as comi)ared with 42 p.c. in early menstruation. 
 Some „ 270, „ 32 „ „ „ 31 „ „ „ 
 
 Great „ 316, ,, 37 „ ,, ,, 2a „ ,, „ 
 
 Very great 55, „ 6 „ „ „ 2 „ „ ,, 
 
 Thus late menstruation is found to be associated with pain of a varying 
 degree in 17 per cent, more than in its earlier manifestations.
 
 THE MENSTRUAL FUNCTION. 707 
 
 (a) Aiiiuunt of Flow in Later Maistniation. 
 
 The average amount of blood lost is very variously estimated. 
 Hi])pocrates tliouglit IS ounces, wliich is much too high; and proVjably 
 Playfair, witli 2 or .3 ounces, is more near correct. 
 
 In 815 cases : — 
 Flow was A^ery scanty in 40, or 5 p.c. as compared with 3 p.c. in early. 
 ,, ,, fecanty ,, 1J4, ,, L4 ,, ,, >> -'i ;< )> 
 
 „ „ Usual „ 227, „ 28 „ „ „ 41 „ 
 
 ,, ,, J- ICC ,, .J I -J, ,, >)^J ,, ,, ,, !^i ,, ,, 
 
 Vervfree S2 10 4 
 
 Comparatively, 
 The flow is of usual amount in 28 per cent. Late, and 41 per cent. Early. 
 Is below the average in 29 ,, ,, ,, 24 ,, ,, 
 
 Is above the average in 4.5 „ „ „ 35 „ ,, 
 
 Instituting a general comparison, it will be seen that in eaily 
 menstruation the flow is more regular, lasts a shorter time, is accom- 
 panied by less pain, is of a normal or usual amount much more often 
 (13 per cent.), is below the normal less often (5 per cent.), and above 
 the normal less often (8 per cent.) than in later menstruation, where 
 the converse holds good. The very great majority of these women in 
 "wliom later menstruation is taken, being married, and having had 
 children, it seems that marriage and parturition tend to cause 
 irregularity, a longer duration, more pain, and more variation from the 
 usual flow than single life, 
 
 (10) Age at tvhich Menstruation Ceases. 
 
 This is generally given as from 40 to 50, and Raciborski states that the 
 largest number of cases of cessation are met with in the forty-sixth year. 
 I have taken out 95 cases, and their average is 46 years ; 4 of these 
 ■women were single and had no children, and in them it ceased at 46^ 
 years. Of the 91 married women, 12 had no children nor abortions, and 
 in them it ceased on an average at 42i years. The average age at which 
 menstruation began in all cases was 15 j years, so that the duration of 
 menstrual life was 30f years ; in the single women it was 32 years, and 
 in the 12 nulliparous married women it was 27'4 years — 3 years less 
 than in parous married women, or longest in the single, and shortest 
 in the married woman with no children. The greatest age at which it 
 ceased was 60, and in this case it began at 13^, so that her menstrual 
 life extended over 46^ years; she was married at 30, and had 2 
 children. The earliest age at which cessation took place was 28 ; in her 
 it began at 15, married at 23, has never been pregnant, her present age 
 being 43. 
 
 It is generally said that women, who commence to menstruate when 
 very young, cease to do so at a comparatively early age ; so that the 
 average duration of the function is about the same in all women, those 
 who commence late ceasing later than usual. I have tested this as 
 follows : — In 37 cases, in which it began at 16 or over, the average age 
 at which it ceased was 45?, years, and the duration of menstrual life was 
 28 years. In 16 cases, in which the function began at 13 or under, the 
 age at which it ceased was 46.', years, and the average duration of their 
 
 Iz 2
 
 708 INTERCOLONIAL MEDICAL CONGRESS OB' AUSTRALASIA. 
 
 menstrual activity was 34| years. These results show that if menstrua- 
 tion commences much later than usual, the average duration of its 
 activit}' is 2f years less, and the age at which it ceases is 6 months less ; 
 while if it commences much earlier than customary, its average duration 
 is 3^ years more than usual, and the age at which it ceases is 6 months 
 more than the average of all cases; so that I agree with Playfair and 
 others, that the earlier the menstruation commences, the longer it lasts — 
 early menstruation indicating an excess of vital energy, whicli continues 
 during the whole childbearing life. 
 
 I have taken out in addition two points of general interest, though 
 not actually included properly under the title of this paper : — 
 
 (c() The average age at which marriage took place was 20'79 years. 
 The youngest was married at 10, menses began at 15, had 1 child, 
 is 28 years old now, and regular. The oldest was married at 46, she 
 began to menstruate at 15, has had no children nor miscarriages, is 49 
 now, and regular. Another married at 12, menses began at 14, had 17 
 children, and at 47 is regular. 
 
 {/>) Average number of children which parous married women bore, 
 is 4 '48 (not counting abortions). A few remarkable cases of excessive 
 childbearing are given : — 
 One had 17 Menses began at 12 
 
 J» )) -l^ >) J) 
 
 1 '^ 
 
 1 'i 
 >> 5> ^''' n J) 
 
 15 
 
 15 
 1 5 
 
 It will be noted, that the average age at which menses first appeared 
 in these prolific women was 14], just about the regular time, while 
 they all married very early, averaging 17i years; the latter fact, in 
 connection with the large number of children they bore, is perhaps 
 worthy of consideration. 
 
 12 
 
 Married 
 
 at 18 
 
 Menses ceased at 49 
 
 12 
 141 
 
 
 „ 15 
 
 GO 
 At 40 is irregular 
 
 IG" 
 13 
 
 
 „ 18 
 „ 17 
 
 At 46 is regular 
 
 13 
 17 
 
 IG 
 
 
 „ 15 
 
 22 
 ,',' 21 
 
 „ 40 „ 
 „ 47 „ 
 
 „ 47 
 
 PILOCARPINE IN PUERPERAL ECLAMPSIA. 
 
 By R. H. J. Fetherston, L.R.C.S.I., L. et L.M.K.Q.C.P.I., 
 M.D. et CM. Edin. 
 
 During my residence at the Women's Hospital, it has been my lot to 
 witness some twenty cases of eclami)sia; and having tried several 
 methods of treatment with varying success, I have determined to give 
 a few particulars of the treatment from which the greatest amount of 
 success has been derived, namely, by the hypodermic injection of pilo- 
 carpine nitrate. Before going into the treatment, I shall briefly give an 
 account of the cases, so that you may be better able to judge of the value 
 of the results. There have been in all twenty-two cases attended in the
 
 PILOCARPINE IN PUERPERAL ECLAMPSIA. 709 
 
 hospital during uiy residence. Of these, twelve developed the convulsions 
 in the hospital, the other ten being brought or sent there at various 
 periods of the disease — three being moribmid on admission, and dying 
 in a few hours. Unfortunately, the notes of two cases have been 
 mislaid, so that I am only able to give the particulars of twenty. Of 
 these, nine were married and eleven single women, their average age Toeing 
 slightly over 24 years; the youngest was 17, and the oldest 44. Fifteen 
 of them were })rimipanx3, and one woman had previously had eight normal 
 confinements. 
 
 As to their condition when admitted — Thirteen were of urtemic type, 
 with well-marked axlema of face and legs ; two were apparently heahhy , 
 the other five being simply noted as delicate. The urine, on testing 
 with heat and nitric acid, was found in every case to contain large 
 quantities of albumen. Labour as a rule was slow, but in three it was 
 rapid and precipitate; and in two it was doubtful if labour began at all. 
 Delivery was completed imaided in thirteen, forceps being used in 
 three, while podalic version was performed in one, and the remaining 
 three died before delivery. Eleven of the children were born alive, 
 only one showing any signs of convulsions during the time they 
 remained in the hospital. 
 
 Coming to theeclampsic seizures — The fits began before labour in five, 
 in five others during the first stage, four during the second, and two in 
 the third, the remainder (four) developing the convulsions after the 
 completion of labour. The attack terminated in four before delivery 
 (three of these being at death), six upon the completion of labour, and 
 the "remaining ten at intervals varying from an hour to 4i days after 
 confinement. The average number of fits was thirteen, but this is by 
 no means an accurate average, as in those who had convulsions on 
 admission it was impossible to obtain the exact number of fits from 
 wliich the}^ had sufiered. As to the mental condition^ — they, with four 
 exceptions, became unconscious after a few fits, and remained so for 
 several hours, in one case for 4^ days. The average maximum tem- 
 peratui-e was I02'.o^ F., the pulse varying from 120 to 160 per minute, 
 while the respirations ran as high as 44. The termination as to the 
 mother was death in five out of twenty-two cases — three, as I have 
 before mentioned, being moribund on admission. 
 
 Treatment. — When possible, chloroform was given at the approach of 
 each convulsion, and its administration continued for sufficient time to 
 cause relaxation of the muscles. I may here mention that I found 
 a very small quantitj' of the drug, if given in time, was sufficient 
 to prevent the violent spasms. The bowels were well em])tied, croton 
 oil being generally chosen from its rapid action, and the simplicity of its 
 administration. In seven, venesection was performed, the amount of 
 blood taken varving from twelve to twenty-four ounces ; and in three 
 cases its beneficial effects was very marked, but in the others it seemed 
 to exert little or no power in controlling the disease. Three patients 
 bad morphia by the skin, in doses of a quarter or a half grain ; and in 
 one a wet ])ack was used, without any ap})reciable result. After free 
 purgation, enemas containing chloral hydrat. and potas. bromid., thirty 
 grains aa, were given in eleven cases, being usually repeated every six 
 hours ; and if pilocarpine was used in the same case, the two drugs were 
 made to alternate. Before going on to the treatment with pilocarpine,
 
 710 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 I may mention that I at fii'st gave it in all cases, but in two of them 
 (feeble delicate women) rather alarming symptoms supervened, such as 
 marked lividity with very feeble action of the heart, coma being pro- 
 found, with considerable cBdema of the lungs ; so that I have now 
 discontinued its use in feeble subjects, only administering it where the 
 patient is strong, and often of ura^mic type (with short thick neck, puffy 
 face and eyelids, and more or less anasarca of the lower extremities), has 
 a full, rapid and incompressible pulse, the urine being at the same time 
 usually dark and scanty, containing much albumen. 
 
 It was in such subjects, more especially if met with early in the 
 attack, that I have found benefit accrue from the administration of 
 pilocarpine, whicli, if given under the skin and in full doses, usually acts 
 in from three to four minutes, causing profuse diaphoresis, the perspira- 
 tion pouring off the body, and drenching the patient's clothes. The 
 pulse almost invariably slows down, and salivation is often very marked, 
 flowing, if the patient is lying upon her back, down her throat, thus 
 causing a loud gurgling noise at each respiratory effort. 
 
 The force of the tits is considerably diminished, and at the same 
 time they often become less frequent for two or three hours, when 
 the effects gradually wear off, and in from four to six hours the 
 perspiration will have completely stopped, the skin again becoming 
 dry, and the injections will have to be repeated as long as the fits 
 continue, or until any symptoms contra-indicating their use should appear, 
 such as the pulse becoming very feeble, permanent lividity of the face 
 and extremities, or any degree of oedema of the lungs, which complication 
 is not uncommon after prolonged and violent attacks, even when 
 pilocarpine has not been used. But since I have only used this drug in 
 such subjects as previously described, I have never .seen it produce any 
 symptoms to cause the least anxiety, though I have repeatedly given as 
 much as three or four grains to one patient. 
 
 Dose and Administration. — The dose that I have generally used has 
 been one-half grain of the nitrate given hypodermically, repeated, if 
 necessary, every six hours for three or four doses ; and then if required 
 longer, I diminished the dose, finding that one-quarter to one-sixth of a 
 grain was sufficient ; this I continued till the convulsions ceased, and 
 until the return of consciousness; and in several. cases, I have kept up 
 its admiiiistration after the return of consciousness in doses of one-tenth 
 of a grain thrice daily for several days, thus keeping the skin moist, and 
 so promoting the excretion of deleterious matter, and at the same time 
 relieving the kidneys, which are usually in a state of disease. Care 
 should be taken that the air of the room is warm, and that the patient 
 is well and warmly covered during the sweating stage, for fear of lung 
 trouble suitervening. 
 
 In conclusion, I wish it to be understood that, while advocating the 
 use of pilocarpine in certain cases, I do not consider that in it we possess 
 a specific or a drug to supersede all others in the treatment of eclampsia, 
 but wish to urge that in it we have, when used in suitable cases, a 
 valuable adjunct to other more widely known and less dangerous drugs, 
 such as chloral hydrate, potas. bromide, morphia, or chloroform.
 
 THE OBLIGATIONS OF GYNiECOLOGY TO OBSTETRICS. 711 
 
 THE OBLIGATIONS OF GYNECOLOGY TO OBSTETRICS. 
 By Felix Meyer, M.B., B.S. 
 
 If the title of this short essny slioulcl seem in any way equivocal, I 
 would premise by saying that fur from being in the slightest degree a 
 depreciation of a specialty tliat is daily receiving greater recognition as 
 a legitimate application of a special surgery and therapeusis for the 
 diseases peculiar to women, it is rather a special plea for a more 
 scientitic development of a phenomenon which, originally universal in 
 its naturalness, is nowadays too often unnatural, misunderstood, and 
 in consequence, more or less — if I may use the term — mal-administrated ; 
 or to come at once to the indictment, I would say, that unscientific 
 obstetrics are a veiy large factor in the product of modern gynaecology. 
 
 This opinion is based mainly on the experience gained by a residence 
 of over four years as House Surgeon to the Women's Hospital, 
 Melbourne, with an annual average accouchment of 600 women, an 
 intirmary treating yearly some 350 gyntecological cases, and an average 
 annual attendance of some 400 out-patients. Private practice has fully 
 confirmed my views. My conclusions are : — 
 
 (1) That single women enjoy a disproportionately larger innimnity 
 
 from special disease than married women. 
 
 (2) That a large proportion of manied women date their special 
 
 trouble from confinement or miscarriage. 
 
 (3) That in a large number of this latter class, it is the first confine- 
 
 ment or miscarriage that is the starting point of the trouble. 
 In making this estimate, I am not ignoring the fact that numbers of 
 single women (and married women also), suffering from special disease, fail, 
 from motives of delicacy, to present themselves for treatment ; that in 
 others, independently of childljirth, there may be hereditary, congenital, 
 or acquired disease ; and that incompatibility in marriage and general 
 pathological conditions play a very important part ; but even after 
 eliminating these causes, I maintain that there still remains an unduly 
 large number of cases which have their first source in the obstetric 
 function ; and it is the perversion of this function which I wish briefly 
 to touch upon. 
 
 The Period of Pregnancy. 
 
 While it cannot be denied that any abnormal condition during 
 pregnancy must discount the chances of a successful jDarturition, it is 
 also true that such abnormal conditions are very often overlooked by, 
 or unknown to, the medical man ; since, except in the case of some 
 remarkaVjly disturbing element for which he may be summoned, he very 
 often sees nothing of his patient between the time of his engagement 
 and the onset of labour. 
 
 Many of these abnormal conditions, especially in the case of first 
 pregnancies, are accepted by their subjects as natural accom^^animents, 
 and are allowed to continue with all their deteriorating effects up to the 
 time of labour. Such, for example, are versions or flexions of the 
 uterus, mal-positions of the child, leucorrhoea, blood discharges, and 
 pathological conditions of the genital tract generally. Wliei'e, in
 
 712 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 answer to questions, there is the slightest suspicion of the existence of 
 anything abnormal, an examination should be insisted on, a little tact 
 and delicacy on the part of the medical man generally overcoming 
 the natural objection of a woman for the first time pregnant. I can 
 only say that, by insisting on this method when deemed necessary, it 
 has fallen to my lot to detect and treat beforehand complications that 
 might have otherwise proved serious. 
 
 The question of surgical interference during pregnancy is one that 
 can be answered only by the individual exigency of the case. While it 
 is true that women have miscarried after the drawing of a tooth, it is 
 also true that grave operations, such as ovariotomy, have been performed 
 without in any way disturbing pregnancy. I have done numerous small 
 operations on pregnant women, with and without an anaesthetic, even to 
 removing a cervical polypus, without any untoward result. 
 
 Coming now to labour itself, we arrive -at a period during whicli 
 unskilled obstetrics provide ample material for the gynaecologist. If 
 labour with the human species were the almost purely physiological 
 process it is with tlie lower animals, midwifery, as an art, would have no 
 need of existence; and what is often sneeringly termed "old women's 
 work " might be safely relegated to old women. 
 
 The conditions of life, however, bring about so many deviations from 
 the natural process, as to render it very often pathological ; and in this 
 part of medical science more than in any other, I take it, does it lie 
 within the function of the practitioner to bridge with the smallest span 
 the distance between the natural and the unnatural. 
 
 How this function is perverted, I wish briefly to indicate. The value 
 of a rational antisepsis needs no comment from me. The enormous 
 reduction of the mortality of lying-in hospitals over the whole world, 
 since its introduction, speaks volumes. Grave, then, is the error of those 
 accoucheurs and nurses — and their number is not few — who ignore it. 
 I use the word "rational," because its employment is very often irrational 
 and excessive. 
 
 The First Stage of Labour. 
 
 And here we come to the questio vexata of the clinical significance of 
 lacerations of the cervix. And while I would not, as some do, ascribe 
 all pathological conditions of uterus to this lesion, I venture to think 
 that few will agree with even such an eminent authority as Noeggerath, 
 wlio, basing his opinion on an examination of one hundred cases, declares 
 tliat lacerations have no influence on the development of uterine affec- 
 tions, either in regard to number or intensity. If wrong, I am content 
 to err in the good company of almost the whole of the American 
 gynsecologists, a large number of Continental ones, and latterly, not m 
 few of the English specialists. 
 
 And though statistics show that lacerations exist in some 30 per 
 cent, of parous women, it does not follow that they do so rightly. It 
 is sufficient for my purpose to state my l^elief, tliat lacerations of tlie 
 cervix have an importance that extends beyond the time of their pro- 
 duction ; that, in addition to tlie risks of haemorrhage and septicfemia 
 at the time, they lead to exaggerated cell-growth (one form of which 
 may be epithelioma), sub-involution, and chronic ceiwical endometritis. 
 On these grounds alone, I advocate a greater care in the guarding of
 
 THE OBLIGATIONS OF GYNECOLOGY TO OBSTETRICS. 713 
 
 the cervix in the iiist stage than T believe at present obtains among 
 accouclieurs. Its claims are surely equally as strong as those of its 
 analogue — the well-cared-for perina-um. T do not for a moment forget 
 tliat lacerations Avill and do occiu-, no matter what care is given, but I 
 defend tlie position that they are largely preventible. Among the 
 preventil)le causes is — Labour going on with a rigid os. In anaesthetics, 
 in addition to other valuable results, we have the almost certain remedy 
 of this complication. 
 
 In connection with this part of the subject, I may mention a 
 somewhat interesting case, so far as I know, unique : — 
 
 I was called one morning at ten o'clock to see a lady in labour. 
 She was the mother of live children, but had had no child for seven 
 years, and some twelve months back had been the suljject of Emmet's 
 operation. Pains were slight. She would permit of no examination. 
 I cannot say I was very anxious as to the condition of the os, never 
 having previously attended a woman who had had the operation. 
 
 I received an urgent message in the night, and coming into the rooDi 
 at the commencement of a strong pain, I examined and found the os 
 small (the size of a threepenny piece), with a hard band of membrane 
 occluding ; and as the pain proceeded, I felt the head of the child 
 gradually tearing through the left lower part of the cervix — the hair of 
 the child's head could be distinctly felt. Thei'e was no time to lose ; 
 1 poured a quantity of chloroform on to an inhaler and made the nurse 
 apply it to tlie patient, and guiding a curved blunt-pointed bistoury 
 along the riglit forefinger to the cervix, I slit through the cervix up to 
 tlie margin of tlie laceration just produced by the head. Even then, 
 as the pain continued, there was great difficulty in preventing the head 
 from pushing upwards and enlarging tlie tear towards the fundus. The 
 head had to be guided by two or three fingers over the cervix, as 
 one would support a perina?um, but delivery was effected without 
 anything worse than severe hemorrhage. The patient made a good 
 recovery, and twelve days after, on examining, I found the laceration 
 healed. 
 
 I have since then had occasion to attend several women who have 
 had this operation on the cervix (Emmet's), and with one exception — 
 where I divided a cicatricial band in the beginning of labour — I have 
 had no trouble. 
 
 While it is in no way the province of this paper to deal with the 
 treatment of lesions at a time remote from the period of parturition, 
 during wliicli they may have been produced, I must — unless I have 
 tliorouglily misunderstood one part of Dr. Batchelor's able and practical 
 address of yesterday — beg to differ from his views as to the wisdom of 
 ignoring the significance of extensive lacerations of the cervix, for T 
 have yet to learn that such solutions of continuity are physiological ; 
 and as for the few cases on which I have operated during only four 
 years of private practice, I feel certain they would have been justified 
 in the eyes of Dr. Batchelor, or any exponent of gynaecological or 
 general surgery, as much from their abnormal appearance as from tlie 
 relief of symptoms which followed operation. 
 
 If in slavish subservience to a fad, some specialists attack every form 
 of cervical eversion and small fissure with operation, it is the wrongful 
 exponent of a system, not the system itself, which must be condemned.
 
 714 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 However, when all is said and done, I think most will agree that we 
 should try to prevent the tearing of the os in labour ; and so far as 
 rigid OS is concerned, in my experience the value of anaesthetics (not 
 necessarily deeply pushed), is beyond a doubt. 
 
 Another cause of laceration of the cervix is the hasty and ill-advised 
 use of forceps, either while the os is rigid — a not uncommon practice — 
 or before it has had time to dilate — a still more common practice. In 
 such cases, the instrument might well be termed pra^ceps. It may seem 
 puerile to allvide to such a self-condemning practice, but I make bold to 
 say it is such a common one, as needs allusion to in a paper like this, 
 which is in the main suggestive. 
 
 If the use of forceps is abused in the first stage, it is much more so 
 in the second. The how and the when of their application cannot be 
 tavight theoretically ; but this is certain, that to their misuse and 
 unskilful application are due, very often, lacerations of perinseum, 
 I'ectocele, cystocele, vesico-vaginal and recto-vaginal fistula, pelvic 
 cellulitis and peritonitis — the latter very commonly the first link in a 
 chain of pathological process, leading up to ovarian and tubal disease. 
 Formidable as this list appears, it is a true bill ; and in taking the 
 history of every woman who attended either as an in-patient or out- 
 patient during my tei'm of residence at the Women's Hosj^ital, how 
 often has the stereotyped reply come, " I have never been well since my 
 first confinement ; I was hurt with instruments." I yield to none in 
 my appreciation of the value of forceps, but in the hands of many, they 
 are a thing of evil. 
 
 Before leaving the subject, I may mention that: — (1) Before using 
 forceps, I never omit to draw off" the urine, or make the patient pass it. 
 (2) I invariably use an ansesthetic more or less deeply. (3) In most 
 cases, I remove the blades before the head has passed the perinteum, in 
 order to allow some gradual distension of the latter, and also to give 
 the uterus some share in the expulsion of the child. 
 
 Of the care of the perinfeum, as a necessity, I need not speak ; but I 
 may mention that I now condemn what I at one time approved of, viz., 
 the practice of pushing the head through the vagina by means of a 
 finger or two in the rectum. Injury to the bowel or fistula may follow 
 from this practice. It is far better to apply pressure at the space 
 between tlie anus and the tip of the coccyx. I consider that all perineal 
 teai's, unless there is some special contra-indication, should be at once 
 brought togetlier with sutures ; good union is seldoni effected without ; 
 no obstetrician, I would ventui'e to say, should be reproachable with 
 the necessity of perinieorraphy. 
 
 The mismanagement of the third stage of labour is responsible for not 
 a little mischief to the uterus and appendages. On the best method, 
 tliere still exists a great diversity of opinion ; but practically there are 
 tvo schools — the advocates of Crede's method, and tliose who follow the 
 expectant line of treatment. 
 
 Dr. Felsenreich states, tliat out of 13,904 cases which occurred 
 during four and a half years in Professor C. Braun's Clinic, Crede's 
 nietliod succeeded pei-fectly well in all but fifty-one cases. In Munich 
 Hospital, on the other liand, Winckel allows two hours to elapse before 
 resorting to Crede's method. The two schools, howe^■er, are gradually 
 approaching each other, tlu; ad\ocates of Crede's method inclining to
 
 THE OBLIGATIONS OP (JYX/KCOLOGY TO OBSTETRICS DISCUSSION. 715 
 
 lengthen the time before using expression, and the supporters of the 
 expectant method shortening their period of expectancy. Personally, 
 I have obtained the best results from Crede's method, and should be 
 Very sorry to allow a placenta to remain in the vagina an hour, when 
 the mildest of traction on the cord, or even the passage of a finger into 
 the vagina, would suffice for innnediate delivery. Hasty and excessive 
 manual pressure on the non-contracting or soft uterus is often followed 
 by displacement, svib-involution, or an inflannnatory condition of the 
 organ and jtarts adjacent. 
 
 One important point in connection with the subject is that ergot 
 should not he given during the placental stage. 
 
 The amount of rest required by women in the puei'pei*al condition is, 
 to my mind, greater than that usually insisted on by obstetricians. 
 The average time required for involution is ten weeks, and when we 
 regard the number of women who from choice, not necessity, are about 
 and active in two to three weeks, resuming the pleasures and labours 
 of life, we cannot be sui'prised at the consequent uterine troubles. It 
 is abundantly proven, that involution is accomplished more slowly 
 where haemorrhage has been an accompaniment of parturition, and also 
 in the case of those who do not nurse — an argument whicli might well 
 be made use of by medical men, in counteraction of the growing 
 tendency, especially among the upper classes of women, to avoid the 
 duties of nursing. 
 
 Such is a crude and imperfect sketch of the prophylactic duties of 
 obstetrics against secondary disease, and while it may contain nothing 
 new or original, or nothing that may not be found scattered through 
 the pages of a standard text work on midwifery, it may, as a purely 
 clinical experience, serve as a reminder. There are medical men who get 
 through a large midwifery practice year after year, in happy ignorance 
 of the fact that many of their former patients are applying to sj^ecial 
 hospitals, or specialists, for the relief of conditions directly traceable to 
 parturition ; and, no doubt, the rank growth of self -constituted, 
 ignorant, and unlicensed so-called midwives is contributing its quota to 
 the sum of gyniecology. If obstetrics are worth doing at all, they ai-e 
 worth doing well ; and, regarding every woman in the light of a " complex 
 organism round a uterus," the maintenance of the uterus in a natural 
 condition during the storm of parturition is a sine qua non in the 
 preservation of the health of that organism. 
 
 Dr. Chambers observed that the nature of diseases of women had 
 changed much in the last twenty years. Formerly, we heard a great 
 deal of vesico-vaginal iistulas, and very little of lacerations of the 
 cervix. Nowadays, matters were very different. He thoroughly 
 agreed with Dr. Meyer, that a confinement was often the starting point 
 of a woman's trouble. We were in need of more careful accoucheurs 
 and nurses. He was of opinion that laceration of the cervix interfered 
 with involution of the uterus. 
 
 Dr. Balls-Headlev believed that, in certain cases, disease of the 
 uterus and appendages was due to parturition. He made it a point in 
 his pi-actice to enquire if forceps and chloroform were used in the 
 confinement. He looked upon lacerations (a subject, by-the-bye, some- 
 what out of the scope of the paper) of the cervix as a wise provision of
 
 716 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 Nature for the prevention of too many cliilclren. He thought they 
 were very often due to the head coming through a rigid os. He was 
 one of those who believed in tlieir importance as a cause of disease. 
 They brought about a slowing of involution, retroflexion, and jjrolapse. 
 
 Dr. Jakins agreed with Dr. Meyer, and would go beyond him, 
 especially in the use of antesthetics, which, more frequently employed, 
 would prevent many grave accidents. 
 
 [At this point, Dr. Batchelor asked permission to interrupt Dr, 
 Jakins, with the object of saving the time of the meeting, as he 
 perceived some remarks he had made had been misunderstood; and 
 although only too pleased to discuss real difficulties, he did not wish to 
 waste time with shadows. As a matter of fact, the opinions he held 
 seemed to be unanimously held by members, viz., that cases of lacei'ation, 
 requiring operation, were without doubt occasionally met with; but the 
 condition was by no means so common as to class it among one of the 
 common diseases of women causing severe and constant symptoms; and, 
 for his own part, he considered the discoveries of Emmet immensely 
 less important than the discoveries of Tait. With all due deference to 
 his friend. Dr. Balls-Headley, whose experiences he most readily 
 admitted were larger and wider than his own, he had formed an opinion 
 diametrically 0]iposed to him on this subject. He had never seen, heard 
 of, or imagined it possible, that a case requiring trachelorraphy could 
 occur in a single girl, except the laceration resulted from a previous 
 jDregnancy, or operative measure.] 
 
 Dr. Jakins continued, that a great many cases of laceration could be 
 cured without operation, and that there were many in which the 
 laceration healed spontaneously. With regard to the third stage of 
 laboui', he removed the placenta almost immediately, by passing a couple 
 of fingers into the uterus. 
 
 Dr. WoRRALL differed from Dr. Meyer as to forceps being a cause of 
 lacerations ; he used forceps once in every six cases. The use of forceps 
 for contracted ]3elvis was rare in New South Wales. If laceration were 
 produced, it was preferable to vesico-vaginal fistula. He differed 
 altogether from Dr. Jakins' method in the third stage. He thought 
 that no man should insert his hand into the uterus after delivery, except 
 in cases of adherent ])lacenta. So far as the treatment of lacerations 
 was concerned, he did not believe in a cure of the laceration. The 
 operation was to take a wedge-shaped jiiece from the cervix, a process 
 which lightened it, and otherwise improved it. 
 
 Dr. Adam agreed with Dr. Meyer. As regarded lacerations, there 
 were no doubt many cases of granular os which healed under the action 
 of chemicals; but he would ask — Why not do a simple surgical operation, 
 which removed unhealthy surfaces "? 
 
 Dr. Foreman did not agree with Dr. Balls-Headley, that lacerations 
 of the cervix put an end to pregnancy. He thought they rather 
 favoured it. He met with a great many cases of laceration. If the 
 surfaces were covered by healthy membrane, he left them alone ; if there 
 were ectropion, he o]ierated. The best proof of the value of the 
 operation was the result to the patient — comfort, and loss of symptoms ; 
 and moreover, there was no danger in the o])eration. 
 
 Dr. Batchelor congratulated the Secretary on his paper. He thought 
 tliat slitting up the os by bistoury, as Dr. Meyer had done, was not done
 
 ELECTlilCITV IN' DISKASES OF WOMEN. 717 
 
 often enougli. If we did not take Nature's hint, plain enough in 
 Dr. Meyer's case, rupture of uterus would follow. He believed that iu 
 a case of eclampsia which he saw, cutting of the cervix done early would 
 have saved life. He quite agreed with Dr. INIeyer as to the abuse of 
 forceps. He objected to Dr. Jakins' introduction of the hand in the 
 third stage of labour. A})art from other objections, such a proceeding 
 (as Dr. "NVorrall noticed), favoured the introduction of bad air into the 
 passages. He knew another pi-actitioner who followed Dr. Jakins' 
 method, and who had had no bad results, but he should be sorry to 
 adopt it. He had done Emmet's operation, and did not agree with 
 Dr. Foreman as to its non- dangerous nature. 
 
 Dr. Meyer, in reply, was pleased to find that practically all the 
 members agreed with him. Dr. Balls-Headley was perhai^s right in 
 saying that the subject of lacerations was hardly within the scope of the 
 paper, and he must admit that he had introduced the subject after 
 hearing the President's address, in order to cause a discussion on the 
 subject, as there were evidently differences of opinion. As regards 
 forceps, he begged to inform Dr. Worrall that his average was almost 
 as great as Dr. Worrall's (1 in 6); still he maintained that, to save 
 time, etc., they were abused. Dr. Balls-Headley 's idea, that lacerations 
 of the cervix were a jirovision of Nature against too frequent preg- 
 nancies (combatted by Dr. Foreman), was oj)posed to the experience of 
 Noeggerath, who thoiight that women with lacerated cervices conceived 
 uiore readily than those with the cervix intact. He could not agree 
 with the Qiethod of Dr. Jakins in the third sta^e of labour. 
 
 ELECTRICITY IN DISEASES OF WOMEN. 
 
 By J. Foreman, M.R.C.S. 
 
 Obstetric Surgeon, Prince Alfred Hospital, Sydnej'. 
 
 This subject is one that has exercised the medical mind to a great 
 extent lately, owing to its re-introduction by Apostoli, who has recorded 
 a marvellous succe.ss, certified to by sevei'al leading men in England. 
 
 One could not hear of a method which promised .so much to the 
 unfortunate patients and to the practitioner, on account of its 
 harmlessness, without being desirous of trying it. Accordingly, I had 
 100 Leclanche cells fitted up in my rooms, and I got the instruments, 
 such as are used by Apostoli, from Paris. At the same time, a large 
 battery similar to mine was fitted vip at the Prince Alfred Hospital, 
 where every facility is always given by the directors for investigation. 
 
 The principal use for this treatment was for tibroids, and so much 
 has been written about it in the medical journals that I need not take 
 up your time with details. The instruments and the modes of applica- 
 tion wei'e as described by Apostoli, namely, a ]>latinum sound introduced 
 into the uterus and guarded by a vulcanite canula in the vagina, and on 
 the abdomen a lai^ge soft clay pad, with a large zinc plate on it. The
 
 718 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 galvanouieter at the Prince Alfred Hospital was a very elaborate and 
 ingenious one made by Professor Threlfall ; mine was Apostoli's, which 
 corresponded exactly with the former. The strength of the current 
 varied from 50 to 300, the latter always under chloroform. The 
 number of fibroids operated on by this method was ten. 
 
 Without going into particulars, which would not be instructive but 
 only wearisome, I will sum up the results, which were disappointing in 
 the extreme. In some of the cases whei'e there was pain, ease was 
 certainly given, but in no case was there a diminution in the size of the 
 tumour, nor was there a decrease in the amount of haemorrhage which 
 could not be produced by other means. In one case where she had had 
 forty applications, I gave a current of 350, and some sloughing and high 
 temperature resulted. In another, with the same current, death ensued. 
 The treatment lasted from six to twelve months, and the applications 
 were generally twice a week when well. 
 
 My experience, you see, has not been a happy one, and I cannot 
 understand a man like Dr. Keith writing as he does about it. It was 
 mainly due to reading his ai'ticles that I persevered, for praise for the 
 system comes with great weight from one who has been the most 
 successful in removing these tumours. I could not see any fault in my 
 way of applying it. The sound was always carefully passed, and 
 generally without pain, the pad was lax'ge, and the current strong 
 enough, and plenty of time given, both in the gradual increase of the 
 current, and the time the patient was under it. At any rate, it has 
 not come up to the expectations I had formed and hoped for. 
 
 I can now speak of cases where it has been of benefit. In cases of 
 endometritis, where there is a thick viscid mucus so difficult to get 
 away, applications two or three times a week will prove of great use ; 
 but even here it is far inferior to curetting, both in point of time and 
 for certainty of cure. Cases of chronic metritis are relieved of pain to 
 a great extent, but it is a curious thing that the improvement lasts 
 only for about forty-eight hours. It otherwise exerts no influence on 
 the tissue of the uterus. 
 
 The cases I have been perfectly satisfied with are those where there 
 has been an enlarged ovary, bound down and very difficult to remove 
 by abdominal section ; in fact, I look on it as the most difficult opera- 
 tion there is. The first of these cases was on the left side ; the swelling 
 about the size of a hen's egg, very fixed, and containing a little fluid. 
 It was very painful, and caused so much discomfort that removal was 
 necessary. Under chlorofomn, it was pierced by this lance-pointed 
 stilette for about half an inch, and a positive current of 150 milliamperes 
 given for ten minutes. No reaction after, and there was such a marked 
 decrease on examination four days later, that it was repeated. She 
 left the hospital perfectly well in a fortnight, with scarcely a trace of 
 the enlargement. 
 
 The second was more instructive, as the growth was solid, and about 
 the same size as the former. A large sized aspirator was used in all 
 dii-ections without a trace of fluid. Three applications were used in 
 this case, with a result l^etter than the formei', if possible. 
 
 The third case was one where the appendages had been matted 
 together from inflammation, and the pain was intense; two applications 
 were made, with perfect relief, and subsidence of enlargement. I have
 
 ELECTRICITY I\ DISEASES OP WOMEN — DISCUSSION. 719 
 
 seen this patient twelve months after, and on examination there is 
 notliing abnormal to be felt, and she says she is in perfect health. The 
 second wrote to say she had no complaints after eight months, and the 
 Hrst Avould have presented herself again had there been any cause. 
 
 This, to put it shortly, has been my experience in electricity. The 
 number of cases of metritis and endometritis has been considerable; 
 the major troubles are given as they occurred. I have not wearied you 
 with details, because, at a meeting like this, most of you are as well, if 
 not better, acquainted with the subject than myself, and one should 
 give his experience, and not wander off into comparative trifles, which 
 every one should be acquainted with. I am sorry I cannot say with 
 Keith, that the knife will never be required for fibroids. T occasionally 
 do a hysterectomy, and have no cause to be ashamed of my success; 
 but no one would hail with greater pleasure any means, such as I 
 thought this would be, that would give us a safe and bloodless cure. 
 
 Dr. Rowan said that he was personally obliged to Dr. Foreman for 
 his paper. In his own case, he had had good experience of the method. 
 He had made himself acquainted with the details, and had read carefully 
 Apostoli and Keith. Having a complete apparatus, he had applied 
 this form of treatment to fifteen cases in his own private hospital, and 
 like Dr. Foreman, he was sadly disappointed. He must, however, 
 except the application to cases of menorrhagia, whei-e he had great 
 results, but on the cessation of the application, there was a recurrence of 
 the old trouble. He never used more than 250 milliamjjeres. He found 
 alarming symptoms follow on exceeding this dose. He thought that 
 the tenderness and pain over the ovary, extending to the groin, which 
 sometimes ensued, was due to the ovei'-stimulation of the nerves. He 
 had applied the method in acute pelvic cellulitis, without good result."!. 
 In answer to a question of Dr. Balls-Headley, he (Dr. Rowan) said that 
 he had passed the sound into the cavity of the uterus in uterine 
 thickenings, and afterwards used the stilette and punctured the wall all 
 round. 
 
 Dr. WoRRALL observed that what struck him in this new method was 
 its great seriousness. The necessity for chloroform rendered this iorm 
 •of treatment largely impracticable. He thought that metrorrhagia was 
 more easily treated by curette. 
 
 Dr. Jakins could speak of this method from his private practice, and 
 not favourably. Apostoli had reported no cures, merely improvements. 
 
 Dr. Balls-Headley remarked that, though it might be said 
 " fibroids did not kill," yet they often broke down, and wore patients 
 •out, causing anasarca, ikc. Dr. Foreman's method of applying electricity 
 was new to him. He had seen Apostoli at work, and was not at all 
 impressed. According to him, two or three applications not exceeding 
 two hundred and fifty milliampei'es sufficed. Moreover, Apostoli's 
 diagnoses were not so definite as one would expect. He had seen 
 ■women in London hospitals carefully treated for fibroids after this 
 method, and their temperatures had gone up to 102''. In brief, he 
 had not had much reason to be pleased with this iorm. of treatment. 
 
 Dr. Batchelor thanked Dr. Foreman for his paper on a wide and 
 important subject, and his special case was an example to us to bring 
 forward bad as well as good results. He was not surprised, however,
 
 720 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 at Dr, Foreman's results. His own experience was too small for a 
 decided opinion on his part, but he must say that Dr. Foreman had 
 missed the essential element in Apostoli's treatment, viz., accurate 
 domqe. He would point out that "seventy or eighty cells" meant 
 nothino- definite, for if one cell liappened to be defective, all below were 
 impaired, and the result might be a weaker current than with only 
 twenty cells. Dr. Foreman had used large batteries ; Keith used a 
 twenty-five Leclanche. Gaiffe, of Paris, used circular carbons, witli 
 a small internal resistance, of twenty-four cells. Treatment was quite 
 possible with an ordinary thirty-cell Stohrer battery, with a strong 
 liichromate solution. Then there was a difference of galvanometers. 
 He (Dr. Batchelor) had all his apparatus made in Dunedin, using a 
 bichromate solution, aii ordinary galvanoscope, graduated by a tangent 
 galvanometer, giving accurate readings. With a Stohrer's battery in 
 good order, and with a fresh solution, he had obtained 200 to 240 
 milliamperes, with an extreme resistance of 170 ohms, which from 
 numerous observations he believed to be the average resistance between 
 the uterus and the abdominal walls. He was convinced that the local 
 effects of the current were those of a strong chemical cautery, with 
 decomposition at the site of the poles. On one occasion, through 
 deficiency of the external rheophore, he caused a severe burn — resulting 
 in a slough which took a month to heal ; this, too, in a current of only 
 eighty milliamperes. Where there is less resistance and a far more 
 concentrated current, we have only to expect much greater effects. On 
 the whole, he believed this method to be a convenient form of cautery. 
 He had, under three months of this treatment, reduced to below the 
 umbilicus a tumour originally extending to the ribs — half an inch above 
 the lowest rib on the right side, and one and a half inches above 
 the corresponding left rib. Although Apostoli might be an enthusiast, 
 and, like himself (the President) in regard to his views on "tubes," 
 extreme, yet we could not possibly ignore statements coming from men 
 like Keith, who had given up hysterectomy. He would point out 
 to Dr. Rowan that he had applied the constant current to an acute 
 inflammatory condition. This was quite opposed to Apostoli, who had 
 recommended the Faradaic form until the subsidence of the inflamma- 
 tion. It was quite possible, in such cases, that length of time sufficed for 
 a cure. 
 
 Dr. FoREJiAN, in re})ly, said that the only good he saw in the method 
 was in its local action. In old inflammatory exudations, his experience 
 differed from that of Dr. Batchelor ; nevertheless, he would try the 
 method. Dr. Worrall's objection, on the score of chloroform being a 
 necessity, he thought could not have much weight. With regard to the 
 remarks of Dr. Balls-Headley, he agreed that cases of fibroids did end 
 fatally. He had seen a large number of such cases. He remembered 
 however one case of a lady, the subject of a large fibroid, living in 
 unhappy circumstances, and wishing for death. She was greatly lowered 
 by ha.'morrhages, till her skin became like parchment. Death was daily 
 exj)ected. He kept her in bed for months, and she was now absolutely 
 well. With regard to dosage, he could tell Dr. Batchelor that he 
 measured his doses with the galvanometer to the extent it permitted.
 
 SECTION FOB DISEASES OP 
 THE EYE, EAR & THEOAT. 
 
 PRESIDENT'S ADDRESS. 
 
 By Mark Johnston Symons, M.D., Ch. M. Edin. 
 Lecturer on Ophthalmic Surgery to the Adelaide University. 
 Hon. Ophthalmic Surgeon to the Adelaide Hospital. 
 Gentlemen, — 
 
 My occupancy of the position of President of the Section for Diseases 
 of the Eye, Ear and Throat, I feel to be a very high, but unearned 
 honour ; and my feeling of gratitude to the organisers of this great 
 Congress is all the deeper, from the knowledge that I am so little 
 entitled to it. I cannot be insensible of the fact, which I freely admit, 
 that rather than to myself, it is to the colony from which I hail, that I 
 owe my selection to this position — the colony in which I am proud to be 
 able to say the idea of an Intercolonial Medical Congress had its 
 inception, the able carrying out of which gave to us the first of what I 
 hope, and indeed may prophesy, will prove to be a long and successful 
 series of these invaluable meetings. 
 
 At the first meeting of the Intercolonial Medical Congress, the 
 Sections were four in number — Surgery, Medicine, Gynaecology, and 
 State Medicine ; there was no division set apart for the subjects included 
 in this Section, Doubtless we have, in most great undertakings, to 
 creep before we run ; but the leap to the dignity of a Section, which has 
 been made here by special subjects, is a matter for congratulation to all 
 of us generally, and especially to those of iis who devote our time and 
 thoughts to any or all of the subjects embraced in this Section. 
 
 The separation of the organs concerned in the three senses of seeing, 
 hearing, and speaking, from general Surgery into a Section of this 
 Congress, leads us to consider this severance, and the existence of 
 specialism in our midst. It is well known that there are many of our 
 profession who regard the existence of specialism with grave doubts as 
 to its justification ; and that its rapid growth in recent years has the 
 more or less silent disapproval of many of our brethren, who are leaders 
 of thought amongst us, whose breadth of idea generally is beyond 
 question, but who still look with alarm at the spread of specialism 
 which is becoming visible in all directions, lest its votaries become 
 narrowed in their knowledge of or interest in disease by the limitation 
 of their work. 
 
 2a
 
 722 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 A glance at the history of Surgery shows us that every medical 
 practitioner was a specialist in early times. Herodotus tells us that the 
 healing art in Egypt was subdivided into many specialties in his day — 
 *' Here, each physician applies himself to one disease only, and not more ; 
 all places abound in physicians — some for the eyes, others for the head, 
 others for the teeth, «fec." Celsus showed predilections for the eye and 
 ear. We find him writing on tumours of the eyelids, pterygium, 
 symblepharon, staphyloma, and on cataract (where he describes the 
 operation of inferior kei-atotomy), and also "the modes of repairing 
 defects of the ear." Antyllus, in the first century, affected throat work, 
 and is supposed to be the first who recommended bronchiotomy in 
 inflammations attended with tumefaction, which threatened suffocation- 
 In the eleventh century, Albucasis, in advocating the operation of 
 depression for cataract, mentions that he had heard of a certain oculist 
 who sucked out the cataract through a small tube. 
 
 In a lesser degree, specialism prevailed throughout the middle ages ; 
 but apparently they did not as a rule become specialists in the ordinary 
 course, but rather acquired what knowledge of general principles they 
 possessed as a result of studying the particular branch in which they 
 professed to be proficient. This kind of specialist exists now in the 
 form of what are colloquially termed " quacks," and we have a variety of 
 them in the Australian colonies. They affect chiefly a special know- 
 ledge of the subjects comprised in this section ; and from the results of 
 their practices, we may gather the unfortunate condition of the patients 
 of many of those specialists who practised in bygone ages, assisted 
 chiefly by rule of thumb and magic nostrums. This specialism of 
 the ancients can hardly be compared with the specialism of to-day. 
 
 In the Legal profession, specialism abounds — some devote themselves 
 entirely to the Law of Probate, others to Divox-ce, to the Admiralty, or 
 to the Ecclesiastical Coiirts. In Engineering, specialism is most marked 
 in the divisions of civil and mechanical, with the subdivisions of sanitary, 
 mining, hydraulic, electrical, &c., &c. But specialism in Medicine is as 
 little comparable to specialism in Law or Engineering, as is the human 
 organism to an Act of Parliament, as the study of the living to the 
 study of the inert. 
 
 The term " specialism " is faulty, as conveying the idea of work done 
 in an unusual manner; while the definition of our work should be the 
 exercise of an expert knowledge of the diseases of a naturally defined 
 oi'gan of the body. 
 
 Specialism immediately takes its rise from the common fact, that 
 attention can be better directed upon a special object than upon a group 
 of objects, particularly when such special object has an inherent interest 
 for the observer; whereas things in which we take only a general
 
 president's address — EYE, EAR AND THROAT SECTION. 723 
 
 interest are " seen, ratlier than distinguished." In Medicine, specialism 
 has an interest whicli can be felt in no other profession. The wondroiis 
 structure of the organs concerned in the special senses, the beauty of 
 their architectural design, the marvellous perfection of their adaptation 
 to the purposes of life, the inaccessibility of their mechanism to ordinary 
 observation, all tend to create a taste for the study of one or more of 
 these organs in health, a longing for an acquaintance with their diseases, 
 and a desire to master the details of their rational treatment. Moreover, 
 there is an absorbing satisfaction in watching their return to health and 
 usefulness. The fascination felt in his work by a specialist increases 
 with his opportunities of observation, the origin and nurture of which 
 may be ofttimes traced to a personal defect, claiming his greater 
 sympathy. He becomes accustomed to the technique of examination, to 
 a high appreciation of the value of the organ with which he has special 
 concern, and to a desire to benefit his fellow sufl'ei'ers, which is dis- 
 associated from mundane calculations. It is with a feeling of j)ride that 
 he finds himself, after years of general work, accepted as a specialist ; able 
 to devote all his time and all his thoughts to that one part of the 
 enormous field in which he labours, but with the knowledge that his 
 own field of study is still very large. It is then that he may be excused 
 the neglect of other parts, to leave unhampered the pursuance of an 
 intimacy with a part of Surgery, where special methods of observation, 
 or special manipulative or operative dexterity, is required. 
 , Specialism in medicine is the natural outcome of progress in medical 
 science ; and, as in every other branch of science, there is a continuous 
 progression from the general to the special ; were it not so, retrogression 
 would be implied, which is practically impossible. The progression is 
 in fact the operation of a natural law, and all we can consider is not 
 whether specialism in medicine is desirable, but whether it is advisable 
 to assi.st the progression as far as lies in our power by artificial 
 means. Are we to assist the acquiring of special knowledge, by 
 sacrificing to some extent the study of general principles ; or are we to 
 continue to recognise in our colleges and universities a general know- 
 ledge only, and allow specialism to mark out its own course ? In 
 attempting to find an answer to this question, I think it may be taken 
 for granted that, under any circumstances, the few years of study 
 at present prescribed for intending followers of our profession are none 
 too long in which to obtain such general instruction as it is absolutely 
 necessary a specialist in any branch should have. If we wish to assist 
 specialism, v,e must confine ourselves to individual exertion — firstly, in 
 following the natural bent of our inclination (if we have one) in taking 
 up the special study of any particular branch of medicine ; and secondly, 
 ^n practically recognising the status of brother specialists in their 
 
 2a 2
 
 724 IXTERCOLONIAL MEDICAL COXGRESS OF AUSTRALASIA. 
 
 particular line. This latter is already done to a large extent ; and so 
 far as I can gather, its only effects have been the benefit of the public 
 and the advantage of the profession, the status of the members of which 
 must naturally be improved thei-eby. Specialism is welcomed by the 
 general practitioner, who can at any time obtain the aid of one 
 presumably more familiar with certain diseases, probably of rare 
 occurrence, without the suspicion that such action may cause the loss — 
 as patients and as private friends — of the sulferer, his family, and 
 probably some of his acquaintances. 
 
 I do not know that an 0])position to specialism exists among the 
 profession in this continent ; but I certainly think that he who is true 
 and just to himself, and honourable in his dealings with others, and 
 who can prove an expert knowledge of certain branches of his profession, 
 need never apprehend being proscribed by his fellows, but may expect 
 the support and co-operation of the busy practitioner, who cannot spare 
 the time for the purpose of making himself as familiar with those details 
 of departments of our work which create the specialist, or the time for 
 the working out of the details which the proper examination of special 
 cases requires. 
 
 The importance of diseases of special organs has been direly neglected 
 in our teaching centres — a fact which entails an after-application, the 
 realisation of which is a question of opportunity, rather than of desire. 
 The growth of specialism in the future will be regulated only by a better 
 attention to the teaching of these important subjects in the curriculum. 
 This limitation of practice is a recent departure, born of the extent and 
 complexity of medical knowledge in its entirety, of the whole of which 
 no one can claim to have an equal grasp ; and the enormous bibliography 
 of the present time will sanction, if not compel, a limitation of correct 
 study. Thus we find the reason for the existence of specialists, in that 
 no one can expect to be cm coiirant with all branches of medicine 
 and surgery. The argument resolves itself into one of the external 
 influences surrounding one's medical life, rather than an aim on the part 
 of the specialist to separate himself from the work of his brethren. 
 
 We have only to look at the pressure of work carried on by the many 
 special hospitals, at the good these hospitals have done and are doing, 
 and at the success of the special societies, to recognise that specialism 
 has done much to relieve former apathy, to realise the fact that th& 
 specialist has the confidence of the public, and to demonstrate that he is 
 accepted by his fellows. To weigh the lasting benefit done by specialists 
 to our craft, we have only to recall the names of such lights in the 
 science of Ophthalmology as Mackenzie, Bowman, Graefe, and Donders; 
 iu the science of Otology, as Cleland, Toynbee, Wylde, and Politzer j 
 in the science of Laryngology, as Tobold, Voltolini, Czermak and Turck f
 
 ON CONVERGENCE. 725 
 
 the bare mentioning of whose names, without alluding to their many 
 illustrious colleagues, would answer the deci-ying note levelled against 
 true specialism from whatever source. 
 
 Can the present, or will the coming generation of practitioners ever 
 rei)ay the si)ecialist for the boon of the post-graduate classes, created by 
 specialists and maintained by themselves. They are the outcome of the 
 specialist's self-sacrificing love of his profession. That specialism is 
 beneficial to the general good, I do not doubt; that it may be carried 
 over far, I do not gainsay. The great drawback to specialism lies in 
 the limitation of the field, which renders possible the existence of those 
 pretending adventurers, who find adverse criticism less fraught with the 
 risk of exposure, in proi)ortion to the smallness of compass of the subject 
 with which they pretend to deal, and so the moi'e easily deceive an over- 
 readily gullible public ; but these pretenders would soon cease to exist, 
 as parasites in a noble profession, and as a fraud on an unguarded public, 
 were the words written by Rhazes in the ninth century applied by the 
 sutiferer of the nineteenth century in the selection of a medical attendant 
 — " Study carefully the antecedents of the man to whose care you 
 propose confiding all you have most dear in the world ; that is to say, 
 your health, your life, and the health and lives of your wife and your 
 children." 
 
 ON CONVERGENCE. 
 
 By Mark Johnston Symons, M.D., Ch. M. Edin. 
 
 Lecturer on Ophthalmic Surgery at the Adelaide University. 
 
 Hon. Ophthalmic Surgeon to the Adelaide Hospital. 
 
 The study of convergence is at once interesting, intricate, and 
 incomplete. A knowledge of it is essential to those of us whose aim it 
 is to enable our fellow creatures to obtain, or retain, for their highest 
 sense its greatest benefit, namely, perfect vision with absolute comfort. 
 Good sight with comfort, in the possessor of two healthy eyes, depends 
 tipon the absence of any defect of static and dynamic refraction ; and it 
 is our duty to correct dynamic as carefully as static refractive defects, if 
 we would do justice to our patients and to ourselves. The subject is 
 still in its infancy, and in the belief that every contribution thereto may 
 be useful, I bring before you, for your consideration, a few notes bearing 
 practically upon that matter. 
 
 Convergence may be simply defined to be the inclination of the visual 
 lines meeting at the point of fixation ; or in other words, the vertical 
 angle of a triangle, of which the eyes form the extremities of the base, 
 and the })oint of fixation the vertex ; which point will lie within 
 infinity, or not more than twenty feet from the observer. For, suj)posing 
 tlie point to be beyond this limit, the inclination of the visual lines is so
 
 f26 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 minute as practicably to be unappreciable, and therefore we say that, for 
 points outside this limit, tlie visual lines are parallel. This inclination 
 is given to the eyeballs by means of the internal recti muscles. The 
 horopter is a curved line along which the two eyes can join in sight, the 
 two eyes initiating a balance at infinity, and governed for points within 
 infinity by the instinctive muscular consent in which the muscles of 
 adduction are harmoniously associated with the muscles of accommoda- 
 tion of both eyes. The law which governs the extra-ocular muscles is, 
 that the fovea centralis retina3 of each eye must be directed upon the 
 object obsei'ved. 
 
 This law, in conjunction with obedience to the law of accommodation, 
 results in an object at the point of fixation being seen as a single 
 clearly defined object, and binocular vision is then said to exist. 
 
 It is recognised that an intimate relation exists between the con- 
 traction of the ciliary muscle and of the internal recti ; between 
 accommodation and convergence. This synergy necessitates the 
 admission of a common centre of innervation. True binocular vision is 
 absent in very young infants, being attained with the functional 
 development of the brain, from which arises the capacity of receiving 
 the image upon associated percipient points — the great essential of 
 binocular vision. 
 
 In some subjects, this capacity is never attained ; in others, it may 
 be lost after having been presumably acquired. The absence of 
 exact binocular vision is frequently unremarked by the subject, and 
 varies from an unconscious lack to the inconsequential orbital i-ollings 
 of cerebral under-development, as typified in young infants. It has 
 been seen, that good vision depends upon accommodation and con- 
 vergence being harmoniously exerted. Of these two, the accommodation 
 depends upon the elasticity of the lens, and the proper action of the 
 ciliary muscle, and, in the absence of disease or functional upsettings, 
 varies little in different individuals of similar age, but gradually lessens 
 from youtli to old age; whilst convergence, on the other hand, varies in 
 persons irrespective of age, depending as it does upon the sufficiency of 
 the muscles. To the latter, consequently, we will devote our attention. 
 
 In regarding the behaviour of the internal recti muscles, we must 
 take into account the resistance of the external recti, and both with 
 their bearing upon binocular vision. 
 
 We are taught several methods by which muscular insufficiency can be 
 gauged : — 
 
 First method. — Instruct the patient to fix a point, such as the tip of 
 the finger, at thirty centimetres distant from the eyes; cover one eye, to 
 conceal the object of fixation. If the eye from which the object of 
 fixation is cut off maintains its direction, the muscles are normal in 
 power; if it deviates outwards the internal muscles, and if inwards the 
 external muscles are insufficient. 
 
 Second method. — Place a prism with its base upwards before one eye, 
 say the left, and direct the patient to gaze at a card, upon which is 
 drawn a vertical straight line having a dot at its centre, placed at 
 reading distance. The prism causes vertical dii)lopia, and prevents 
 binocular vision. Two dots will be seen; if seen on the same vertical 
 line, the muscles are said to he competent. If two lines, having a dot 
 upon each, be seen, insufficiency of the muscles is proclaimed. Should
 
 ON CONVERGENCE. 727 
 
 the upper dot, which belongs to the eye having the prism in front of it, 
 be seen to the right, i.e., crossed vertical di])lopia, tliere is said to be 
 insufficiency of tlie internal recti. Should the upper dot be seen to the 
 left of the lower dot, i.e., homouj^mous vertical diplopia, there is said 
 to be insufficiency of the external recti, and that the prism placed 
 horizontally, which will bring the upper dot directly above the lower, 
 is the measure of the insufficiency. 
 
 Third method. — Place a prism of 5° base upwards before one eye, 
 say the left, and a red glass before the right eye. Direct the patient to 
 fix a lighted candle at twenty feet. Two flames will be seen; the red 
 flame of the right eye will be seen on a higher level than the uncoloured 
 flame of the left eye. Should the red flame stand directly above the 
 other, there is said to be equilibrium of the muscles. If the red is to 
 the right — homonymous diplopia — we have insufficiency of abduction ; 
 and if to the left — crossed diplopia — we have insufficiency of adduction. 
 The prism placed horizontally, which brings the images vertical, is the 
 measure of the insufficiency. 
 
 Fourth method. — To measure the capacity of the muscles at twenty 
 feet, place a series of weak prisms with the base inwards. The prism 
 inmiediately below the one which causes diplopia marks the measure of 
 the abductive power, the adductive power being similarly measured by 
 .stronger prisms placed, base outwards, before the eyes. 
 
 These methods are found in all standard works on the Eye. 
 
 Landolt, in his book on " Refraction and Accommodation of the Eye," 
 teaches : — 
 
 Page 333. — " In order to fuse distinct impressions of each eye in 
 single binocular stereoscopic vision, the degree of convei'gence required 
 by the position of the object must be made to agree with the degree of 
 accommodation which corresponds to the ametropia." 
 
 Page 342.—" Two-thirds of the convergence niust be held in reserve, 
 in order that one may work with the remaining one-third." 
 
 Page 344. — "The further away the object is, the less convergence is 
 required for its binocular perception." 
 
 Page 352. — "Notwithstanding their greater mobility, hyperopic eyes 
 do not attain a range of convergence markedly higher than that of 
 emmetropes." 
 
 Page 354. — " We know that the two functions are associated in such 
 a way that, for a given degree of convergence, there is always a nearly 
 equal degree of accommodation, and vice vend." 
 
 Page 422. — "Not taking into account the distance between the eyes, 
 convergence depends, for all eyes, solely upon the distance of the 
 object." 
 
 Page 491. — " Knowing the great amount of convergence required for 
 work, it will not astonish us to find this function so often in default in 
 myopes." 
 
 Page 502. — " We must confess that our knowledge as regards mus- 
 cular asthenopia and insufficiency of convergence is still in its infancy, 
 losufficiency of the power of convergence is quite a widespread affection, 
 and a frequent cau.se of asthenopia. It is not by any means peculiar to 
 myopes only. Whilst great advantage is gained by Graefe's test 
 (Method II), it is not true that the latent insufficiency is always 
 brought thus to view."
 
 728 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Noyes writes, page 85 : — "This power and abduction beyond parallel- 
 ism reaches to a prism of from three to eight degrees in most people, 
 while adduction for distant objects, say at twenty feet, extends to 
 twenty or to fifty degrees, and for the average of persons who have not 
 cultivated their power, it is about twenty-five degrees. If an object 
 come near, adduction increases ra])idly, being aided by association with 
 accommodation." 
 
 Page 87. — "The most frequent cause of these troubles is error of 
 refraction ; and in a general way, weakness of adduction goes with 
 myopia, and weakness of abduction goes with hyperopia. Many excep- 
 tions are, however, noted." 
 
 Page 91. — "The most common error (muscular abnormalities) is 
 insufficiency of the internal recti. This is most often associated with 
 myopia, but with nearly equal frequency is found in emmetropia, and 
 sometimes, too, with hyperopia." 
 
 Page 93. — " But we must sometimes order prisms for permanent 
 wear, either with or without i-efractive correction, and this is indicated 
 when a muscular error has been detected in testing for the distance of 
 twenty feet." 
 
 Williams, page 328. — " Relative divergent strabismus may occur in high 
 degrees of luyopia where convergence is impossible, or it may also be due 
 to insufficiency of the internal recti, without myopia — the eye deviating 
 outwards when the internus is fatigued." 
 
 The necessity for bringing small things very near to myopic eyes, and 
 thus demanding of the interni excessive strain in convergence, is partially 
 provided for by a greater muscular development ; but it is a very 
 frequent cause of insufficiency. For infinity, the optic axes remain 
 parallel ; but for near vision, the internal recti act in harmony with the 
 ciliary muscles of the two eyes, and produce a degree of convergence, 
 corresponding to a certain extent with the focal adjustment. 
 
 In Carter and Frost, chapter on Insufficiency, we are taught that: — 
 " The relative power of the ocular muscles is of much greater importance 
 than their actual power." 
 
 jMeyer tells us that : — " Weakness of the internal recti may be 
 observed either in hyperopic, emmetropic, or myopic eyes. It is 
 however most annoying to persons having the last, a.s they are 
 obliged to bring objects very close to them ; they must make their eyes 
 converge for very short distances. 
 
 We will now proceed to analyse 150 cases, in which measurements of 
 the abduction and adduction have been made by the method of the 
 vertically displaced images (Methods II and III) ; and 200 additional 
 cases, in which the abduction and adduction at distance have been 
 measured by horizontally-placed prisms. 
 
 In all of these cases, the refraction has been noted under the 
 divisions of emmetropia, when the refraction did not amount to over 
 + 1 D or — 0"50 D, the remaining cases coming under the head of 
 ]iyperoj)ia or myopia. The ])resence or absence of binocular vision is 
 also notfid. The cases are collected fx-om refraction cases, avoiding any 
 in which there was strabismus, or in which the vision was in any way 
 interfered with by disease or injury. 
 
 The 150 cases were tested by the first method, that is, by covering 
 one eye after fixation at thirty centimetres, and in each case there was
 
 ON CONVERGENCE. 729 
 
 divergence of the exoliuled eye, irrespective of the refraction or measure- 
 ment of the muscular state by any of the other metliods. 
 
 Table I. 
 
 Talk of 150 Cases tested hi/ means of Vertical and Horizontal 
 
 Prisms : — 
 
 Emmetropic . . . . . . . . 64 cases 
 
 Hypeiopic . . . . • . . . 68 ,, 
 
 Myopic . . . . . . . . . • 18 „ 
 
 Total 150 „ 
 
 ,j.^ p (Abduction = 962°; average, 6-128 
 
 ^^" ^^^^^ (Adduction = 1717°; „ 11-446 
 
 Vision at Reading Distance. 
 
 Homonymous diplopia, 
 Crossed ,, 
 Balance . . 
 
 12 cases = 
 124 ,, = 
 
 56°, = 
 733°, = 
 
 = 0-373 each 
 
 -- 4-888 „ 
 
 Vision at 
 
 Twenty Feet. 
 
 
 Homonymous diplopia 
 Crossed ,, 
 Balance . . 
 
 — 54 cases 
 = 43 „ 
 = 53 ,, 
 
 = 144' 
 ^ 96° 
 
 = -94 each 
 = -64 „ 
 
 Emmetro^jia . . Abduction- 
 Adduction 
 
 -64 cases. 
 
 392° = 
 791" = 
 
 6-125 each 
 12-359 „ 
 
 Hypermetropia . . Abduction- 
 Adduction 
 
 —68 cases. 
 
 470" = 
 727° = 
 
 6-911 each 
 10-691 „ 
 
 Myopia . . . . Abduction 
 Adduction 
 
 - 18 cases. 
 
 100° = 
 199" = 
 
 5-505 each 
 11-105 „ 
 
 116 binocular vision 
 
 . Abduction 
 Adduction 
 
 —each 
 
 6-991 
 13-534 
 
 34 not binocular vision. . 
 
 . Abduction 
 Adduction 
 
 — each 
 
 4-212 
 4-545 
 
 The cases in this table show that, in testing for the muscular state at 
 reading distance, instead of balance there was heteronymous diplopia on 
 an average equal to a prism of 4°, and at twenty feet there was 
 homonymous diplopia on an average equal to a prism of J° ; and that 
 the average abductive power at twenty feet is equal to a prism of about 
 6", and the adductive power to a prism of about 12°; the emmetropes 
 most nearly approaching these measurements, while the hypermetropes 
 have a larger measure of abduction, and a lesser measure of adduction, 
 than the myopes. 
 
 Those possessing binocular vision give a greater measure of both 
 abduction and adduction than the average of the whole, while those 
 not ))ossessing binocular vision have their measure of abduction and 
 adduction so much alike as only to leave a small fraction between 
 the two. Absence of binocular vision occurred in thirty-four cases, 
 each of which had the measuie of abduction so closely reaching that of 
 adduction as to amount to within a range of 2° prism on either side 
 of the adduction ; and in all the cases where the abduction was either 
 over two degrees greater or less than the adduction, binocular vision 
 existed.
 
 730 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Table II. 
 
 Table of 200 Cases, in ivhich the Measurevient of the Muscular State 
 was taken at Twenty feet, by means of Horizontally -'placed Prisms, 
 in which the Refraction was dealt tvith as p7'eviously indicated, 
 and the presence or absence of Binocidar Vision noted : — 
 
 Average Measurement. 
 
 200 cases 
 
 Myopia 
 Hyperopia . . 
 Emmetropia 
 
 Having Binocular Vision, . 
 Mj'opia 
 Hyperopia . . 
 Emmetropia 
 
 Not having Binocular Vision 
 Myoi^ia 
 Hyperopia . . 
 Emmetropia 
 
 12-280 
 
 19-066 
 
 12-914 
 
 9-448 
 
 7-650 
 
 8-428 
 8-416 
 6-750 
 
 Table III. 
 350 Cases.— Abduction, 5-920 ; Adduction, 11-136. 
 Table III is composed of the cases in Table I and Table II, measured 
 at twenty feet by horizontally-placed prisms. 
 
 Table IV. 
 
 Table of Forty Cases, in ivhich the Measurement of Adduction at Tiventy 
 
 Feet is compared ivith the Maximum of Convergence in Metre Angles : — 
 
 Adduction. 
 
 Metre Angles. 
 
 Adduction. 
 
 Metre Angles. 
 
 9 
 
 16 
 
 31 
 
 20 
 
 8 
 
 9 
 
 7 
 
 11 
 
 22 
 
 8 
 
 26 
 
 17 
 
 17 
 
 6 
 
 7 
 
 15 
 
 7 
 
 12 
 
 9 
 
 15 
 
 7 
 
 10 
 
 3 
 
 20 
 
 6 
 
 10 
 
 32 
 
 20 
 
 11 
 
 9 
 
 22 
 
 10 
 
 '.) 
 
 9 
 
 3 
 
 6 
 
 7 
 
 14 
 
 7 
 
 12 
 
 7 
 
 16 
 
 1^ 
 
 20 
 
 7 
 
 13 
 
 1 23 
 
 20 
 
 23 
 
 14 
 
 3 
 
 20 
 
 12 
 
 18 
 
 1 5 
 
 15 
 
 10 
 
 20 
 
 1 4 
 
 10 
 
 11 
 
 9 
 
 5 
 
 10 
 
 9 
 
 15 
 
 3 
 
 14 
 
 19 
 
 20 
 
 10 
 
 20 
 
 11 
 
 4 
 
 15 
 
 10 
 
 8 
 
 20 
 
 8 
 
 20 
 
 This tal)le shows correspondence between these two kinds of 
 measurements.
 
 RESECTION OP THE OPTIC AXD CILIARY NERVES. 731 
 
 These, Gentlemen, are the facts I liave to bring before you. I will 
 farther crave your indulgence while I lay before you the thoughts that 
 have occurred to me whilst working out these cases; these I will put in 
 the form of aphorisms to save space, but with no intention to dogmatise : — 
 
 The point at which the measurements of abduction and adduction 
 ought to be taken, is situated on that part of the horopter line at which 
 the eyes meet with the least effort of convergence and accommodation, 
 namely, at a point twenty feet distant from the eyes, on a line drawn 
 from the centre of, and at right angles to, the base line. 
 
 The method of measurement by means of horizontally-placed prisms 
 is the only method by which the amount of abduction and adduction can 
 be gauged, so as to be a guide to the power of convergence employed by 
 the individual. 
 
 That the measurement of the maximum of convergence does not give 
 a reliable indication of the amount of convergence employed by the 
 individual. (See Table IV.) 
 
 That the absence of binocular vision destroys the normal relationship 
 between the external and internal recti mn.scles. That the normal 
 relationship between abduction and adduction may l)e regarded as in the 
 proportion of one to two in the untrained. That insufficiency of the 
 external recti so rarely produces distressing symptoms, that its- 
 measurement may be disregarded in practice. That asthenopia, from 
 insufficiency of the internal recti, was not found in any case where the 
 measurement of adduction amounted to a prism of 12°. 
 
 That the large majority of cases of insufficient employment of the 
 power of adduction may be cured by the judicious use of prisms, as a 
 means of gymnastic training, tenotomy of the opposing muscle or 
 advancement of the insufficient muscle being seldom required. 
 
 In conclusion, I wish to point out that the result of the examination 
 of these cases has assured me, that the best indication for the need of 
 treatment in cases of muscular asthenopia is found in the measurement 
 of the adductive power at distance. 
 
 A SERIES OF CASES OF RESECTION OF THE OPTIC 
 AND CILIARY NERVES. 
 
 By H. LiNDO Ferguson, F.R.C.S.I. 
 
 Lecturer on Ophthalmology in the Otago University, New Zealand. 
 
 Professor Schweigger's paper on Resection of the Optic Nerve, in 
 Vol. XIV of " Knapp's Archives of Ophthalmology," is undoubtedly the 
 most important contribution to the literature of the subject that has 
 appeared of late years. In it, he deals so fully with the objections 
 which have from time to time been raised against optic neurotomy, and 
 points out so clearly the safety against sympathetic dangers, ensured. 
 by resection of a portion of the nerve, that 1 should be merely para- 
 phrasing his sentences, if I were to detain you by entering into the 
 .subject at any length.
 
 732 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 Ill September 1886, Dr. Bell Taylor published in the British Medical 
 Journal a report of thirty-one cases in whicli lie had performed the 
 operation, and his results, together with Schweigger's paper, induced me 
 to adopt it. Any alternative that will secure protection to the fellow 
 eye in cases where there is risk of sympathetic inflammation, whicli 
 stops short of removal of the injured organ, will be equally acceptable 
 to the patient and to the surgeon. 
 
 Excision, though it often terminates the patient's troubles in the way 
 of pain or risk to the other eye, is very frequently the beginning of a 
 series of annoyances, in the way of purulent discharge from the con- 
 junctiva and discomfort, with an artificial eye ; or lachrymation, and 
 collection of dust and foreign bodies in the orbit, without one. 
 
 Of late. Mules' operation of introducing an artiticial vitreous has 
 been brought prominently forward, but it does not obviate the drawback 
 of having to wear an artiticial eye, and merely improves the stump on 
 which the shell rests. Wliether it secures immunity from sympathetic 
 trouble remains to be seen ; but there is no doubt that the class of 
 cases, where the lids are too irritable to stand an artificial eye after 
 excision, will stand it no better because it is supported by a metal ball 
 inside the stump. 
 
 In a very large number of cases calling for operation, the eye to be 
 dealt with is as sightly, if not more so, than the artiticial eye which 
 replaces it ; and even when this is not the case, most patients prefer to 
 retain their eye, unless the disfigurement is extreme. 
 
 I have operated on fifteen cases since November 1886, in all of which 
 I should otherwise have had to excise, and had once begun the 
 operation, but been obliged to excise. This case was one of severe 
 injury to tlie cornea and sclera from glass, which had healed imperfectly, 
 and as there was very severe pain, I operated at once. During the 
 operation the wound ojDened, and I was obliged to remove the globe. 
 All of the other fifteen cases, except the last, which is only recovering 
 from operation, and of which I cannot speak, have been most satisfactory 
 in their results. I have seen no material return of coi-neal sensibility, 
 and have seen as much relief of sympathetic irritation in the other eye as 
 if I had excised. In Case X, symj^athetic iritis set in on the sixteenth 
 day, but there had been sympathetic irritation before the operation, and 
 excision would probably have been no greater safeguard. 
 
 So far as the cosmetic result of the operation in these fourteen cases 
 is concerned, the appearance, except in Case X, was the same as before 
 interference, and I have no reason to suppose the last case will do any 
 worse than the others. Of course, the operation is not adapted to 
 every case ; but in many instances where excision is now practised, I 
 have no doubt a fi'eely movable eye of presentable appearance might 
 be pi'eserved if resection of the nerve were adopted, and the cosmetic 
 effect is known beforehand, wliicli is not the case with excision. 
 
 I pej-form tlie operation by dividing the tendon of the internal rectus, 
 fl,nd freely di\iding the conjunctiva and capsule of Tenon upwards and 
 downwards at the same time. The middle needle of three on one silk 
 is then passed through the divided muscle from within outwards, as if 
 for advancement of the muscle, and the suture is drawn across the 
 bridge of the nose out of the way. The globe is then rotated outwards 
 by means of a small sharp hook, and the nerve divided as far back as
 
 RESECTION OF TIIR OPTIC AXD CILIAHV NKKVES. 733 
 
 possible with a curved scissors. A strabismus hook is slipped round 
 the portion of the nerve attached to the globe, and used to rotate the 
 eye till the posterior pole appears in the wound, when the nerve is 
 snipped oft' close to the sclerotic, and the ciliary nerves cut off short. 
 The globe is tlien replaced, and the rectus stitched forward to the 
 conjunctiva aboAe and Ijelow the cornea. The lids are cai'efully closed, 
 and a compress of lint, wrung out of carljolic oil, used as a dressing. 
 The stitclies cause no inconvenience, owing to the insensiti^•eness of the 
 cornea, and are removed on the third or fourth day. The last opera- 
 tion, from introducing the speculum to pinning the bandage, took 
 twenty-one minutes ; bvit if the haemorrhage is smart, it may cause 
 delay in getting back the eye into place, and make the operation more 
 tedious. The following notes of the cases speak for themselves, and do 
 not require any furtlier explanation : — 
 
 Case I. 
 
 C. P., aged 8. Oc. Dex. was lost some months previously from a 
 blow from a stick at whicli he was chopping on the ground. The stick 
 tiew and struck the eye, penetrating the cornea and wounding tlie lens. 
 At the time of operation, he had an occluded pvipil and anterior 
 synechia. The cornea was somewhat shrunken, and the globe was very 
 sensitive, especially in tlie ciliary region below. Oc. Sin. was showing 
 signs of sympathetic irritation. Tliere was sufficient intolerance of 
 light to prevent ophthalmoscopic examination, and a great loss of 
 accommodation with some conjunctival irritation. Half an inch of the 
 nerve was excised in November 1886. When last seen, in September 
 1888, he was attending school, and the left eye was normal in every 
 respect. The injui*ed eye had perfect movements, but hardly any 
 corneal sensation, and would stand stroking with a piece of paper 
 without winking. The eye was absolutely quiet, and there was nothing 
 to show that an operation had been performed. 
 
 Case II. 
 
 H. F., Jet. 35, sailor, presented himself on No^ ember 10, 1888, ha^ing• 
 had his right cornea ruptured right across, below the centre, by a blow 
 from a marline spike eight weeks before. The iris was adherent in the 
 cicatrix, and the pi'ojection of light was bad. Oc. Sin. V. = f , some 
 letters, and J 1 with effort. Ophthalmoscopically, fundus normal, but 
 very sensitive to light. He was admitted to the hospital for observation, 
 and some days later, the intolerance of light increasing, V' of the nerve 
 of the injured eye was resected. He left the hospital a foi'tnight later 
 with perfect motions of the globe, and very slight corneal sensation. 
 The intolerance of light in the other eye had quite disappeared. 
 
 Case III. 
 
 T. B., aged 17, on November 24, 1886, gave the following history: — 
 Two months before, in opening a sodawater bottle, it burst, and one 
 of the fragments struck his right eye. There had been considerable 
 pain, which had gradually subsided, but vision had not returned. 
 There was a long cut from the equator inside, running forwards and 
 rather downwards to within two millimetres of the corneal limbus.
 
 734 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 This was lirmly healed by a somewhat depressed cicatrix. The cornea 
 was normal, but the iris was pressed forwai'ds against it in its inner and 
 lower portions. The lens showed commencing opacity in its outer 
 lower quadrant. The retina was detached on its inner side, and there 
 was a considerable cyclitic membrane along tlie cut, involving the 
 retina. The nerve was veiy hazy, and the vessels of the attached 
 portions of the retina were very hazy. In the macular region, was an 
 exudation similar to that in albuminuric retinitis. V = Fingers at 
 0*3 millimetres, T-3; Oc. Sin. V = |^ and J 1. After some corres- 
 pondence with his parents, between ^" and ^" of tlie nerve was excised 
 on December 6. The stitches were removed on the 9th, when the eye 
 was quiet, movement good, and cornea insensitive. On the 10th, he had 
 an attack of acute rheumatism, and a temperature of 104°, but by the 
 21st he was able to I'eturn home. The eye was then quiet; the pupil 
 was dilated and lixed, and the cyclitic membrane visible behind the 
 lens ; the cornea was insensitive to slight irritations, such as touching 
 with paper, but he was conscious of firmer pressure. A satisfactory 
 report was received from the patient's father two months later, since 
 when he has not been heard from. 
 
 Case IV. 
 
 Mr. G., aged 48, applied December 21, 1886, saying that he had 
 been struck in the left eye twelve weeks before by a piece of iron, 
 which flew from his hammer. Oc. Dex. V = -^■^, fundus normal ; V Oc. 
 Sin. = doubtful perception of light ; T — 3. There was a linear scar 
 from two to three millimetres long in the corneo-scleral junction above. 
 Tlie iris was jiressed forwards almost to the cornea by the lens, which 
 showed streaky haze in its centre ; the retina was almost entirely 
 detached. He was admitted to the hospital, and ^" of the nerve 
 resected. He made a good i-ecovexy, and left with an insensitive fi-eely 
 moving globe. The right eye had improved to about V = ■^■^, and he 
 did not care to have his manifest H corrected, to get better sight than 
 this. 
 
 Case V. 
 
 J. W., aged about GO, was operated on in tlie Dunedin Hospital, in 
 1886, for a large orbital sarcoma which displaced the eye down and 
 outwards, so that it lay outside the orbit below the outer canthus, 
 completely hidden by the lower lid. He stipulated that the eye should 
 on no account be removed, so, though the tumour was adherent to the 
 upper inner posterior quadrant of the globe, the sclera was carefully 
 scraped and the eye retained. 
 
 In January 1887, lie presented himself, complaining of great pain in 
 the eye, which was of stony hardness. The lens was opaque wlien he first 
 came under observation, and there was no perception of light. He 
 still refused excision, so ^" of the nerve was excised without difficulty, 
 and some months later he remained free from pain and with a 
 presentable eye. He was lost sight of about the middle of the year. 
 
 Case VI. 
 
 Mr. Wm. G., aged 45, presented himself November 8, 1886, stating 
 that he had been struck in Oc. Dex. by a " spark," when quartz reefing
 
 RESECTION OF THE OPTIC AND CILIARY NERVES. 735 
 
 nine months before. V subsequently was nearly normal till three or 
 four months befoi'e the visit, when it began to fail, and the iris began 
 to change from a blue grey colour to a light brown. 
 
 When seen, Oc. Sin. was normal, V = §, iris light blue. Oc. Dex, 
 V = Fingers at 0"5 millimetres. The cornea showed a cicatrix two milli- 
 metres long, running inwai'ds and downwards from the outer limbus. The 
 iris was light brown in colour, showing slight indications of the old 
 blue colour near its base, inside and above. It showed a laceration 
 beliind tlie corneal cicatrix, corresponding with it. The anterior 
 capsule was completely covered with a tine powdery cloud of pigment 
 spots, denser in some spots than others. Tlie lens behind showed a 
 dirtuse haze. He projected light well, except on tlie temporal part of 
 the retina, where the projection was slow and uncertain. Being 
 disinclined for operation, he was told to remain under observation. 
 
 He returned on April 9, 1887, suffering from headaches. The lens 
 was now completely opaque, and the projection of light very bad. V 
 Oc. Sin. f . As there was no doubt as to the presence of a foreign 
 body in the eye, he consented to operation, and on April 13th, ^" of 
 the nerve was resected. He was very drowsy on the two following 
 days, but on the third day, when the stitches were removed, he was 
 much brighter. On the fourth day, there was doubtful corneal sensatio)i, 
 and motion was good in all directions except outwards. 
 
 On the 18th, outward rotation was better, and he left for home. 
 
 On the 27th, he reported that he had been exposed to cold, and 
 had suffered severe pain in the eye, which had ceased two days before 
 his return. Rotation outward was slightly defective, but was good in 
 other directions. The cornea was very slightly sensitive, and the eye 
 was quite quiet. Oc. Sin. normal. He has not retui'ned since, but his 
 employer has at intervals I'eported to me that he is well and free from 
 discomfort. 
 
 Case VII. 
 
 H. L., a miner, was operated on in April 1887, for a rupture of the 
 cornea from side to side. He was discharged from the hospital a 
 fortnight latei*, with a freely movable stump and doubtful corneal 
 sensation. 
 
 Case VIII. 
 
 C. B., aged 33, miner, had his right eye injured by a blasting 
 accident in February 1887. On April 20, the stump was very tender. 
 The cornea was much cut, on'e cut extending into the ciliary region 
 above. The iris was incarcerated in the corneal wounds on its 
 temporal side. Lens opaque. T - 2 ; V = P. light ; Oc. Sin. V = § 
 letters. Some intolerance of light. Tlie right nerve was resected on 
 April 21st, and on May 13th he returned to work. V Oc. Sin. =|^ and 
 J 1 ; intolerance of light gone. The injured stump was not tender, 
 looked fairly quiet, and had an insensitive cornea. He reported two 
 months later, and his condition was then satisfactory. 
 
 Case IX. 
 
 Master T. C, aged 7. First seen on May 12th, 1887. A soda 
 ■water bottle had exploded three weeks before, and a fragment had
 
 736 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 entei^ed his left eye. His mother was witli him at the time, and drew 
 out a piece of glass which projected from between the closed lids. 
 There was a depressed scar from the ciliaiy region outside, extending 
 down and back to the equator. Over the ciliary portion of the scar, 
 was a granulation. The retina was extensively detached. T - 2. No 
 perception of light. The stump was excessively tender to the touch. 
 Oc. Dex. normal. The nerve was resected on the same day ; the 
 stitches were removed four days later, and on the 20th he returned 
 home with a painless insensitive stump. Two months later, the eye 
 was reported as being still bloodsliot, but free from pain or sensibility, 
 and his medical attendant (who is a careful observer, and occasionally 
 writes to me) has not since reported anything wrong. 
 
 Case X. 
 
 Thos. S., aged 30, presented himself on January 6th, having had his 
 right eye injured the pi'eviovis day. He was sewing sacks, when the 
 twine broke as he was pulling it, and the packing needle entered his 
 right cornea. V = P. light ; lens opaque ; T. low n. The wound was 
 across the pupillary area, and the iris was incarcerated in the outer 
 part. He was admitted to the hospital, and the anterior synechia was 
 cut, and a considerable portion of the opaque and swollen lens was 
 extracted. The case, however, ran on to plastic cyclitis, and I advised 
 resection of the nerve. This he refused for some weeks, but consented 
 in the latter part of Febi'uary, as he felt his left eye failing, though 
 there were no recognisable changes in it. The operation was attended 
 by severe hsemorrhage behind the globe, which forced it out between 
 the lids. After very great difficulty it was reduced, and the lids closed. 
 On the following day the eye was again protruding, and could not 
 be thoroughly reduced, but steady pressure was kept up over the globe, 
 which in about a fortnight was in good position, though outward 
 rotation was very defective. The cornea was infiltrated with pus on 
 the third day, but cleared up after threatening to necrose for over a 
 week. On the 16tli day, he had a mild attack of sympathetic iritis in 
 the left eye, which, however, readily yielded to treatment. 
 
 On May 23rd, he had V 3-% without lens, f letters + 1 D Oc. Sin., 
 and the right eye was a presentable stump, with good motion, except 
 outwards ; but outward rotation seemed to be improviiig. The cornea 
 of the stump was absolvitely insensitive. 
 
 Case XL 
 
 C. B., aged 8, was operated on in the hospital on April 18, for a 
 perforating wound of the ciliary body Oc. Dex. Operation and recovery 
 were normal, and he was discharged in a fortnight Avith a painless, 
 insensitive, freely movable stump. Oc. Sin. normal. 
 
 Case XII. 
 
 Mrs. S., aged about 45, was operated on in the hospital in June last. 
 She had absolute glaucoma in botli eyes, for Avhich iridectomies had 
 been done .some years previously. She was suffering intense glaucoma- 
 tous pain in the head from the right eye. During the operation, the 
 ciliary nerves were found to be enormously enlarged, aixd fully f ' of
 
 RESECTION OF THE OPTIC AND CILIARY NERVES. 737 
 
 them was removed. She later complained much of pains, which she 
 could not locate, in tlie back and stomach and globus hystericus. These 
 symptoms were referable to the menopause, but the glaucomatous pain 
 ceased absolutely from the time of operation. When discharged, except 
 by some conjunctival redness, the eye operated on could not be dis- 
 tinguished from the otliei". 
 
 Case XIII. 
 
 C. B., aged 52, lost Oc. Sin. thirteen years ago by an accident. 
 He had severe intlanunation, and was many weeks in hospital. He 
 has always since had tenderness in the eye, and has been liable to 
 severe pain from such trivial causes as touching it while washing his 
 face. When seen on August 28 last, he said the eye had been very 
 painful for two months, and for four nights he had not slept. V. no P.L. 
 T — ? great ciliary tenderness. There was a scar ^" long running 
 through the outer limbus of the cornea into the ciliary region, in which 
 the iris was incarcerated. The pupil was drawn to the edge of the 
 coi'nea, and the lens was opaque. Great ciliary congestion and duski- 
 ness. Oc. Dex. V = Y^2 j nerve distinctly hypersemic. The nerve was 
 resected next day, and the pain ceased at once. He was discharged a 
 fortnight later with a freely movable, quiet, insensitive stump. The 
 riglit eye was quiet, and V had gone up to letters of f . His delight at 
 being able to wash his face, without hurting his eye, was quite comic. 
 
 Case XIV. 
 
 Master W. A., aged 15, was brought to me on August 27 last, having 
 had his right eye injured by a steel fork ten days previously. There 
 were two perforating wounds of the cornea, at the level of the upper 
 pupillary margin, to which were fixed two fine threads of iris. The 
 pupil was contracted and much bound down, and there was great ciliary 
 congestion. Lens opaque. T.n.; projects light badly. Every efibrt 
 was made to dilate the pupil without success, and the boy's father 
 consented to resection, when the left eye began to lose its accommoda- 
 tion. The wounded eye then had T— 1, ciliary tenderness, a completely 
 occluded pupil, and iris bulging forward. Oc. Sin. V = f and J 1, 
 slowly and with difficulty. The nerve was resected on September 24, 
 and there was some proptosis, but the lids covered the lids after some 
 trouble. On the 29th, the stitches were removed ; some conjunctival 
 sensation, but none in cornea. October 1. — The bandage was removed. 
 October 17. — When last seen, eye quiet and movements perfect; no 
 corneal sensibility. Oc. Sin. is strong, and bears the light well, V = § 
 and J 1 easily. 
 
 Case XV. 
 
 R. S., aged 58, had his right eye injured by gorse five months before 
 he applied at the Dunedin Hospital, on November 16, 1888. The globe 
 was then flattening under the recti, and was in a condition of chronic 
 cyclitis, and excessively tender. The lens was opaque, and the iris 
 adherent all round the pupillary margin, and vision was absolutely 
 destroyed. The other eye was " feeling weak," ])ut had no inflammatoiy 
 condition. He was suffiering great pain over the right side of the head, 
 
 2b
 
 738 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 radiating from the injured eye. Three days ago (November 19) three- 
 quarters of an inch of the optic nerve was excised, and the proptosis, 
 after the operation was complete, was nearly half an inch before the 
 other eye, leaving fully one inch between the end of the nerve in the 
 orbit and the globe. There was pain on the following day, which 
 ceased on re-adjusting the bandage, and has not returned. To-day he is 
 quite easy, and the proptosis is diminishing. 
 
 SANDY BLIGHT AND GRANULAR OPHTHALMIA. 
 
 By T. Aubrey Bowen, L.K. et Q.C.RL, M.R.C.S. Eng. 
 
 In this paper 1 have used the term " Sandy Blight " (muco-purulent 
 ophthalmia), as it is the popular term for perhaps the best known 
 and the most frequently occurring disease in these colonies. At certain 
 seasons of the year, notably in the middle and late summer months, it 
 commences in a spoi'adic form, occasionally becoming epidemic in limited 
 areas, and attacking a whole district, so that the State schools have 
 from time to time to be closed for some weeks. Both in the endemic 
 and epidemic forms, the sequela? of this disease have been by far the 
 most frequent cause of blindness in the colonies; not on account of the 
 serious nature of the disease at its commencement, but owing to its 
 being allowed to continue in a chronic form, inducing trachoma, pannus, 
 ulcers of the cornea, and all the disasters resulting thei-ef rom. Certain 
 varieties of trachoma are so intimately associated with this disease, 
 that it will be difficult to make any observations on the subject of 
 granular ophthalmia, as it is oftenest seen in the colonies, without also 
 glancing at this so-called blight. 
 
 The subject of trachoma, or granular ophthalmia, is a most difficult 
 one to deal with, both as regards its causation, its essential nature, and 
 its treatment. The nomenclature is both imperfect and deceptive, and 
 the words " granular ophthalmia " and " trachoma " are used by some 
 as synonymous, and by others as expressing different diseased conditions. 
 Others again give names in accordance with the particular theories 
 they hold as to their distinctive characteristics, such as follicular and 
 papillary granulations, and hypertrophy of the papillfe — these three 
 forms being held as essentially different diseases. Others, as Von Arlt, 
 regards the blenorrhcea of gonorrhoea and that of ophthalmia neonatorum 
 as the same disease in the acute form as follicular and papillary 
 granulations in the chronic form; and that these diseases only 
 diii'er from one another partly by the rapidity of their course, and 
 partly by the changes that take place in the conjunctiva. M. Wecker 
 considers wliat he calls true granulations as new deposits analogous to 
 tubercle. There is great diversity of opinion as to whether these 
 granular bodies are new formations, or alterations of the adenoid tissues 
 already existing. At present, I do not tind any satisfactory evidence 
 as to these granules being the product of a specific micrococcus, and 
 having a distinct origin or running a different course from the other
 
 SANDY BLIGHT AND GKANULAR OPHTHALMIA. 739 
 
 altered states of the conjunctiva in tliis ati'ection. T cannot agree that 
 we are in a position to draw deductions as regards nomenclature or 
 treatment from the present uncertain state in which the question 
 stands. 
 
 Sattler, ^Michel, and one or two others believe that tliey luive 
 found a specitic micrococcus in the granular bodies, and that they have 
 reproduced a similar disease with the cultivated germs; but their 
 conclusions have not been sufficiently corroborated Ijy other investi- 
 gators. I am perfectly prepared to believe that this disease, in common 
 with a very large number of others, is caused by micro oi'ganisms ; but, 
 granting that this may be true, the question still remains open — whether 
 these same organisms are not also present in other forms of the disease. 
 The more we consider the study of micro-organisms in connection with 
 disease as of paramount importance, the more cautious we should 
 be in admitting all the numerous so-called discoveries as proven, until 
 they have l)een subjected to the test of time, and the unanimous 
 concurrence of a large number of experienced workers in the same held. 
 
 I do not tind that the usual descriptions of trachoma at all accurately 
 represent the forms of the disease as it exists in the colonies ; nor are 
 the various gradations nearly so clearly marked as usually described. 
 On this account, I have thought it might be of interest to give my 
 impressions of the disease, after having watched its progress in Hospital 
 and private practice for twenty-five years; during which time I have 
 had a very large number of cases pass through my hands, and have 
 been able to contrast it with the disease as I have seen it in Egypt, 
 Ireland, and England (although in England it is rare, in comparison to 
 its frequency in the other counti'ies). In these colonies, it is perhaps 
 more prevalent than in any paii of the Globe inhabited l)y Europeans. 
 
 I am inclined to the belief, that the various forms of trachoma are 
 modifications of the same disease, but differing in degree; and that one 
 form may reproduce another foi-m, modified by the manner of 
 transmission, and by the surrounding circumstances of the case. Some 
 years ago I attended, on behalf of tlie Government, a very serious 
 attack of purulent ophthalmia in the State Schools for children, in 
 which many hundi'eds were attacked, and a large number lost one or 
 both eyes. I have already described this epidemic, and only mention 
 it now to point out that the forms of trachoma left after the subsidence 
 of the disease were markedly different. In some, there were the well- 
 marked sago grain bodies ; in others, these were never visible at all 
 (and I watched the progress of all the cases from day to day), but only 
 the enlarged and hypertrophied villi and conjunctiva. Through the 
 kindness of my confrere, Dr. J. P. Ryan, and in conjunction with him, 
 we examined over four hundred of the children at Abbotsford. 
 Amongst a large number of them, trachoma was present in a greater or 
 lesser degree. In some, the sago grain bodies were visible, but in by 
 far the greater number they were not present; and in the cases in which 
 they were seen (a strong lens was used), the enlarged villi gi'eatly 
 predominated. Blight has several times visited this school, and, a large 
 number of the children have been attacked, but not in a severe form, 
 or as an epidemic. I cannot help thinking that it would be much 
 better, whilst there is any serious difference as to the causation and 
 essential nature of this disease, not to give a name or names in 
 
 2b 2
 
 740 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 accordance with the particular theory of its nature or development, but 
 for a time at least to describe the conditions simply as we see them, and 
 on these grounds I should like this disease of granular ophthalmia not 
 to be subdivided, but all forms to be classed under the sole name of 
 ti'achoma, or trachomatous eyelids — signifying simply rough eyelids. 
 
 I will now give a brief outline of the disease popularly known as 
 sandy blight in these colonies. It is simply a muco-purulent con- 
 junctivitis, and commences with a slight redness and itching of the 
 conjunctiva of the lower eyelid. This soon extends to the ujjper lid and 
 the globe; and on the second day, the eyelid swells moi'e or less, 
 according to the severity of the case. There is usually a considerable 
 amount of pain about the third or fourth day. On everting the upper 
 lid, it is found somewhat roughened by the enlarged and swollen 
 papilla:;, a muco-purulent discharge exudes from the eye, but unless in a 
 very severe case, it is more of a mucous than a purulent character ; 
 frequently however, in constitutions debilitated by drink or disease, and 
 with vmhealthy surroundings, the disease takes on a decidedly purulent 
 character, and the resulting trachoma (supposing the case is not 
 properly treated) and pannus are of a far more serious character than 
 in an ordinary case. 
 
 All the prominent symptoms fade away in aljout a fortnight with 
 ordinaiy cleanliness, and not much discomfort remains, and in this 
 freedom from any serious annoyance lies the danger. In a large 
 number of these untreated cases, the disease continues in a chronic 
 form ; a slight mucoid discharge comes from the eyes during the night, 
 or in a glare or strong wind ; and if the lids ai'e examined, the enlarge- 
 ment and thickening of the papillaj can be seen to be slowly progressing, 
 exudation of lymph is taking place into the tissues, thickening the lids, 
 and in course of time, if nothing is done, pannus, ulceration of cornea, 
 and all the other sequela? take place ; whilst in this chronic condition, 
 as in gleet and other diseases of mucous membranes, exposure to cold, 
 drinking, and other like causes, renew it with much of its original vigour. 
 
 Blight is much more common in the country than in the towns, and 
 amongst children than grown up people. It is rare except in the 
 summer months, and is in a worse form at a late than at an early 
 period of the summer. In looking for the causes of this disease, we 
 must separate those which give it a chai^acter endemic to a particular 
 country or district, and those which immediately concern its production 
 in an epidemic form in a limited area. There can be no doubt that the 
 usual causes inducing inflammation of mucous membranes are operative, 
 as cold air draughts, dust, and especially Aiolent alternations of heat and 
 cold : and in tlie case of the eyes, bright light will occasion the affection. 
 A bright sun (especially when x'eflected from a briglit-coloured sandy 
 surface) is without doubt an irritant to the eyes, and predisposes them 
 to disease. The dust also, especially when it exists in an almost 
 impalpable powder, acts very injuriously. We know that damp is a 
 great medium for carrying the poison of many infectious diseases ; and 
 I consider one of the chief causes of the propagation of this affection by 
 contagion is an atmosphere loaded with moisture, whether produced by 
 evaporation after a liot day, or from the moisture exhaling from the 
 bodies of a large number of people crowded together in badly ventilated 
 sleeping apartments. Both these causes may act at once, and usually
 
 SANDY BLIGHT AND GRANULAR OPHTHALMIA. 741 
 
 exert their influence on eyes predisposed to take disease from previous 
 exposure to tlie sun, dust, Ac, and in constitutions debilitated by 
 fatigue, drinking, improper food, or insufficient exercise. One of 
 the principal causes of the disease in its simple form here is exposure 
 of the eyes to the sudden changes of temperature in the early morning, 
 Tliis change is very great in tlie summer in our climate ; and in tlie 
 country districts, people, especially the young, often sleep during t!ie 
 hot weather in exposed places, where they are subjected to its full force. 
 In towns, they are usually in rooms more protected from atmospheric 
 influences. Formerly, in the early days of gold-mining, when teams 
 with large parties of miners, Arc, went to the diggings, sleeping in 
 tents en route, a large number of the party almost invariably had blight. 
 It is a common practice amongst the Tent Bedouins to cover their eyes 
 at night in order to guard against a similar change that takes place 
 in Egypt. 
 
 The great decrease in blight and its consequences, that has taken 
 place of late years from year to year, I attribute in great measure to 
 the improved conditions in which the farmers and miners now live. 
 They generally have fairly comfortable cottages, instead of log huts or 
 tents. This disease is, without doubt, both contagious and infectious, 
 but it is certainly by no means exclusively or chiefly to be attributed 
 to tills cause. My own opinion is, that it is highly contagious, but 
 infectious only in a minor degree, and in a suitable nidus. * 
 
 I have given an outline of this disease, as I consider it is by far the 
 most frequent cause of trachoma in these colonies, and of the irreparable 
 damage that may be caused by neglecting its treatment — a disease so 
 easily cured, and if untreated, leading to such disastrous results. 
 
 This neglect is now being, to some degree, remedied by the greater 
 facilities the country people have of reaching a doctor, and by the 
 greater knowledge the profession now possess of the treatment of the 
 disease. For my own part I have found fomentations, with or without 
 leeches, in the acute stages ; and alum washes, with or without weak 
 nitrate of silver drops, in the later stages ; with absolute cleanliness 
 throughout, amply sufficient in nearly all cases to eftect a cure, and 
 leave no trace of enlarged papillae behind. In sjDeaking of trachomatous 
 (or rough) eyelids, as I have before stated, the sago-like bodies or 
 granules are comparatively rare in this country, and are intimately 
 associated with the other forms of trachoma. I have seldom seen them 
 alone ; and it is very rare here to see a case of trachoma, which has not 
 been preceded by some acute or long-continued sub-acute form of 
 conjunctivitis, and generally no history of previous weakness of the 
 eyes can be gathered. 
 
 In the large Military Eye Hospital at Cairo, I have frequently seen 
 cases of old trachoma, with tlie conjunctiva smooth and bright, but 
 studded witli small, hard, round seed-like bodies, embedded in the 
 conjunctiva, and wliich can be picked out with tlie point of a knife, 
 and wlien placed on the palm of the hand can be rolled about like 
 marbles. These I have never seen here. 
 
 * By Contaijion, I mean immediate contagion, communicated through a material 
 and visible substance. 
 
 By Infection, mediate contagion communicated through the medium of the 
 atmosphere, and invisible substances suspended in it.
 
 742 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Of the trachomatous patients who have passed through my hands, I 
 have not found any great predominance of a particular nationality. It 
 is rare amongst the Jews, which I attribute to so few of them living in 
 the bush, and out of reach of medical attendance ; and it is certainly 
 rather more prevalent amongst the Irish, this I attribute to an exactly 
 contrary reason — so many of the poorer classes of this nationality 
 being small settlei^s, and gaining a mere subsistence. 
 
 Pannus, here as elsewhere, is a very common accompaniment of 
 trachoma ; and ulcers of the cornea also are far commoner here, in 
 my experience, than in England, as a sequela of the disease, and are 
 the most frequent cause of blindness, as they render it difficult, and 
 often impossible, to properly treat the trachoma. I do not think it is 
 of much use to attempt to cure the pannus until the trachoma is 
 sufficiently recovered to enable us to beneficially treat the two together. 
 The cicatricial bands in the conjunctiva of the upper lid, occasionally 
 met with in old cases, are as often, I think, caused by the free use of 
 solid caustic — which was formerly a common method of treating 
 trachoma — as by contraction caused by changes in the granules. 
 
 I do not intend to say much as to the treatment of this disease. It 
 is sad to contemplate the infinite number of remedies that have been 
 tried, extolled as almost specifics, and now fallen into utter disuse, 
 or only used once in a way as of doubtful utility, and it has a tendency 
 to shake one's faith in the wonderful results constantly reported of new 
 methods of treatment. Of course, this may be accounted for to some 
 extent by the fact that in this, as in other diseases, the same remedies 
 iict in a very diflerent manner in diftei^ent persons, and in accordance 
 with the various phases of the disease and of the constitution. I haA-e 
 not found shaving the tops of the villi of much use, although when 
 they are very large and vascular, the bleeding may do good sometimes ; 
 a better plan is scarifying. Nor have I found much benefit from the 
 actual or thei'mo cautery. I have not used the electric cauteiy 
 sufficiently to form an opinion. Dr. C. Bell Taylor has adopted a 
 method (in accoi'dance with the bacteria theory), of squeezing out the 
 granules and scarifying, and afterwards applying liquor potassiB. I 
 very rarely indeed meet with cases in which the sago gi'ains are 
 sufiiciently isolated or numerous, and unaccompanied with enlarged 
 papillte, to apply this treatment with any hope of success. 
 
 He also in some cases, in common with others, excises the I'etro-tarsal 
 fold. I have made trials, in some cases ^^rolonged ones, with tannin, 
 perchloride of mercury, and others of the numerous forms of treatment 
 that have been from time to time advocated, such as the aqupe chlorinatte 
 so strongly recommended by Graefe, Pagenstacher's yellow oxide of 
 mercury ointment, Worlomont's — cantharides, sulphate of copper, and 
 glycerine ; Bowman's spirits of turpentine and olive oil, &c. itc. ; and 
 although tliey ai'e most of them undoubtedly useful in certain cases 
 (I have found the perchloride particularly so), I have as a general rule 
 come back to the thi'ee old remedies of the mitigated nitrate of silver 
 stick, applied lightly to the lids, and afterwards neutralised ; followed 
 by the sulpliate of cop])eT', divine stone, or a brush OAer with a ten or 
 twenty grain solution of nitrate of silver, neutralised after a short time, 
 as the most reliable i-emedies in bad cases of trachoma. Local depletion 
 and counter-irritation are of course used from time to time.
 
 GRANULAR CONJUNCTIVITIS. 74^ 
 
 Jequirity is undoubtedly a valuable remedy in extensive pannus ; the 
 effects produced are somewhat alarming in appearance ; but unfortu- 
 nately, the cases in wliicli it is safe to use this remedy are far from 
 numerous, as they are often accompanied with corneal ulceration, either 
 existing, or with the scars from former ulcers ; in such cases it would 
 not be prudent to employ jequirity ; the effect, however, as with inocula- 
 tion of pus, seems to be rendered safer when preceded by the operation 
 of peritomy. 
 
 Peritomy T have very frequently performed, and have seen the results 
 after months, and in some cases years. The effects are veiy slow in 
 arriving, and T do not consider the results as a rule satisfactory. The 
 pannus is often greatly cleared away, but a general corneal haziness is 
 often left, in many cases permanently. 
 
 I do not know any remedy that supersedes prolonged treatment, 
 patience, and extreme care, and watching, the general health being 
 very carefully attended to, and the frequent febrile attacks to which 
 these patients are liable combatted. With these means, I think almost 
 all cases are curable if the pannus is not too thick, and no ulceration 
 exists. 
 
 We have here a veiy large number of cases of young people, with 
 only a moderate amount of trachoma and pannus of not a very 
 pronounced character. The health is generally much impaired, fi'om 
 the constant suffering and misery. In these cases, for some years, I 
 have been in the habit of using the following method of treatment : — 
 
 T tell them to place as much as two pin heads of quinine, in the 
 linest possible powder, between the lid and the eyeball every morning ; 
 and at night, a drop of solution of sulphate of atropine, two grains to 
 the ounce. I also give them a tonic, usually syrup of the iodide of 
 iron, and tell them to bathe the eyelids for a minute or two, three or 
 four times daily with cold water. After a short time, I have found 
 the pannus to disappear in a satisfactory manner, and the conjunctiva 
 to become of a pearly whiteness ; the ti-achomatous condition of the lids 
 at the same time slowly but satisfactorily lessens. I am so satisfied 
 with this method of treatment, that I am anxious my confreres should 
 give it a trial. It of course does not succeed in all cases, and does not 
 seem suitable in grown up people. 
 
 GRANULAR CONJUNCTIVITIS. 
 
 By R. B. Duncan, F.R.C.S. Ed. (l)y Exam.), Kyueton. 
 
 Hon. SurfTeou, Kyneton Hospital. 
 
 Late Clinical Assistant, Glasgow Ophthalmic Institution. 
 
 Granular conjunctivitis is a disease that has always occupied a pro- 
 minent position in ophthalmology. It is not so much that it is a disease 
 which often proves fatal to useful vision, lint that it is one almost 
 invariably of long duration, most difficult to cure, and when aiiparently 
 cured, liable to frequent relapses. 
 
 This disease may be said to have made its first appearance in Europe 
 in 1798, when it was imported by the French army on its return from
 
 744 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Egypt, lience the name " Egyptian ophthalmia," by which it is sometimes 
 designated. There is reason, however, to believe that in Italy at least, 
 it was known long anterior to this date. At the periods of which I speak, 
 its propagation was easy, and its results wide-spread and disastrous. 
 
 It is only within recent years, however, that its causation and mode of 
 propagation, the various social conditions with which it was associated, 
 its insidious beginnings and rapidity of spreading in reformatories, 
 barracks, and prisons, or wherever large collections of people were 
 congregated under bad hygienic conditions, have been investigated and 
 studied with a care and discrimination which leaves little to be desii'ed. 
 
 The chief causes, then, of this disease, in its epidemic form at least, 
 may be traced to the " overcrowding of human beings, together with 
 filth, impure air, want of proper food ; and, in fact, deficient sanitary 
 arrangements in general are doubtless the most ])rolific sources of this 
 disease, and are capable of not only causing conjunctivitis in men, but 
 also in the lower animals."* 
 
 What I wish to speak of to-day, more particularly however, is the 
 granular conjunctivitis in its isolated forms, as we generally meet 
 with it in ordinary practice, in contra-distinction to its existence in 
 communities to which I have just alluded. And first, as to its name. 
 There is no term in ophthalmology which is more confusing, or which 
 more absolutely misrepresents a disease than this. As if the designation 
 "granular conjunctivitis" was not enough to make "confusion worse 
 confounded," other terms have crept into our nosology; hence the names 
 trachoma, Egyptian ophthalmia, military ophthalmia, follicular, papillaiy, 
 and even vesicular conjunctivitis. I am not prepared to ofler any sug- 
 gestion in the way of curtailment of this formidable nomenclature, but 
 it is to be hoped that systematic writers on the subject will, in the near 
 future, find a means of designating it more in keeping with its pathology. 
 
 The appearance of an eye affected with granular conjunctivitis is not 
 always characteristic, and will depend to a great extent on the stage of 
 development reached by the granules. At times, a magnifying glass will 
 be required to make them out. In the majority of cases, however, they 
 are observable as small semi-transparent bodies, occupying chiefly the 
 upper and lower tarso-orbital folds; but, by preference, the latter. They 
 often attain the size of boiled sago grains, to which they have been 
 com])ared. 
 
 What, then, is their structure, and what are the pathological conditions 
 producing them 1 This question is not easily answered, since opinions 
 regarding the histology and pathology of trachomatous granules are at 
 present in a transitional state. They consist, according to Pollock, " of 
 collections of lymphatic corpuscles, enclosed in the meshes of a delicate 
 reticulum, the whole being invested by a capsule, formed by a condensa- 
 tion of the normal tissue." More recent investigations, however, have 
 shown that their anatomico-pathological structure is not quite so simple. 
 Is a granule in fact a perfectly new formation, or a mere hypertrophy of 
 a jjre-existing structure 1 It is a new formation undoubtedly, and not 
 only so, but the seat of a specific micro-organism or tracliomacoccus. 
 
 Considering the nature of the disease, and its intensely contagious 
 charactfT when combined with a discharge, something of this kind was 
 
 * " A Manual of Diseases of the Eye " (Macnamara).
 
 GRANULAR CONJUNCTIVITIS. 745 
 
 long suspected. Its important bearing on the subject of treatment will 
 be discussed further on. By adopting this view of the matter, some 
 features of the disease, which liave always been more or less inexplicable, 
 are easily explained. It is quite evident that the question is chiefly a 
 bacteriological one, and from that side only will it advance. A dis- 
 tinguished writer (Arlt, " Pathology of the Eye ") on the subject tells us, 
 that the chief characteristics of a granule are "tubei"cle-like aggregations 
 of round cells;" while another informs us that they are purely composed 
 of lymphoid cells. Both opinions are to a certain extent correct, but 
 they do not advance our knowledge of this important matter in any way. 
 Any elucidation of this question then, from a new standpoint, is to be 
 welcomed. It may be stated that the human conjunctiva at least contains 
 no lymphatic follicles. " Small collections of lymphatic cells may be 
 found in it, arranged in clusters." A trachomatous granule being a new 
 formation, what are the conditions of its development? Given a healthy 
 human conjunctiva, to which some of the discharge from one affected 
 eye has gained admittance, and what is the course of events 1 Modern 
 bacteriological research has placed it beyond a doubt, that the disease 
 depends on a specific trachomacoccus, which finds its s})ecial seat of 
 development in the sub-e})ithelial connective tissue. How does it get 
 there, and in what manner is it possible that it can penetrate an 
 apparently intact and healthy membrane 1 Various conjectures have 
 been hazarded to account for this, but with as yet no satisfactory result. 
 •'Once introduced, however, the changes begin, and like many diseases 
 due to a micro-organism, have a distinct period of incubation ; and it is 
 not till the end of the second week that the external manifestations of 
 the disease are visible. If a section of a trachomatous granule be 
 examined, say about the tenth day from the entrance under the con- 
 junctiva of the specific germ, it will be found to consist chiefly of white 
 blood corpuscles and lymphatic cells, having no particular arrangement, 
 and no definite investing membrane. As it attains maturity, however, 
 the collection of cells is permeated by a fine reticulum, and acquires an 
 investing membrane. The early growth and development have not yet 
 been worked out with that accuracy of detail, which the importance of 
 the subject demands. As the result, however, of recent investigations, 
 we are justified in assuming — 
 
 (1) That granular conjunctivitis is a disease due to the development of 
 
 a specific germ in the conjunctiva. 
 
 (2) The specific germs penetrate into the sub-e])ithelial connective 
 
 tissue, and produce there an irritation capable of determining 
 the migration of white blood coi'jmscles from the neighbouring 
 blood-vessels. 
 
 (3) The parasitic germs collect in the pi'otoplasm of these cells, and 
 
 the cells themselves by a series of modifications produce the 
 finely interlaced fibres which constitute the delicate connective 
 tissue stroma of the granulations. 
 
 (4) A granulation, in all its surroundings, is formed by new elements 
 
 proper to it alone.'"* 
 The papillary variety of conjunctivitis is essentially different to that 
 just alluded to. Here we have a true hypertrophy of existing structures, 
 
 * Staderiui, " Annali di Ottalmologica," Anno xvi., Fasc. 5 e. 6.
 
 740 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 modified according to whether they are merely an accompaniment of the 
 follicuh\r variety, or the result of some preceding purulent or gonorrhffial 
 inflammation. In the first instance, they are usually hard, and somewhat 
 whitish ; in the latter, soft and succulent. In structure, they do not 
 differ from papilhi3 elsewhere. When they exist in any considerable 
 quantity in conjunction with the follicular variety, the term "mixed 
 gi'anular conjunctivitis" will sufliciently indicate the connexion. Though 
 scarcely alluded to by some authors, there can be no doubt of their great 
 importance, and the damage that they are capable of inflicting. While 
 always due to some present irritation or previous inflammation, they are 
 often, on that account, most rebellious to treatment. 
 
 There is a form of the disease we are discussing, which has been termed 
 " malignant," and which is fortunately rarely seen. In the so-called 
 malignant form, we have a combination of papillary and follicular con- 
 junctivitis, on a most extensive scale. The whole of the conjunctival 
 membrane, even including the cornea, is the seat of granulations; 
 and the latter, in addition, is generally in a state of hopeless pannus. 
 The chief feature of this disease is, however, seen in the lids. These 
 are thickened to an extraordinary extent, and the tarso-orbital folds 
 almost filled with fleshy-looking masses. What are the causes of this 
 formidable affection, and do we find an ordinary granular conjunctivitis 
 progress to this almost hopeless condition 1 In my experience, this 
 malignant variety shows some exceptional aspects from the first, in 
 marked contra-distinction to the ordinary variety. This is generally 
 . shown by the i-apid sjjread of the granules, or their almost simultaneous 
 appearance on conjunctiva and cornea, the lids keeping pace in their 
 thickening and induration. The real cause, if cause there be, for what 
 is possibly after all only an aggravated degree of a less serious trouble, 
 is qi;ite obscure. 
 
 Granular conjunctivitis falls into two well-marked divisions, regarding 
 which it is necessary to have the clearest possible understanding. In 
 the one class, we have granulations in various states of development, 
 without any ])erceptible discharge, and with little external manifestations 
 to indicate their presence. In the other class, we have granulations 
 attended by a discharge. This discharge, as we all know, is distinctly 
 contagious, and can give rise to granular conjunctivitis in a healthy eye 
 Eyes belonging to the first category are exceedingly prone to be affected 
 by the second; hence the imperative necessity in public institutions, such 
 as reformatories, of thorough inspection and careful isolation on the 
 slightest appearance of the disease. Finally, the non-discharging kind 
 are liable to inflammatory action at all times. These distinctions are 
 valuable, no less in private than public practice. I had a patient lately 
 who suffered from the disease, and had a mild discharge, from whom 
 enquiry elicited the fact, that other members of the same family were 
 suffering from what she termed "weak eyes." Further investigation 
 showed the supposed weak eyes to be distinctly granular. They were not 
 considered sufficiently bad by the parents, however, to demand treatment. 
 That this must prevail to a considerable extent is evident from the 
 fact that, in a large percentage of our cases, the patients do not come 
 under observation iintil the disease is well advanced. The relation of 
 catarrhal states to the question we are considering is of high interest 
 and importance, and in a special degree to treatment. The majority of
 
 GRANULAR CONJUNCTIVITIS. 747 
 
 text-books tells us that, where no discharge exists, sulphate of copper 
 is indicated ; and when present, nitrate of silver solution. Such state- 
 ments, to my mind, are calculated to do considerable harm ; and their 
 adoption, of course, more so. Experience does not teach us that such 
 advice is either sound, or based on correct principles. 
 
 There is one feature of this disease which is always perplexing, and 
 always a source of discouragement. I allude to the frequency of relapses. 
 What is the cause of a relapse 1 It is not ditficult in many diseases to 
 answer this question. But in granular lids, the individual granules of 
 which are visible and tangible for a time, and evidently completely 
 disappear-— what is the reason of their re-appearance? It is not 
 re-infection ; for although recently cured granular conjunctivitis would 
 leave a surface unquestionably more susceptible than one previously 
 unaftected, still we have in many instances abundant evidence to show 
 that a genuine relapse has to do with influences seated in the eye itself. 
 Bacteriology is, I think, making it every day more clear, that a 
 relapse is due to a specific trachomacoccus, already alluded to. For 
 undoubtedly, in many cases, when all active manifestations of disease 
 at least will have passed away, there will still remain some of these 
 micro-organisms in an undeveloped state, embedded in the tissue. 
 Their development may have been retarded during the period of treat- 
 ment, l)ut when this has been abandoned, they have started into fresh 
 activity. Hence the continued watchfulness necessary after an apparent 
 cure. The division of this disease into acute and chronic stages is not 
 a happy one. It is much better to i-egard it as essentially chronic, with 
 acute exacerbations. 
 
 The real raison d'etre of this paper, however, has reference chiefly 
 to treatment, and the surgical management of one of its principal 
 complications — pannus. The limits of this short paper preclude me 
 from dealing with other complications, which are scarcely less important. 
 There are few diseases where hygienic conditions should form more 
 prominent a feature, than in granular conjunctivitis. " It begins in 
 filth, is nurtured in filth, and is propagated chiefly by the same 
 means."* A remarkable instance of this is related by Macnamara. 
 Writing on the same subject, he says : — " An instance of the same kind 
 will be found in certain schools in Calcutta. The children in one of 
 these schools were of different nationalities — natives, half-castes, and 
 Europeans — but the buildings were situated in a most filthy part of the 
 city, and were surrounded by open drains and every conceivable abomi- 
 nation, and granular conjunctivitis was never absent from among the 
 boys ; whereas in other schools of a similar nature, but situated in a 
 healthy locality, not a single instance of the disease was to be met with." 
 It is necessary to know the domestic life, if I may so term it, of 
 every individual patient ; and it may be affirmed that in few instances 
 something will not he found that requires correction and advice. It is 
 an undoubted fact, which experience almost daily confirms, that sanitary 
 defects often defeat our best directed efforts. Whenever they can be 
 attained, perfect hygienic conditions, suitable food, tonics, and fresh air — 
 or, in many cases, a complete change — are always desirable, and often 
 absolutely necessary. I was much impressed with this some years ago. 
 
 * Macnamara op. cit.
 
 '748 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 A brother and a sister came under my care with granular lids, which 
 had been iinder careful and skilful treatment for a long period, without 
 any tangible benefit. I treated them for a considerable time with a like 
 result ; and at last, in despair at what to do, I prevailed upon them, at 
 great personal inconvenience to themselves, to reside in a different part 
 of the country, and where scarcely any but constitutional treatment was 
 adopted. On examining them some time afterwards, the disease had 
 almost entirely disappeared. 
 
 Having seen then, that the patient's surroundings are as perfect as 
 circumstances will permit, the next consideration is the treatment of 
 the affected eyes. Before adopting this, it is well to ask ourselves. 
 What do we aim at, and have we any guide to treatment 1 The routine 
 method of treatment sometimes adopted in tliis disease would almost 
 incline one to believe that ophthalmic therapeutics had not yet escaped 
 from empiricism. Our aim, briefly stated, is to procure absorption of 
 the foreign products, and the restoration of the conjunctiva to a state of 
 health. We aim at this in various ways, which are better noticed in 
 detail. The term " papillary" may be regarded as representative of a 
 state requiring a particular treatment. When occurring as a sequence 
 of a previous disease, its treatment calls for nothing special; when 
 occurring in conjunction with follicular conjunctivitis, so as to constitute 
 the mixed variety, its treatment will come under the remarks I am 
 about to make. I wish to allude for a moment to a class of cases, viz., 
 those distinctly and typically acute. In these cases an amount of 
 inflammation may have been set up, which will be sufficient to cure the 
 granular state without our aid. Here, non-interference may be highly 
 desirable. I alluded before to the two divisions into which granulations 
 naturally fell — the non-dischai-ging and the discharging. First, in 
 regard to the former, we have here granulations in a quiescent state, 
 causing only, perhaps, slight conjunctival hypersemia and discomfort in 
 the eye, and nothing more. There are two methods of treatment available 
 here — To set up a sufficient amount of inflammation in the eye, which will 
 cause absorption of the granules; or to treat them by scarification, massage, 
 and astringents. The latter method I will deal with, in conclusion, as 
 being the plan I prefer, and nearly always practise. Sulphate of copper, 
 either alone, or in combination with other substances, has long been a 
 favourite in the present affection, witii the object of setting up an 
 amount of inflammatory action necessary to cause the disappearance of 
 the granules. That it sometimes succeeds, is undeniable; but no one 
 wlio has watched the time it takes to effect a cure, and its often unsatis- 
 iactory results, would be ])repared to say that it is a remedy of much 
 value. The reason of this is not far to seek. A remedy that we know 
 •will be perfectly safe, so far as the integrity of the other structures of 
 the eye is concerned, is not of sufficient intensity, in too many 
 instances, to accomplish the object aimed at. In a typically mixed case, 
 the remedy would have a positive disadvantage. We might, it is true, 
 benefit the follicular granules, but not the enlarged pa{)illa3. To effect 
 any improvement in them, our remedy must be purely astringent, and 
 of a strength graduated to the needs; not an irritant, as the remedy we 
 ■are dealing witli undoubtedly is, in the sense we are using it. Going 
 back to the (piestion of the intensity of a remedy, and the desirability 
 of its safety, it is not long since jequirity gave high promise of, in
 
 GRANULAR CONJUNCTIVITIS. 749 
 
 some measuro, ;iccomi)lisliing this desirable end; but it has not realised 
 the expectations formed regarding it. While, at times, undoubtedly 
 useful, it is exceedingly uncertain in its action, and doubtful in its 
 results. 
 
 The treatment of granular lids, with acute inflammatory symptoms 
 and a free discharge, is a proljlem of gre;it complexity. Allusion has 
 already been made to granular states without a discharge. Two factors 
 are chiefly or solely engaged in bringing a discharge about, putting aside 
 the question of dii-ect infection, either a certain stage being reached by 
 the development of the granules, or some disturbance to the general 
 health. The resulting ophthalmia is one of the methods by which a cure 
 takes ]>lace, but except in the so-called acute form it is hardly ever 
 successful. Nay more, it is genei-ally entirely abortive, and of little 
 practical value. On the decline of the inflammatory attack, matters are 
 often found worse than before it. The treatment of the discharging 
 stage is essentially the treatment of the ophthalmia. Various remedies 
 are in \ise for this purpose ; among which, a solution of nitrate of silver, 
 in different strengths, occupies a prominent ])lace, so that it may stand 
 for the whole astringent group. While clearly recognising its value in 
 attaining a certain amount of good, it must be remembered that the 
 objects it accomplishes are only temporary in many instances. The cure 
 of tlie ophthalmia does not necessarily mean the cure of the disease. 
 If it is true, however, as German and Italian investigators are 
 endeavouring to jirove, that the disease is parasitic, the method of 
 treatment will no doubt be soon placed on a sounder basis. And this is 
 what is being attempted. At the conclusion of an elaborate paper, 
 where the subject of granular conjunctivitis is studied from a purely 
 bacteriological point of view, and the opinion expressed that the disease 
 is due to a specific trachomacoccus, Staderini at once applies the 
 knowledge gained to the test of clinical ex])erience. As might have 
 been expected, the drug selected is corrosive sublimate. If this applica- 
 tion should turn out a success, as the author declares it has, it will prove 
 what often turns out to be the case, that empiricism has established the 
 value of a remedy long before it was scientifically proved ; for as far 
 back as 1825, we find Buzzi* writing that he had used corrosive 
 sublimate for the last twenty years. His formula was — Hydrai-g. 
 bichlor. gr. j, chloride of ammon. gr. ij, water 8 oz. This he declares to 
 have used with the happiest results in ophthalmia and the disease under 
 consideration. In Glasgow, Scotland, which I visited a few years since, 
 and which was the home and field of labour of that distinguished 
 ophthalmologist, McKenzie, I was given a prescription of his, which the 
 donor assured me was " good for anything " in the shape of inflammation 
 of the eye. This, strange to say, contained the same ingredients as the 
 above, with the addition of belladonna. To enter at length into the 
 results attained by Staderini would scarcely come within the scope of 
 this paper. They are encouraging so far, l)ut necessarily crude and 
 incomplete, as first investigations generally are. He recommends, if 
 there is a dischai'ge, that solution of nitrate of silver may be used in 
 addition ; not necessarily however, as he treated a number of cases 
 
 * Buzzi — Eagiouamcnto siill' oftalinia pustolare contagiosa, quoted by Staderini, 
 •' Annal di Ottalmol."
 
 '750 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 witliout it. This method, if tiie apparent facts on which it is attempted 
 to found it are true (and I do not doubt but they are), may prove a 
 most valuable one. I have used it in some cases, but I cannot say with 
 much benefit. This has arisen in a great measure, I think, from the 
 solutions being too weak, the eye being cajjable of bearing with 
 advantage solutions of much greater strength than are now being used. 
 Whatever may be the pathology of granular conjunctivitis, or whatever 
 .stage it may have reached, or under whatever conditions it is found to 
 exist, I have derived the best and most lasting benefits from a treatment 
 first recommended by Prof. J. R. Wolfe, of Glasgow. This consists of 
 scarification of the lids, massage, and the employment of syrup of tannin, 
 in the proportion of two drachms of the tannin to an ounce of simple 
 syrup. The parts are first painted with a 4 per cent, solution of 
 cocaine as often as may be necessary, to abolish all sensibility. To take 
 the upper lid as an example ; this is strongly everted, and the patient 
 requested to keep the eye fixed in a downward direction. The extent 
 to which the scarification is carried, will depend on the extent of the 
 granular condition. Beginning at the lowest part, so that tlie haimorrhage 
 Avill not interfere with the view, the incisions are to be carried along the 
 horizontal axis of the lid as closely together as possible, over every part 
 of the seat of morbid action. When there is considerable engorgement 
 of the tissues, a thing not at all improbable, the incisions may be 
 further extended, although no granulations are visible. When this has 
 been accomplished the lids are closed, and massaged by the fingers of 
 the operator. This the ]3atient is carefully instructed to do for the next 
 few days. A lotion of weak boracic acid, to be used several times 
 daily, is then oi'dered. After a few days' use, the syrup of tannin is 
 substituted, and its instillation carried out according to the requirements 
 of the case. 
 
 Now, in considering this method a little in detail, its advantages 
 will be more apparent. In the first place, I would remark, that 
 scarification of the lids has never occupied that high position in 
 0])hthalmic surgery which its unquestionable advantage demands. My 
 experience of it, for some years, has been considerable; and, if its good 
 results were more widely known, they would be more highly appreciated. 
 In the present instance, what does it accomplish? If carefully and 
 properly done, the contents of every granule have a chance of escaping; 
 hypertrophied papillae are unloaded, and their pernicious development is 
 retarded; and finally, the conjunctival vessels participate in the depletion. 
 The scarification may be repeated as often as may be necessary, the 
 same routine treatment following it, already alluded to. I may say that 
 I have practised this method for a long time, and increased experience 
 only confirms my belief in its efficiency. It will be observed, that when 
 contrasted with other methods, it has some recognised advantages. It 
 Ulcerates the contents of the granules, that is undoubted ; and if 
 commenced at an early stage of tlie disease, will certainly cure it, and 
 leave the conjunctiva intact. The action of the tannic acid on the 
 diseased conjunctiva is rapid and effectual, and without possessing any 
 specific pro])erties, it is, to my mind, the best of all astringents. 
 
 The limits of this short paper will only allow me to notice one of the 
 Bccoiidary conditions that granular conjunctivitis gives rise to, viz., 
 panuus, and this purely from an operative point of view. The ope}"ation
 
 A CASE OF SARCOMA OF THE EYELIDS. 751 
 
 of jieritomy for ])aiiims is so easy, and so simple in jierformance, and 
 often so beneficial in its results, that it is surprising it is not more often 
 resorted to. The operation itself, if we may dignify it by such a name, 
 has, in reality, a much greater scope than would at first sight appear. It 
 is not only that it is singulai'ly useful in itself, but it is a powerful adjunct 
 to other treatment. It will often be found that a pannus, rebellious to 
 medical measures, will not be cured by peritomy, but the effect of the 
 j)eritomy will be that it may, and often does, 3'ield to treatment which 
 was formerly used witliout avail. It may thus have a double function, 
 and on that account its value is enhanced. Anaesthesia, general or 
 local, is required for its performance, which I do in the following 
 manner : — A cut is made with a pair of fine, blunt-pointed scissors, 
 close to the cornea, through the conjunctiva and sub-conjunctival tissue. 
 Into this a strabismus hook is introduced, and the structures put on the 
 stretch. The scissors are inserted between the hook and the cornea, 
 and follow it round, snipping the tissue close to the cornea till the circle 
 is completed. The free conjunctiva is then seized with forceps, and a 
 strip two and a half millimetres in width is cut off in the whole of its 
 circumference. The only really essential part of the operation is, to see 
 that the tissues have been quite removed from the sclerotic ; in fact, 
 that the latter is completely bare. The immediate results are extremely 
 variable — the cornea sometimes clearing quickly, and at other times very 
 slowly. 
 
 Such is a slight sketch of a disease and its treatment, that we are 
 called upon daily to deal with, and which we deservedly look upon 
 always with a feeling of doubt as to our capabilities of dealing with it. 
 It is to be ho])ed that the day is not far distant when, with a better idea 
 of its pathology and the various phases of its development, it will become 
 more amenable to treatment. 
 
 A CASE OF SARCOMA OF THE EYELIDS. 
 By Odillo Maiieii, M.D., Ch. M. 
 
 A maiden lady named S., aged 72 years, consulted me on May 10th, 
 1887, on account of a very peculiar condition of her eyelids. She was a 
 thin feeble w-oman, who had spent a life of toil as a needlewoman, finding 
 it not at all times easy to obtain more than the bare necessaries of life. 
 She stated that frequently during the last two years her eyelids and 
 cheeks had become so swollen that she had hardly been able to see out 
 of her eyes ; and that after one of these attacks, five months previous to 
 her consulting mc, the swelling of the eyelids did not altogether disappeai-, 
 and had since gradually increased in size. 
 
 Immediately under the right supra-orbital arch, and extending along 
 its whole length, was a smooth tense semi-elastic growth composed of 
 three lobes, which extended downwards into the eyelids between the 
 skin and tarsal cartilage. The lower Ijorder of the growth was some- 
 what arched, and did not extend to the edge of the eyelid. The tumour 
 was about the size of a pigeon's egg. Neither bruit nor thrill could be
 
 752 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 detected. Over the position of the right lachrymal sac was a .smooth 
 hard tumour, about the size of a large pea ; and in the lower eyelid, a 
 growth consisting of two lobes similar to that in the upper eyelid, but 
 not quite so large. It extended fi"om the margin of the orbit almost to 
 the edge of the lid. The skin was everywhere movable, and the growth 
 in the upper lid was not continuous with that in the lower. The condition 
 of the left upper and lower eyelids was similar to that of the right, but 
 the growths were not quite so large. The patient for some months had 
 been unable to see out of the right eye, and could only separate the 
 eyelids of the left about a millimetre and a half. There was slight 
 hypertrophy of the conjunctiva;. The eyeballs were normal. There was 
 no proptosis, nor were the movements of the eyes in any way affected. 
 The lymphatics, along the borders of the sterno-mastoids, and in front 
 of the ears, were slightly enlarged. An aspirating needle, passed into 
 the growths, proved them to be solid. 
 
 Five months later (October 1887), the growths had increased in size, 
 but the lymphatics appeared normal. She was unable to open the left 
 eyelids at all, and was practically blind. As long as she could see to get 
 about, I was averse to operating, on account of her age and feeble 
 condition ; Ijut, as she was now practically blind, I operated on the 
 left eyelids, freely removing the growths. I submitted them to Dr. 
 M'Cormick, the Demonstrator of Histology at the Sydney University, 
 for examination. The following was his report : — " The growth consists 
 of large rounded granular cells, about one and a lialf times the diameter 
 of a red blood corpuscle, embedded in a small amount of delicately-fibril- 
 lated inter-cellular substance. It is very vasculai', and the blood-vessels 
 lie in immediate relation to the cells of the part. It has got all the 
 histological appearances of a large round-celled sarcoma." 
 
 In April 1888, it was evident that there was a recurrence in the left 
 eyelids, and as they were again closing, I operated on the right eyelids. 
 In about ten days she left the Hospital, seeing well out of the eye 
 which had been closed for sixteen months. 
 
 There is now — December 1888 — recurrence in all four lids, and the 
 left have almost closed. 
 
 REMARKS ON OPHTHALMIC WORK IN WESTERN 
 AUSTRALIA. 
 
 By James William Hope, F.R.C.P. Ed., Fremantle, W.A. 
 
 The soil along the sea-board of the Colony, where settlement chiefly 
 exists, is mostly sandy and in large part lime-stone. Up to parallel 29° S. 
 the rain falls chiefly from May to October, from there north it falls 
 during the summer, consequently there is a large part of the year in all 
 places which is very dry. During the summer months, breezes from the 
 land occur from svmdown until aljout 10 a.m., then the wind comes from 
 the sea, cooling the air, but still keeping it charged with dust ; flies are 
 very troublesome in tlie summer. It is to these A-arious causes that 
 diseases of the eye are principally due.
 
 REMARKS OX OPHTHALMIC WORK I\ WESTERN AUSTRALIA. 753 
 
 Ophthalmia. — This aH'ection, althougli general, is of greater severity 
 ill some parts than in others, and the more serious attacks Iiappen in the 
 north west. Many cases there have the acuteness of purulent ophthalmia, 
 and \ea\e damage to sight not less than a specific form of that inflam- 
 mation. These cases are locally spoken of as " blight," and are probably 
 due to inoculation by flies and dust and dirt, conveyed by the breeze, 
 and by the liands in wiping away perspiration. The attacks are accom- 
 panied by pain, chemosis, purulent discharge, intolerance of light, and 
 feverishness. 
 
 A lamentable want of anxiety about the attack is often shown by 
 parents, and the difficulty of getting medical treatment until lately 
 caused many cases to run an unattended course, and left all the forms 
 of sequehe that can result from svich cases, as nebula, leucoma, perfora- 
 ting ulcers, with fusion of anterior parts of the eye, pannus, and granular 
 lids. In most cases, however, there have been some attempts at 
 treatment by those attacked, usually consisting in the api^lication of 
 domestic or commercial eye lotions, and perhaps some golden ointment, 
 but even these are used in such a superficial way as to be practically 
 useless. Cases which present themselves for treatment are commonly 
 those in which considerable damage has resulted, and are sad spectacles 
 of ig-norance, apathy and disease. 
 
 Milder attacks of ophthalmia are common throughout the Colony, 
 and are frequently allowed to become chronic, although recourse is had 
 to the ordinary eye lotions ; yet people are in ignorance that the lids 
 become inflamed similarly to the ocular mucous membrane, and after 
 the eyes have apparently become cured, they are surprised that there 
 remains a gluing of the lids at night ; and in the day, lachrymation, with 
 intolerance of light. It is only when the sight is impaired, and what is 
 called a " scum " appears over the pupil, that assistance is sought. 
 
 The cases almost invariably turn out to be granular lids, with perhaps 
 pannus, and some ulceration of the cornea, caused by the friction of 
 the rough lids ; the attendants or friends are surprised when the lid is 
 turned up, and they see the red and brick-like roughness of the inner 
 surface. Granular lids after some time usually produce in-growing 
 eye-lashes, and one or the other or both will surely cause keratitis, 
 ulceration of the cornea, or other damage. 
 
 It is for this affection of the lids that most patients seek relief, 
 and numerically it forms the chief work in diseases of the eye. To treat 
 successfully, a great amount of patience and perseverance are required 
 by sufferer and doctor, for it often takes months to get the lid smooth, 
 in some cases as long as eighteen months ; nevertheless, my experience 
 is that they can always be cured. I have never failed to effect a cure 
 in the most obstinate case, if treatment be persevered with. 
 
 Treatment. — I usually employ a 10 grain sol. argent, nit., sometimes a 
 15 grain solution, daily, at the same time using some ointment of the 
 yellow oxide of mercury, or insufflation of calomel if nebulous cornea 
 be present ; but if ulceration exists, eserine is the most effective drug. 
 The great objection to the long continued use of the caustic solution is 
 the pain it causes, and staining of sclerotic which I'esults, if care be not 
 taken to prevent the lotion getting on to the eye. These drawbacks 
 may be avoided by taking care to entirely evert the upper lid, then 
 with the second finger draw up the lower lid so that the upper rests 
 
 2c
 
 754 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 upon it. After applying the drug, absorb any surplus lotion by placing 
 a small piece of good blotting-paper in contact with it, and it will 
 be quite taken up. When the lid is released, very little pain or 
 lachrymation will follow. 
 
 Jequirity, as an auxiliary, is worthy of a place, but I have not had 
 the good results from its use I expected. In some cases it sets up 
 inflammation by one application, other cases tolerate it for many times, 
 and upon lids that have had caustic applied it is almost inert. Where 
 I have found some good from its use, is in protracted cases ; in these, 
 after using it for a week, the re-application of the caustic solution is 
 productive of more marked action. I consider it desirable to allow a 
 few days to pass now and again without treatment, especially when the 
 lid is nearly well, to see if any irritation is kept up by the applications. 
 
 Pannus, the result of granular lids, will gradually disappear as the 
 roughness of the lids is i^emoved, and its removal will be assisted by 
 touching it with a mild caustic point two or three times a week. 
 
 Ulcers of Cornea occur without any assignable cause, and in the 
 acute form cause pain, redness, lachrymation, photophobia. Treatment, 
 consisting of the application of eserine, a blister to temple, or the 
 artificial leech, with a pad and bandage to keep the eye quiet, and 
 supported with the administration of opium, will cure the patient. 
 Clironic ulcers.— Scraping the sides and base will often liven up the 
 parts, and the same local treatment will do good. 
 
 Leucoma will also be benefited by following the same line of treatment 
 as for chronic ulcers. 
 
 Nebula may be removed in many cases by the continued use, locally, 
 of calomel dusted on the eye, or ungt. hydrarg. ox. flav. 
 
 Onyx, accompanying ophthalmia, will yield and disappear under the 
 use of calomel and opium, or sulphide of calcium internally. 
 
 Hypopion, like ulcers on the cornea, occurs without any other trouble 
 of the eye, and frequently assumes a startling severity ; it is also 
 sometimes associated with corneal ulcer. There is great pain, circum- 
 corneal zone of redness, and often general haziness of the cornea, with 
 a considerable collection of pus. By incising the eye, to remove the 
 pus and relieve tension, great relief will follow. Eserine should be 
 applied regularly, and the eye supported by a pad and bandage ; a 
 blister to the temple, or the use of the artificial leech, with the adminis- 
 tration internally of calomel and opium, or sulphide of calcium, will 
 generally cure an eye that looks beyond improvement. 
 
 In-growing Eyelashes of the upper lids, whether all or a few, can 
 only be effectually cured by the removal of them all. 
 
 Corneal Prominence, so as to prevent the lids covering it, is seen as 
 the result of tliinning of anterior part of eye, with fusion of iris and 
 cornea. Where it occurs in a man to whom time is of importance, the 
 sight entirely lost, and who lives out of reach of medical help, I enucleate 
 the eye ; but for women, I remove successive wedge-shaped pieces, which 
 gradually brings the eye to its normal size, after which I tattoo a pupil. 
 The latter treatment is also effectual in cases of conical cornea. 
 
 Pterygium occurs very frequently, sometimes on one, sometimes on 
 both eyes, growing usually from the nasal side towards the pupil, and in
 
 RKMAKKS 0\ OPHTHALMIC WOHK IN WKSTKltN AUSTRALIA. 100 
 
 time covering it, and so forming a complete barrier to vision. This 
 condition is but rarely seen, but there are some who in the earlier days 
 of the colony could not get treatment, and who have gone away to get the 
 growth removed. I can merely reiterate an opinion I saw expressed in the 
 AiistraldsiuH Medical Gazette, namely, that it attacks the exposed part of 
 the eye where, from the heat of the atmosphere causing dryness, coupled 
 with dust, hypertrophy of the mucous membrane is set up, and keeps 
 on spreading. For treatment, T find transplanting into a wound of 
 mucous membrane, after detaclunent, is not satisfactory, as it leaves an 
 uncomfortable and unsightly lump, which remains for some time. I 
 pi'efer to carefully dissect otl" the growth and remove it, applying to the 
 stump either iodoform or solid argent, nit. ; sometimes they will recur, 
 but the second removal is generally final. I have not heard any 
 complaint that the removal causes any resulting scar, which interferes 
 with the movements of the eye. When the growth is just forming, 
 it can be made to disappear by applying the solid argent, nit. a fev/ 
 times. 
 
 Choroiditis and Choroido-Iritis I have seen to occur, when no 
 cause nor history could be obtained or conjectured for the attack, but 
 the fact that it followed upon working at a dry salt lake, where the 
 heat and glare were intense. 
 
 Cataract is, I think, more frequent than in cooler climates (though 
 I have no statistics to guide me), from the number of cases that have 
 come under my notice, considering our small population. The cause 
 would be the heat and glare from our light sandy soil. 
 
 Bunged Eves are common in summer, especially with children. 
 They are due to the bite of a fly, which does not aj^pear to be of one 
 particular sort, but rather one that causes the local trouble by puncturing 
 the mucous membrane with a proboscis charged with some irritant, 
 probably some decayed animal or vegetable matter. The lips, throat 
 and nose are sometimes " bunged." When available, and before there 
 is much swelling, if eucalyptus oil be rubbed vigorously on the eyelid, 
 the swelling will go down ; when the swelling has taken place, olive oil 
 instilled between eyelids will be comforting. Ophthalmia frequently 
 follows these attacks. 
 
 Aborigines. 
 
 These never suli'er from ophthalmia, so far as I am able to ascertain, 
 and I have had opportunities of examining their eyes in different 
 districts, especially Rottnest penal settlement, where men from all 
 parts of the colony are located ; they never seem to have any impair- 
 ment of sight from disease. AVhen the sight is damaged or lost, it is 
 usually the result of accident. They have bushy eyebrows and long 
 lashes. 
 
 2c -2
 
 756 INTERCOLOXIAL iMEDICAL CONGRESS OF AUSTRALASIA. 
 
 THE TREATMENT OF CHRONIC CATARRH OF THE 
 MIDDLE EAR. 
 
 By James W. Barrett, M.D., M.S., F.R.CS. Eng. 
 
 Assistant Siirgeou to the Victorian Eye and Ear Hospital, and Demonstrator and 
 Examiner in Physiology in the University of Melbourne. 
 
 It is in the first instance necessary that I shall clearly indicate what 
 I mean by Chronic Catan-h of the Middle Ear, or, as many term jt, 
 Chronic Non-suppurative Inflammation of the Middle Ear. In the 
 great majoi'ity of cases, the appearance of the membrana tympani 
 indicates the existence of the disease usually described by these names. 
 It is sunken, thickened, atrophied, the bright spot is altered, or in some 
 way the appearance deviates from that of the healthy membrane. The 
 watch and conversation hearing is deficient, and in advanced cases the 
 tuning fork test gives a more or less minus result. Abovit this class of 
 case, there can be no doubt; but in a fair number of cases the 
 membrane looks normal, yet the watch hearing is greatly deficient, and 
 inflation by Politzer's method improves but slightly. This class of 
 case may be fairly grouped with the former. 
 
 It is however necessary to exclude from the categoiy two classes of 
 cases : — Firstly, those of Eustachian obstruction. These cases, though 
 certainly not very numerous, seem to have passed out of tlie sight of 
 some modern writers, who believe by implication that deafness cannot 
 occur fi'om simple obstruction of the tube uncomjDlicated with disease 
 of the tympanum. Yet the explanation of a proportion of the cases 
 of deafness met with in common cold, would appear to be the obstruction 
 caused by catarrh of the throat and of a portion of the Eustachian 
 tube; in these cases, the membrane appears perfectly normal. 
 
 A similar condition of things (but which is usually complicated with 
 indrawing of the membrane, on account of the chronic nature of the 
 disease) is met with in children who suffer from naso-pharyngeal catarrh. 
 In both sets of cases, inflation by Politzer's method almost completely 
 restores the hearing instantly. For such cases, it seems to me, the 
 term " Eustachian obstruction " is justly applicable. 
 
 In other cases arising from cold, the tympanum is affected, and 
 inflation does not at once relieve. 
 
 I have therefore excluded from consideration in this paper the cases 
 of Eustachian obstruction. Had I included them, my percentage of 
 complete recoveries woidd have been greater. 
 
 Another class of case which I have excluded occurs mostly in old 
 peoi^le. Their watch-hearing is very defective, and the tuning-fork test 
 gives a very negative result, and this often with signs of catarrh of the 
 drum. One is uncertain how far the deafness is due to senile degene- 
 rations taking place in the cochlea, or in the joints between the ossicles, 
 or how far to catarrh of the drum — which is primary, or which is 
 secondary ? I refer to these cases in my note-book as senile catarrh of 
 the middle ear. They are also excluded from consideration, or the pcr- 
 centairc of recoveries would have been diminished.
 
 TREATMENT OF CHRONIC CATARRH OP THE MIDDLE EAR. 757 
 
 To give Jin idea of tlie gravity of chronic catarrh of tlie middle ear in 
 this country, I append the result of the examination of Hfty hopelessly 
 deaf ears. By this, I understand cases in wliich, if under fifty years 
 of age, the watch could only be heard on contact; if over that age, 
 the conversation-liearing was reduced to nil, i.e., persons incapable 
 of following any conversation, and in all of which treatment was 
 useless. 
 
 Of tlie fifty deaf ears — 
 
 25, or 50 per cent., were caused by chronic catarrh of the drum. 
 
 10, or 20 per cent., were caused by a combination of chronic 
 catarrh and impairment of the nervous apparatus, it 
 being uncertain which was primary and which Avas 
 secondary. 
 
 1, or 2 per cent., was caused by disease of the labyrinth. 
 
 2, or 4 per cent., were congenital. Exact cause of deafness 
 
 unknown. 
 
 2, or 4 per cent., were caused by intra-uterine catarrh of the 
 middle ear. 
 
 5, or 10 per cent., were caused by acute catarrh of the middle 
 ear. 
 
 5, or 10 per cent., were caused by chronic suppurative catarrh 
 of the middle ear. 
 
 Probably, then, over lialf the cases of deafness were due to chronic- 
 catarrh of tlie middle ear. 
 
 Let us take, then, a typical case of chronic catan-h of the middle 
 ear, in which there is indrawing of the membrane, possibly redness of 
 the malleus, and some affection of the naso-pharynx. What treatment 
 is usually adopted 1 
 
 Nearly all aurists, in spite of apparent differences, ideally adopt a 
 similar treatment. They attack the morbid condition of the throat by 
 the use of gargles, the nasal douche (in spite of the accidents which 
 have been attributed to it), or, what is more efficacious than either, 
 alkaline and antiseptic sprays, and the use of various local applications, 
 including the galvano-cautery. They treat the ear itself by systematic 
 inflations, either by Politzer's method, by the catheter, or by Valsalva's 
 method, and many inject vapours into the tympanum. Most of them, 
 however, .seem to have given up all vapours, except that of chloride of 
 ammonium. They all seem to agree, that it is a disease which can be 
 rarely cured, but which tends to become steadily worse as the patient 
 grows older; but it would seem that the one circumstance in their 
 treatment, which is essential, is this systematic inflation. 
 
 There seems no doubt that in many cases a certain amount of 
 improvement is produced ; the catarrli is got rid of, the hearing remains 
 stationary for some time, and the patient passes away from treatment. 
 A cold is then caught, a sliglit inflannnation of the drum follows, and 
 away goes the improvement in the hearing and some additional liearing 
 ■as well. No treatmeiit is adopted, and the hearing never returns to its
 
 758 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 old condition. A patient suft'ering fi'om this disease must be informed 
 that, to a greater or lesser extent, he must place himself under the 
 treatment of an aurist for the rest of his life. He should present him- 
 self for examination at least once in every six months whilst the disease 
 is stationary. At such a visit the hearing should be accurately tested, 
 and the result compared witli that of the last examination. In addition, 
 if at any time he catches cold, or notices that his hearing is manifestly 
 worse, he should immediately seek advice. 
 
 The treatment which I have adopted has been as follows : — 
 
 (1) The treatment of the catarrh of the pharynx which is often 
 present. I usually inquire carefully into the habits of the individual, 
 and endeavour to obviate the liability to catarrh from which so many 
 people who follow sedentary occupations sutler. Errors of digestion 
 play a part in its production, and especially in women should the 
 excessive tea-drinking be cliecked. Regular bathing and open air 
 exercise are recommended, and patients are cautioned against two 
 errors into which people are very apt to fall in this country — that of 
 o^•er clothing and of under clothing. This latter piece of advice is 
 especially necessary, on account of the extraordinary variations of 
 temperature in Melbourne. Locally, I use saline douches, sprays, and 
 other applications (including the galvano-cautery) in the treatment of 
 the naso-pharynx. 
 
 (2) With regard to the ear itself, I act on the following principles : — • 
 Redness of the handle of the malleus indicates active change [vide Paper 
 in this volume) in the middle ear, and calls for blistering, protection 
 from cold air, and very careful Politzerisation. 
 
 In nearly all cases in which the aftection is not sub-acute or acute, 
 Politzerisation seems to be indicated, and it is my custom to practise it, 
 when called for, twice or three times a week for five or six weeks. In 
 the intervals between the visits, the patients are instructed to practise 
 the method of Valsalva from two to four times a day, and massage of 
 the ears for one minute a day. Of late, I have been adopting the 
 method of alternate inflation and exhaustion by the Ward-Cousens 
 apparatus in place of the Politzer method, and with rather better 
 results. I do not now use the vapour of chloride of ammonium, because 
 of the difficulty in getting patients to use the apparatus. The whole 
 of the local treatment may be regarded as liaving for its object the 
 preservation of the mobility of the ossicles and membrane, and to 
 obviate the consequences of adhesions and air exhavistion. It seems 
 to be partly analagous to tlie effect of passive motion on a chronic 
 inflammation of a joint. 
 
 It lias never fallen to my lot to see any injurious consequences follow 
 tlie use of the nasal douche, the Politzer or Valsaha methods employed 
 in the manner indicated. 
 
 Subjoined is a synopsis of a taVnilar statement of the cases of forty- 
 eight patients treated, and about wliom I hiive taken careful notes. 
 The tal)le (not given here on account of ])ressure of space) sliows the 
 age of the patients, tlie duration of time which they believed they had 
 surt'ered before consulting me, the distance at which they could hear 
 the watch Ijefore treatment was begun, the duration of treatment, and
 
 TREATMENT OF CIIKONIC CATARRH OF THE MIDDLE EAR. 759 
 
 the distance at ■which they could heai' the watch when treatment was 
 discontinued. The figures indicate a less favourable result than that 
 which should have been obtained, since many of the patients dis- 
 continued treatment before I wished them to. 
 
 Any one who can hear the watch I employ at ten inches can hear 
 conversation fairly well. People aged 25 can liear it at about one 
 hundred inches distant; from one hundred to ten inches I regard as the 
 range of their surplus hearing. They do not usually complain till the 
 hearing is less than ten inches ; then they cannot follow conversation, 
 and they seek advice. The time occupied in this reduction is usually 
 years, and it is this loss of time which makes the treatment of this 
 disease so unsatisfactory. Those who could hear the watch at 
 a distance of more than fifteen or sixteen inches are x'eported as 
 cured. 
 
 Analysis of the table shows that of the ninety-one ears (forty-eight 
 cases) — 
 
 10, or 11 per cent, were cured. 
 27, or 30 per cent, were absolvitely unimproved. 
 54, or 60 per cent, were impi'oved. 
 Taking the first thirty-seven cases, those in which the treatment was 
 usually continued for a fair length of time, of the seventy-two ears 
 treated — 
 
 8, or 11 per cent, were cured. 
 23, or 32 per cent, were absolutely unimproved. 
 41, or 57 per cent, were improved. 
 Taking the first twenty-thi^ee cases, that is all those under 25 years 
 of age, we find that of the forty-six ears treated — 
 6, or 13 per cent, were cured. 
 
 13, or 29 per cent, were absolutely unimproved; whilst 
 27, or 58 per cent, were improved. 
 
 Taking the 24th to the 37th cases, that is the cases between 25 and 
 57 years of age, we find that of the twenty-six ears treated — 
 2, or 8 per cent, were cured. 
 10, or 35 per cent, were absolutely unimproved ; whilst 
 
 14, or 53 per cent, were improved. 
 
 From these tables, it seems that the number of cases of recover}- is 
 somewhat gi*eater, and the number of unimproved cases is somewhat 
 smaller, in those under 25 years of age, than in those over 25 years of 
 age. Wliere the membrane is much sunken, where the patient is young, 
 or where there is redness of the handle of the malleus, considerable 
 improvement may usually be expected as a result of treatment. Where 
 the membrane is not sunken, but is pale or opaque, where the disease is 
 long-standing, and the patient advanced in years, improv^ement is usually 
 slight; the disease is stationary, and we have to deal, not with an active 
 disease, but with the consequences of former disease. Yet in a fair 
 number of cases, it seems impossible to even conjecture whether improve- 
 uient can be effected oi' not. Until some better method is devised for 
 obtaining information as to tlie condition of the interior of the 
 tympanum, the business of the aurist will continue to be as relatively 
 inexact as it is at present.
 
 760 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Table (Roosa) showing the Results of Treatment of Chronic Nonsuppurative 
 Inflammation of the Middle Ear : — 
 
 Reporter. 
 
 No. OF Cases. 
 
 Cured. 
 
 Improved. 
 
 Unimproved. 
 
 Un- 
 known 
 
 Spencer * 
 (St. Louis) 
 
 56 
 
 6=16| percent, 
 of those actu- 
 ally treated 
 
 18=50 per cent. 
 
 10=27 percent. 
 
 20 
 
 Schwartz t • . 
 (Halle) 
 
 230 
 
 30=20 per cent. 
 
 94=60 per cent. 
 
 30=20 per cent. 
 
 75 
 
 Gruber \ 
 
 (Vienna) 
 
 187 
 
 38=32 per cent. 
 
 61=60 percent. 
 
 9 = 9 per cent. 
 
 84 
 
 Eoosa § 
 (New York) 
 
 514 
 
 23=4^ per cent. 
 
 160=31 per < 171=34 per 
 cent. cent. 
 
 159 
 
 Barrett 
 (Melbourne) 
 
 95 
 
 cases in all 
 
 48 
 
 actually 
 
 treated 
 
 10= 11 per cent, 
 of the 91 ears 
 (48 cases) 
 treated 
 
 54=62 percent, 
 of the 91 ears 
 (48 cases) 
 treated 
 
 27 = 30 percent, 
 of the 91 ears 
 (48 cases) 
 treated 
 
 47 
 cases 
 
 * Reprint from St. Louis Medical Journal. 
 
 t Archiv. ftir Ohrenheilkuude, bd. 1, v. passim. 
 
 X Monatsclirift fur Olireuheilkiuide, bd. 1, iv. passim. 
 
 § "On Diseases of the Ear," Lewis, London, 1S79. 
 
 Dr. Iredell (Melbourne) said that tests for hearing were unsatis- 
 factory, and the watch test was no exception to the rule ; still, it 
 aiforded some indication of the hearing power. In cases of chronic 
 catarrh, where no active change was going on, he had found cases 
 usually became worse under any circumstances, perhaps more rapidly 
 when treated. He objected to the Valsalva method. It was more 
 powerful than the Politzer method, and liable to produce flaccidity of 
 the membrane. He had never seen any harm result from the use of 
 the nasal douche. He agreed with Dr. Barrett, tliat where redness 
 of the malleus existed — an active condition — some improvement can 
 usiially be effected. This redness can rapidly be removed by instilling 
 vapour of chloroform into the drum. He thought that, in old cases, 
 the nervous apparatus is affected secondarily. 
 
 Dr. T. K. Hamilton (South Australia) said that, in many old 
 sclerosed cases, passive motion was useful. He used hypodermic 
 injections of pilocarpine in cases of labyrinthine disease, and also in 
 chronic catarrh ; it tended to produce absorption. He did not use 
 the nasal douche, but preferred sprays in the treatment of the naso- 
 pharynx. He believed that the treatment by multiple incision of 
 the membrane was hopeful in some cases. It was possible also, that 
 something might be done in the future by tlie local application of 
 electricity to the pharynx and to the Eustachian orifices. He objected 
 to the use of the Valsalva method, because of the congestion produced 
 by the expiratory effort. 
 
 Dr. Brady (Sydney) had found great benefit in the treatment of 
 the pharynx, by removing the liypertropliied tissue with the cutting 
 forceps.
 
 OPTIC NEURITIS FOLLOWING EXPOSURE TO HEAT. 761 
 
 NOTES ON A CASE OF OPTIC NEURITIS, FOLLOWING 
 EXPOSURE TO HEAT. 
 
 By H, LiNDO Ferguson, F.R.C.S.L 
 
 Lecturer en Ophthalmology in the Otago University. 
 
 Leber, in liis article in "Graefe and Saeniiscli's Handbuch," mentions 
 ill half a dozen Avords that optic neuritis may follow sunstroke ; and 
 Professor Williams, of Harvard University, in his book on " Diseases 
 of the Eye," says: — "Insolation of the head may cause pailial amaurosis, 
 the prognosis depending on the degree in which the central nervous 
 organs are affected, and the recovery being slow." Dr. Wood, in 
 " Pepper's System of Medicine," refers to a case of chronic meningitis 
 following sunstroke, with diplopia and some blurring of the optic discs, 
 but gives no complete details as to vision or field. AVith these three 
 exceptions, T have failed to find any reference to the condition in such 
 works on Ophthalmology as I have at my command ; and, as the 
 condition is not referred to in the indexes to the sixteen volumes of 
 "Knapp's Archives," which give a very complete periscope of ophthalmic 
 literature from 1869 up to the present time, I may conclude that optic 
 neuritis, as a result of exposure to heat, very rarely comes under the 
 notice of ophthalmic sui'geons. 
 
 The only published case I have come across is quoted in the British 
 Medical Journal, July 7, 1888, from the JSpao York Medical Record. Dr. 
 Tuttle of Jefterson was the sufferer, and reports that in June 1863 he 
 had sunstroke, and was quite blind till the third day. Vision slowly 
 improved, but the fields of vision were so much contracted, that he felt 
 as if he were looking through two gimlet holes. Vision, twenty -five years 
 later, is still very imperfect, and the fields are much contracted, witli 
 complete night blindness. The case is unfortunately very incomplete, 
 as there is no reference to the ophthalmoscopic appearances ; and though 
 the present condition of the vision is consistent with the assumption 
 that there is atrophy of the optic nerves, the absence of examination of 
 the fundus in the early part of the case leaves us in doubt as to whether 
 the visual troubles w-ere the effect of injury to the visual centres, or of 
 optic neuritis, secondary to the cerebral lesion. 
 
 I have seen two cases of optic nerve lesion — one of old standing, in 
 which the patient attributed his condition to sunstroke, but in which 
 the history was very imperfect; and one recent case, the notes of which 
 I propose to place before you. 
 
 In the first case, a seaman of over middle age applied to me at the 
 out-patient room of the Richmond Hospital, Dublin, during the summer 
 of 1880. He stated that two and a half years previously he was 
 employed in a trading schooner in the South Seas, and exposed to very 
 intense heat. He suffered from very severe headache, and lay on deck 
 at night for coolness. On the third day his sight failed, which he 
 attributed to lying on deck in the moonlight, though he blamed the 
 insolation for causing him to do so. At the end of his trip he 
 w'as admitted blind into the Dunedin Hospital, where he was treated 
 for many weeks, during which he still suffered excruciating pains in 
 the head. He had been discliarged, free from pain, but with bare
 
 762 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 perception of light, and had somehow found his way home to Dublin. 
 He had intense post-neuritic atrophy of both optic nerves, and l^are 
 perception of light in the left eye. Treatment was unavailing. Only 
 having seen ophthalmic work in tempei-ate climates, I inquired as 
 to other likely causes without eliciting any, and finally passed the case 
 over as puzzling, iDut hopeless. Unfortunately, I have no record of his 
 name, so that I have been unable to trace him in the hospital records 
 here. The history of the case makes the suggestion, that the neuritis 
 was due to insolation, at all events possible ; but though he denied 
 ever having had syphilis, the possibility of a specific cause in a 
 seafaring man is too considerable for the case to be accepted as a wholly 
 satisfactory one. 
 
 The second case is a recent one, and all other causes were carefully 
 excluded, or have been excluded by the subsequent history : — 
 
 Miss K. ]M., aged 5, living in Canterbury, was brought to the study 
 on March 11th, 1884, with the following history : — Slie was in perfectly 
 good healtli till the third day of a hot wind, thirteen days before her 
 visit. The nursery was very hot, and she was constantly running 
 in and out through the verandah into the garden in the heat. On this 
 day she complained of a pain behind the right ear, which lasted three 
 days. On the fourth day her sight was noticed to be defective, and 
 gradually failed for four days, since when it had been stationary. She 
 had had no treatment except a vermifuge. She was the eldest of four 
 healthy children, and the family history was good. When seen, V 
 Oc. Dex.= fingers at 0"5 millimetres; Oc. Sin. = mot. hand. With the 
 ophthalmoscope the right disc was seen to be blurred, the retinal veins 
 large and the arteries small and indistinct. The left disc was swollen 
 on its nasal side. 
 
 A diagnosis was made of descending optic neuritis, secondaiy to 
 meningitis, due to exposure to heat. A fairly favourable prognosis was 
 given, and she was put on the iodide and bromide of potassium, and 
 also given two grain doses of pulv. hyd. c. cret. thrice daily. She was 
 freely heurtelouped on both temples, and kept in the dark for the 
 subsequent twenty-four hours. 
 
 On March 13. — V = mot. hand Oc. Utr., and the discs were more 
 swollen. Slie was ordered inunctions of ung. hyd. gr. xv thrice daily, 
 a,nd given pil. col. co. and pil. rhei. co. aa. gr. v. 
 
 On March 14. — V = F 0*5 millimetres Oc. Dex., mot. hand Oc. Sin., 
 and she had numbness and loss of power in the right hand. The 
 inunctions were pushed. 
 
 The following day slie had more power over tlie right hand, but had 
 had spasmodic twitchings of her throat during sleep. 
 
 On March 16. — V Oc. Dex. - F 1"5 millimeti'es, Oc. Sin. mot. hand. 
 Had had severe twitchings and jumping of legs during sleep. She was 
 ordered a draught of bromide of potassium and chloral if twitchings 
 should occur during the night. 
 
 During the three following days the swelling of the discs increased, 
 in spite of the renewed use of the artificial leech. She was very 
 restless and delirious at niglit, but would sleep heavily from 3 a.m. till 
 1 p.m., or later. In the restless stages, she rolled her head continually 
 from side to side.
 
 OPTIC NEUHITIS FOLLOWIN'G EXPOSURE TO HEAT. 76S 
 
 On March 21 she was looking well, and the symptoms of nei'vo 
 irritation were less. Her gums were not touched, though she was 
 having 3 j of ung. hyd. rubbed in daily. 
 
 On March 23. — V Oc. Dex. had risen to F 3-5 millimetres; but on 
 the 25th, she was complaining of pain in the right mastoid, and had 
 slept from 3 a.m. till 5 p.m. The vision had gone down to F 2-5 milli- 
 metres Oc. Dex. Oc. Sin. V = P light. 
 
 March 26. — There was more mastoid pain, and V had fallen to F 
 1 millimetre Oc. Dex. The left disc was much paler and shai'per in 
 outline than before; temp, normal. Ordered half a minim ol. crotonis 
 in 3 ij ol. ricini, and gr. xx of bromide of potassium every four hours. 
 
 The following day she had been much purged by the croton oil, and 
 had slept very little, but the ^■ision was a shade better. Dr. Batchelor 
 saw the child later in the day with me, with reference to the nature of 
 the cerebral lesion. He concurred in the existence of meningitis of the 
 base, and in the treatment, which was continued. 
 
 After two quiet nights, V on the 29th was F 1-5 millimetres Oc. 
 Dex., which was impi'oved to F 2 millimeti'es by the use of a continuous 
 current for three minutes. The discs looked white, and the arteries 
 very small. The inunctions were stopped. 
 
 By April 2, Y had risen to F 3 millimetres Oc. Dex., F. 1-25 milli- 
 metres Oc. Sin. ; but on the 4th, there was fresh occipital headache, and 
 V fell to F 1 millimetre Oc. Utr. 
 
 She had no severe headache later than the night of the 5th, and 
 from the 7th the vision began to improve steadily. The constant 
 current was used at each visit to the study, and always produced some 
 improvement, which was generally retained. 
 
 On the 11th, she was ordered Kirby's phosphorus, quinine and nux 
 vomica pills, her vision then being F 2 millimetres Oc. Dex., F 1-5 
 millimetres Oc. Sin. Both discs very white. 
 
 On the 20th, V was ^ Oc. Dex. and F 2 millimeti'es Oc. Sin.; and on 
 May 7th, V was -^^, and letters J 1 better, and F 5-5 millimetres Oc. Sin. 
 She was then allowed to return home, with directions to continue the 
 pho.sphorus pills. 
 
 She made steady pi'ogress, and on October 31 Y was y\ Oc. Dex., 
 and y\ letters Oc. Sin. and Prox. J 1 Oc. Utr. easily. The discs were 
 white and sharply defined, but the arteries were larger than before. 
 All treatment was then stopped, but she was ordered to return to the 
 pills from time to time whenever she did not seem thox'oughly strong 
 and well. 
 
 In December 1887, Y was f letters Oc. Dex., § letters Oc. Sin., and 
 the nerves remained about the same as when last seen. 
 
 On October 12, 1888, Y was f letters Oc. Dex., f Oc. Sin., and 
 Prox. J 1 Oc. Utr. The fields of vision were normal, and the only 
 anomaly of function I could detect was, that she seemed slow to recog- 
 nise retinal impressions. Both discs were very sharp and white, and 
 the arteries small. Her general health is perfect, aiid both her physical 
 and mental development are above the average for her age. 
 
 The fact of the child's physical and mental health being good four 
 and a half years after the attack, and the absence of any cerebral 
 symptoms in the mean time, except an occasional headache on a hot- 
 wind day, practically put the existence of a cerebral tumour out of the
 
 764 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 question ; and of the family history being good, except that the mother 
 is neurotic, there is absolutely no doubt. The only explanation of the 
 neuritis that occurs to me is the diagnosis I made in March 1884, and 
 that insolation is not recognised as a cause by the majority of authors 
 does not preclude the possibility of its producing this effect. 
 
 Most authors who wi'ite on ophthalmic subjects live and practise in 
 tempei'ate climates ; but insolation is fairly common in many of the 
 lai'ge American centres, and occurs sufficiently often in London and 
 the large continental cities to make it likely that, if optic neuritis were 
 a frequent complication, the fact would have been recorded. Since 
 treating this case, I have kept a special watch on the reports of the 
 Madras Branch of the British Medical Association, to see if Brigade- 
 Surgeon Sibthorpe, or any of his colleagues, have noticed similar instances, 
 but without success. Possibly, the natives are not very susceptible to 
 heat, and the Europeans take sufficient precautions against it. 
 
 It appears to me that the most likely soil for the observation of the 
 conditions likely to cause ocular troubles in connection with insolation 
 is Australia, wliere iiitense heat is far more common and universal than 
 either here or at home, and where the tendency in the rising generation 
 to develop tlie neurotic strain, common alike to America and the 
 colonies, has had a longer time to show itself than in New Zealand. 
 
 It is in the hope tliat these notes may call forth similar observations, 
 if any exist, that I have ventured to bring them forward. 
 
 A CASE OF CEREBELLAR ABSCESS, UNSUCCESSFULLY 
 TREATED BY TREPHINING. 
 
 By H. LiNDO Ferguson, F.R. C.S.I. 
 
 Ophthahuic and Aural Surgeon to the Dunedin HosiDital. Lecturer on 
 Oplithahnology in the University of Otago. 
 
 E. C, aged 17, presented himself on July 21, 1888, with the following 
 history :— He had suffered from otorrhcea from the right ear, of nine 
 years' standing, following scarlatina. The dischai'ge ceased at intervals, 
 to give way to naastoid pain and tenderness. He had been in the 
 Dunedin Hospital three years previously under my care for mastoiditis, 
 but recovei'ed after a large Wilde's incision had been made. He had 
 not since liad any severe attack until the one for wliich he sought 
 advice. Tlie discharge Jiad ceased four days previously, and he had 
 since suifered from severe headache and mastoid pain. 
 
 The memljrana tympani was gone, and the mucous membrane of the 
 middle ear was much swollen and glazed, but showed hardly any 
 discharge. It was excessively tender, and he could hardly bear it to be 
 touched with cotton wool. There was great pain and tenderness in the 
 mastoid region, which showed the scar of the old incision. Syringing 
 the ear caused considerable giddiness, so he was given no lotion, but
 
 CEREBELLAR ABSCESS UNSUCCESSFULLY TREATED BY TREPIIIXING. 765 
 
 was ordered constant poultices over the ear and mastoid, and told to i^o 
 into the hospital at once. At this time the boy was looking very ill, 
 and he had been shivering. His tongue was thickly furred, and the 
 ])0wels wei'e contincd, but his temperature was normal, and his pulse 
 about 80. 
 
 For some reason, he did not go into the hospital till the 23rd, two 
 days later, when his condition was much about the same. He was 
 given a purgative, and put on the iodide and bromide of potassium, and 
 the poultices were continued, a slight discharge from the ear having 
 been established. The mastoid tenderness was less, and there was no 
 putfiness about the ear. 
 
 On the morning of the 25th, his temperature ran up to 103°, without 
 marked rigor, falling in the evening to 100°, but he expressed himself 
 as feeling better and in less pain. The following day his temperature 
 rose to 101°, falling to 100° after he had been given gr. iv. of calomel 
 witli gr. V. of sod. bicarb., and it never rose abo^■e this point till the end 
 of the case. The constipation continued, and on the 28th, he was given 
 a saline purgative, which seemed to make his head more comfortable. 
 He did not complain much of pain, but moved his head slowly as if 
 motion hurt him. His genei'al condition otherwise seemed better. 
 There was no loss of power on the left side, and he answered intelligently 
 when spoken to. 
 
 On the 29th, he had occasional attacks of drowsiness, and at 3 a.m. 
 on the morning of the 30th, he woke with severe mastoid pain, for 
 which Dr. Fleming, the House Surgeon, was called and gave gr. v. of 
 calomel by the mouth. The pain shoi'tly afterwards ceased, but he 
 became comatose, and was only capable of being partially roused at 9 a.m. 
 This slight improvement at 9 o'clock coincided with the establishment 
 of a free foetid discharge from the ear, and his temperature was then 
 only 99°. At 11.30, the free fojtid discharge from the ear continued, 
 and he was lying in a state of semi-coma. Both pupils were contracted, 
 and both optic discs were intensely red and congested. He groaned 
 slightly on the head being moved ; but from his condition, no loss of 
 power on the left side could be detected, to give any clue to the seat of 
 the abscess. His respiration was 18, and stertorous. Pulse 76, and 
 good. 
 
 At a consultation of the Staft' two hours later, it was thought that 
 there was less resistance to passive movement on the left side than on 
 the right ; but his condition of coma was deeper, and he no longer 
 groaned when the head was moved. The discharge from the ear had 
 lessened considerably. In the absence of any paralytic symptoms, the 
 motor ai-ea could be excluded as the seat of the lesion ; and it was 
 decided that the best chance of reaching the abscess lay in opening 
 the temporo-sphenoidal lobe. 
 
 While he was being chloroformed, a gush of nearly half an ounce of 
 fearfully foetid pus came from the ear, and the meatus was immediately 
 plugged, lest by the escape of the matter the abscess cavity should be 
 missed, and the chance of establisliing satisfactory drainage lost. A 
 spot three-quarters of an inch above, and one and a half inches behind 
 the axis of the meatus, which had been the most tender spot on 
 percussion, was selected as the centre of the opening. A curved 
 horizontal incision, with its convexity downwards, was made below this
 
 766 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 spot down to the bone, and a vertical incision meeting the first one at 
 its centre. Tlie periosteum was raised with the flaps, showing the bone 
 below healthy, and an inch disc of bone was removed at the chosen spot. 
 Some little difficulty was experienced from the lower edge of the 
 trephine cutting tlu'ough the thick bone at the head of the mastoid, so 
 that the incision down to the dura mater being complete elsewhere, the 
 disc was still held in place. When it was elevated, the dura mater was 
 seen to be light green in colour, and thickly infllti'ated with matter ; 
 but wlien it was divided, the brain substance below seemed perfectly 
 healthy. As a few drops of matter welled up from the anterior lower 
 part of the opening, between the dui'a mater and the bone, a three- 
 quarter inch disc was removed farther forward, the pin of the trephine 
 being placed about an eightli of an inch in front of the edge of the first 
 opening. 
 
 When this was removed, the dura mater underneath was found to be 
 healthy, and the pui'ulent meningitis was found at the post-mortem to 
 be confined to the area exposed by the fii^st opening. A needle was 
 then passed into the brain in six or seven directions up to a depth of 
 three inches witliout finding matter. A probe passed downwards slid in 
 along the surface of the tentorium, and it was not considered wise to pass 
 a needle down for fear of entering the lateral sinus. Further attempts 
 were abandoned. A drainage tube was left to the dura mater, and the 
 wound was closed. After tlie operation, his pulse was 76 and his 
 respiration 17 and irregular, but not so stertorous as early in the day. 
 At 5 p.m. his pulse was 100 and his respirations were 22, shallower, 
 but more regular. His temperature had fallen to 98°, and he answered 
 rationally when spoken to, and recognised his mother. 
 
 The following day his condition was about the same, but on August 1 
 he roused up and asked for beef-tea. This improvement coincided 
 with fresh discharge from the ear. On the 2nd, he relapsed into a 
 condition of deep coma, and died during the night. 
 
 At the post-mortein examination made next day, a patch of purulent 
 meningitis Avas found, almost exactly corresponding in extent with the 
 first disc of bone removed. The wound had healed by first intention, 
 except where the drainage tube projected at the lower angle. An abscess, 
 the size of a small egg, occupied the front of the right lobe of the 
 cerebellum, and connnunicated with the ear by the passage seen in the 
 specimen. It is difficult, looking at the specimen, to understand how 
 the boy escaped pyaemia, as the channel through the bone opens directly 
 into the groove for the lateral sinus, and the passage by which the matter 
 escaped lifted the walls of the sinus and passed below it. Had any 
 attempt been made to pass a needle thi^ough the tentorium into the 
 cerebellum, it would have pierced the sinus, and resulted in emptying 
 the abscess into the vessel. There is no need for me to do more than 
 refer to the specimen, which speaks for itself ; but I regret tliat, as I 
 was not present when it was removed, only a small portion of the 
 trephine opening was preserved. 
 
 The temperature chart is of interest in connection with Dr. Bristowe's 
 observatioii that, tliough the temperature is usually normal in cerebral 
 abscess, there is generally fever when the lateral sinus is involved. 
 Though this remark lias been made with reference to cerebral abscess, 
 I am not aware of any series of observations as to tlie temperature in
 
 A CASE OF CEREBELLAR ABSCESS 
 
 UNSUCCESSFULLY TREATED BY TREPH?NiNG 
 
 Bjr KLindo lergusoa, ERCSJ. 
 
 DATE 
 
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 COXfiKNITAL CYST OP THE LOWER EYELID. 767 
 
 cerebellar abscess ; and from the close relations of the cerebellum and 
 lateral sinus, it must always be a matter of difficulty to say whether 
 the high temperature is due to cerebellar lesion, or to implication of the 
 sinus. 
 
 The case only throws a negative light on cerebral surgery, by show- 
 ing once more that there are no localising symptoms in cerebellar 
 abscess ; and coi'roborating the observations of others, that the seat of 
 most intense pain is not a reliable guide to the situation of the lesion. 
 One very interesting observation was made on section of the brain — 
 that the needle punctures had caused no irritation and left no trace, 
 wliich encourages exploi'ation in doubtful cases. The literature on the 
 subject of cei'ebral surgery is as yet so limited, that even an unsuccess- 
 ful case is of interest, and I have tlierefore felt emboldened to bring 
 this one before the Congress. 
 
 A CASE OF CONGENITAL CYST OF THE LOWER 
 EYELID, WITH MICROPHTHALMOS. 
 
 By W. Odillo Maiier, M.D., Ch. M. 
 
 In June 1887, an infant was brought to me by its mother, who 
 was anxious to ascertain whether the child's left eye had been "burst 
 at l)irth." My attention was at once drawn to a smooth tense tumour 
 in the left lower lid, about the size of a cherry. The skin over it was 
 of a bluish tinge, and fairly movable. The eyelids were well developed, 
 but the upper one sank inwards as though tlie eyeball was absent. The 
 left half of the frontal bone was ill-developed. On separating the 
 eyelids, a cavity lined with conjunctiva came into view, but nothing 
 resembling an eyeball could be seen. As the child had an imperforate 
 anus, and evidently could not live long, I refrained from administering 
 an anajsthetic to facilitate the examination. 
 
 A few days later, Dr. Crago (to whom 1 am indebted for the 
 opportunity of examining this case) sent me word the child was dead, 
 and I was then able to make a thorough examination. On separating 
 the eyelids, the cyst in the lower lid was seen to extend along the floor 
 of the orbit. At the bottom of the cavity, which was lined with 
 conjunctiva, was seen the small cornea (about a millimetre in diameter) 
 of a rudimentary eye. The rudimentary eye, which I incised, was about 
 the size of a large pea. The cyst contained about a drachm of thin 
 yellowish-green fluid. There was a coloboma of the iris of the other 
 «ye.
 
 768 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 A CASE OF GLAUCOMA, IN WHICH IRIDECTOMY 
 APPEARED TO BE HURTFUL. 
 
 By James T. Rudall, F.R.C.S. 
 
 If the object of this communication were to discuss, ever so briefly, 
 the real value of iridectomy in glaucoma, while I should by no means 
 claim for the operation a universal success, it would be possible to refer 
 to cases in my own practice where it has produced beneficial resvilts, 
 sometimes, indeed, to a degree unlooked for, if not almost incredible. 
 And probably, thus far, my experience is not widely different from that 
 of many other practitioners in this department of surgery. For, 
 although Von Graef e's brilliant discovery was first met, in some quarters, 
 by strenvious opposition, time has shown that iridectomy in glaucoma 
 is one of the great advances in modern ophthalmic practice. But, this 
 being admitted, it by no means follows that we need no further study 
 of glaucoma and its management; and since it is possible sometimes to 
 learn from failure as well as from success, I now desire briefly to 
 record the following case, which caused me unusual regret and 
 disapj)ointment : — 
 
 A single woman, forty years of age, was sent by a medical friend for 
 my advice on March 16, 1888. According to her statement, about two 
 years ago she lost the sight of the left eye, which was now found to be 
 without perception of light; to have the pupil so much dilated that the 
 ii'is was a mere atrophied ring; to have staphylomatous bulgings of the 
 sclera at the outer margin of the ciliary zone in the lower and outer 
 quadi'ant, and likewise to be affected with secondary cataract. This eye 
 also had T + 2. She said further, that three days ago the sight of the 
 right eye became misty, she had pain in the eye and orl^ital circum- 
 ference, and she saw rainbow colours around the candle flame. On 
 examination there was little, if any, conjunctival or scleral injection; 
 the pupil was not dilated, but the iris was thrust forwards, and there 
 was increased tension — T+ 1. Vision was nearly fg, and some letters 
 of 2 Snellen could be made out at 12 inches. The fundus could not be 
 illuminated by the ophthalmoscope. Eserine drops (gr. iij to ^j) were 
 ordered to be instilled four times in the twenty -four hours. 
 
 March 18. — Vision was reduced to y%% T + 2. The anterior chamber 
 Avas almost obliterated, the iris lying nearly in contact with the cornea. 
 I now considei'ed that, having regard to tlie previous loss of sight in 
 the left eye, and the rapidly failing vision in the one (right) newly 
 attacked, iridectomy on the latter was urgently demanded. 
 
 The patient being in poor circumstances, I took her into the 
 hospital, and performed an upward iridectomy on March 20. As it 
 would not have been possible to use the ordinary lance knife 
 witliout great risk of wounding both iris and lens, I employed in the 
 operation a very narrow knife (De Wecker's), and with it I was able 
 to make a satisfactory, though slow, upward section of the coi^nea. In 
 other respects also, the completion of the operation answered my 
 expectations ; there was, however, some bleeding from the cut iris. She 
 was for a time relieved from pain, but when we opened the eye two 
 days afterwards, vision was found to lie quite abolished. Soon, the
 
 EXCISIOX OF A SU^PU1^ATINCJ KYEBALL. 769 
 
 tension, whicli liad been temporarily reduced by the iridectomy, became 
 as high as before, and pain also returned. Subsequently the scar 
 became cystoid, and although sight was irrecoverably lost, I performed 
 a second iridectomy (downwards), in the hope of relieving pain and 
 tension. This proceeding liad \-ery little immediate eftect, and she had 
 to remain under supervision for a considerable period. I confess myself 
 unable to explain satisfactorily why in this instance the operation of 
 iridectomy pro\ed futile, if note\en injurious; for it seemed improbable 
 that the disease, left to itself, would cause absolute loss of perception of 
 light in so shoi't a time as four or five days. 
 
 DEATH FROM SEPTIC MENINGITIS, FOLLOWING 
 EXCISION OF A SUPPURATING EYEBALL. 
 
 By James T. Rudall, F.R.C.S. 
 
 In more than twenty years of my practice, one case only had been 
 fatal after excision of the eyeball ; and as was proved both by the 
 symptoms and by a post-mortem examination, death in that instance 
 had nothing to do with the eye affection, or the enucleation of the 
 globe which was performed for it. The orbit and the cranial contents 
 were found to be sound and healthy. The cause of death was extensive 
 suppuration and sloughing of the connective tissue outside the lower 
 part of the bowels, produced by the injection of a turpentine enema. 
 
 The case was published at the time in the Australimi Medical Journal, 
 and the only supplementary statement I have here to make is that, 
 whereas when it was reported I was inclined to hold the nurse blame- 
 less, information subsequently obtained has led me to attribute the 
 death to gross cai^elessness in the administration of the enema. 
 
 On August 21, 1886, a medical gentleman of my acquaintance 
 
 requested me to meet him in consultation on Mr. , living about 
 
 twenty-five miles from Melbourne. The patient was a fairly healthy 
 man between 30 and 40 years of age, the sight of whose left eye had 
 been destroyed many years before by an injury. A few weeks before 
 my visit, the eye had become much inflamed, and the ordinary remedies 
 were found quite inefficient. When we met, the patient was suffering 
 agonising pain, the lids were much swollen, the eyeball protruded, and 
 there was very severe pan-ophthalmitis. It seemed clear that we must 
 either enucleate, or make a fi'ee incision through the front of the eye. 
 In the hope of at once ridding the patient of all diseased structures, 
 we chose enucleation, and the patient having been chloroformed by my 
 colleague in the case, I then and there performed that operation. 
 
 In respect to this, it is only needful to mention that a spring 
 speculum could not be used, in consequence of swelling of the lids 
 and protrusion of the globe ; and that the bleeding was, as would be 
 expected, veiy free. The patient was much relieved by the operation, 
 passed a good night, and continued to do well the next day.
 
 770 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA 
 
 On the second night, he did not get much sleep, but his medical 
 attendant, on visiting him, saw no cause for apprehension. 
 
 On the fourth day, I was again telegraphed for. Before entering his 
 bedroom we heard liim calling out loudly, and declaring that he was 
 dying ; after a little remonstrance and assurance from us, he became 
 calm and rational. He complained of pain in the top of his head, and 
 said he felt sure that he would not recover. The tongue was clean, the 
 pulse 80, respirations 18 to the minute, the temperature 101-2°. The 
 orbit was healthy, so far as inspection and examination with the finger 
 could show. On enquiry, we were informed that he had some shivering 
 last night. Although strong atropine drops had been put into the 
 right eye previous to my visit, examination with the ophthalmoscope 
 was not easy, owing to the restless state of the patient. I obtained a 
 view of the fundus in the erect image, and found the disc rosy but well 
 defined, and showing the black margin of the choroid at its outer edge. 
 As I was subsequently informed, the symptoms of meningitis became 
 unmistakable, and he died comatose three days after. No post-mortem 
 examination could be obtained. 
 
 The next case of pan-ophthalmitis, for which I had to operate, occurred 
 in an adult inmate of the Victorian Asylum and School for the Blind. 
 It was severe, though not so bad as the foregoing. I performed 
 evisceration, and the patient did well, but convalescence was much 
 slower than is usual after enucleation. 
 
 Another patient with pan-ophthalmitis was a youth of seventeen 
 years of age. His case was less acute, and I enucleated with a good 
 result. With present knowledge and experience, I am inclined, in 
 a long standing or very severe case of pan-ophthalmitis, to prefer 
 evisceration, rather than to enucleate the eyeball. 
 
 Dr. Symgns (South Australia) had hitherto never hesitated to excise 
 a suppurating eyeball. In the future, however, he felt that the 
 propriety of excision in such cases must be considered. 
 
 Dr. Barrett (Melbourne) related two fatal cases of excision of 
 suppurating globes ; both occurred at Moorfields. In a case in his own 
 practice of perforating wound of the cornea and lens, followed by 
 operation for the removal of the lens, the temperature suddenly rose to 
 102°; there was severe headache; the symptoms increasing for forty- 
 eight hours, the eye was excised. It was not purulent, simply intensely 
 inflamed. The excision did not relieve symptoms, the temperature 
 continued to rise, the headache increased, and the lids and tissues of the 
 orbit swelled enormously, and for seventy-two hours after excision the 
 condition of the patient was critical. Ultimately, he made a good 
 recovery. 
 
 Dr. T. K. Hamilton (South Australia) said that, of the two 
 operations before the profession for the treatment of suppurating eyes 
 — enucleation and evisceration — he preferred tlie latter.
 
 OCULAR MANIFESTATIONS OF LATE HEREDITARY SYPHILIS. 771 
 
 THE OCULAR MANIFESTATIONS OF LATE HEREDITARY 
 
 SYPHILIS. 
 
 By G. Adlington Syme, M.S., M.B. Melb., F.R.C.S. Eng. 
 Surgeon to Out-patieuts, Melbourne Hospital. 
 
 Notwithstanding the many exhaustive researches on tliis subject, 
 one or two questions in connection with it are still unsettled, and it may 
 be of some interest to put on record the following observations: — 
 
 I find I have notes of 120 cases of various eye affections, mostly 
 keratitis, presumably due to hereditary syphilis; but as some of these are 
 ji little doubtful, I have pruned them down, so to speak, leaving about 
 100, the specitic origin of which, I think, is unquestionably revealed by 
 other conditions, such as the state of the teeth, the nose and the ears, 
 the history of the period of infancy, or, of most reliance, the history of 
 the rest of the family, and the signs or history of syphilis in the parents. 
 The fact that, in considering the eye affections of hereditary syphilis, 
 one has had to reject about twenty cases of affections, which most 
 "wi'iters consider in themselves absolute evidence of specific taint, must 
 not be taken to imply a doubt as to the correctness of such a view. 
 Notwithstanding the opinion of many French authorities (well 
 expressed by Fournier), that interstitial keratitis is a trophic lesion 
 which may be due to various causes, syphilis being the cause generally, 
 but not exclusively, and notwithstanding the appai'ent reasonableness 
 of this view, I think myself that Hutchinson's opinion, that interstitial 
 keratitis is always due to syphilis, is more correct; it is also more generally 
 accepted. Keratitis need not always be due to an inherited taint, however, 
 and some of the cases referred to have been rejected, because there was a 
 pi'obability that they wei'e due to acquired syphilis. Assuming then, 
 that all these 100 odd cases are due to hereditary syphilis, what tissues 
 of the eye appear to be most affected by this disease 1 
 
 Here we at once enter debateable ground. Most authorities say the 
 cornea is the structure by far the most frequently affected, and that 
 interstitial keratitis in par excelleiice the eye lesion of hereditary syphilis. 
 Trousseau maintains that choroiditis is the most frequent condition; 
 but that keratitis always comes under observation, while choroiditis 
 does not. Unfortunately, my cases do not directly help the solution of 
 this question, because, being collected from the oculist's standpoint, 
 almost all the cases came under observation with keratitis; but still 
 they reveal this fact, that choroiditis is generally to be found in an eye 
 affected by hereditary syphilis. 
 
 Out of the whole 120 cases, in onlyS-l was it possible to carefully examine 
 the fundus, either by examining one eye before the keratitis was present, 
 or by examining after the keratitis had recovered. This examination is 
 always difficult. The cornea is seldom perfectly clear ; oftentimes the 
 pupil is bound down ; and as the choroiditis is almost always situated 
 at the extreme perii)hery, it is easily overlooked. Notwithstanding 
 these difficulties, evidences of choroiditis were found in 47 out of these 
 54 cases. 
 
 Out of 102 cases in which the fact was noted, iritis was either present, 
 or had left its traces, in 44. Keratitis, iritis, and choroiditis were all
 
 772 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 three found in only 17. It must be remeuiberecl, however, that most of 
 the cases where choroiditis was found were examined after the keratitis 
 had passed off, and where the iritis, if it had been present, would have 
 passed off also, and especially where the case is early treated, without 
 leaving any traces by which its presence could be detected at this time. 
 The cases where iritis was seen, on the other hand, were in the eai-ly 
 stages, when it was impossible to detect choroiditis. 
 
 So far as these observations go, therefore, they seem to me to tend to 
 justify the conclusion, that the cornea, iris, and choroid are all affected 
 in the majority of cases (all being undoulited cases of hereditary syphilis). 
 
 The next question to be settled is — Are these structures affected 
 simultaneously, or if not, in what order are they affected 1 I think the 
 general opinion is that they are all affected simultaneously. Others 
 hold that the cornea is first affected, then the iris, and that from this 
 (especially if neglected) the affection spreads back, causing cyclitis and 
 choroiditis. 
 
 Another view is that the choroid is first attacked, and the affection 
 spreads forwards some time after the first choroidal changes. This last 
 view may be elaborated as follows : — Syphilis is due to microbes. In 
 hereditary syphilis these are conveyed to the offspring, and excite the 
 so-called secondary phenomena of infancy. Among these, iritis is 
 admittedly not nncommon ; choroiditis also occurs, but is not observed. 
 The tissues gradually get the better of the microbes, and the affection 
 subsides. But the microbes are not utterly destroyed ; they are only 
 held in check, and lie dormant, as it were. Then at a later period, 
 during the second dentition, or in adolescence, when the vital powers 
 are severely taxed, if any depressing cause be added, the microbes over- 
 come the feeble resistance of the tissues, and attack the non-vascular 
 cornea, in which cells quickly accumulate to expel the invading 
 microbes, and new roads, for the access of fresh cells, are formed by its 
 vascularisation. 
 
 Now this is a very pretty theory, but what facts are there to support 
 it 1 Infantile iritis is not at all common ; on the other hand, as I have 
 shown, iritis very commonly accompanies the keratitis. Again, keratitis 
 may occur, and when it has cleared up, no trace of choroiditis can 
 apparently be found (7 out of 54 cases), and choroiditis almost inevitably 
 does leave some trace in the way of disturbed pigment, or small patches 
 of atrophy ; so that it may be fairly concluded that in some cases, at all 
 events, keratitis occurs without antecedent choroiditis. 
 
 Then I find I have notes of eleven cases in which one eye only was 
 affected at the time of examination, and in six of these an examination 
 of the choroid of the apparently unaffected eye showed signs of old 
 choroiditis, and in two of these cases the unaffected cornea was watched 
 until it also became affected ; and as interstitial keratitis almost invari- 
 ably does attack l)oth eyes, it may fairly be assumed that the other 
 cornea became affected in the other four cases also. In five cases the 
 choroid was very carefully examined, but no trace of choroiditis could 
 be found — so that we have six cases in which the choroiditis was ante- 
 cedent, as against five in which it was not. Tlie number of cases is too 
 small to form any general opinion as to which event is the more 
 common. We can only say that cither may happen, and that there is 
 no invariable rule.
 
 TREATMEKT OF INHERITED SPECIFIC KERATITIS. < / .) 
 
 Tlien I tried to find out, l)y direct examination of tlie fundus of 
 infants with hereditary syi^hilis, whether the choroid was affected at 
 tliat period, but I had very few opportunities, and when tliey occurred 
 the motliers objected to the prolonged examination and to atropine, 
 and tlie infants were so restless, that I found it impossible to be 
 absolutely sure that there was no choroiditis, and I gave up the attempt. 
 
 I did tind it in one case, however, at 10 months old, but it was 
 associated with neuro-retinitis and optic atrophy. I have also notes of 
 one case, who appeared at ^loorfields, with interstitial keratitis at 19, 
 and who brought an old card which showed that, at the age of 11, he 
 had attended with choroiditis. He also had high myopia, but his sister 
 had keratitis, and the history of the family and other collateral 
 evidence showed the specific nature of the case very clearly. 
 
 Thus we may fairly conclude, that in some cases, at all events, the 
 choroiditis does precede the keratitis, but in what proportion of cases 
 this happens is undetermined. It also appears that keratitis may occur 
 alone, but I think in by far the majority of cases keratitis, iritis, and 
 choroiditis occur pretty much about the same time. 
 
 The age at which the choroiditis occurs is obviously difficult to 
 determine, because its onset causes little or no disturbance in most cases, 
 and it is only found long afterwards. It may be remarked, that 
 Trousseau considers that it occurs at a comparatively late period — 9 to 
 12, or 20 to 25. Out of the forty-iive cases in which I found it present, 
 it was discovered before the age of 12 in twenty-one cases ; and of these, 
 ten were discovered under 9. 
 
 There is only one other point to which I wish to refer. It is 
 generally admitted that choroiditis may occur apart from syphilis ; and 
 Hutchinson, after many years' research, concludes that in a few cases 
 it may so occur, and that when it does, the final results are indis- 
 tinguishable from those of syphilitic choroiditis. As far as my 
 observations go, they are fully in accord with this opinion ; but some 
 confirmation of a supposed syphilitic origin has been found in unexpected 
 ways, when the direct evidence seemed very slight indeed, and the extreme 
 difficulty of eliminating the possibility of a syphilitic origin has im- 
 pressed itself upon me most strongly. 
 
 ON THE TREATMENT OF INHERITED SPECIFIC 
 KERATITIS. 
 
 By James Jackson, M.D. Lond., M.R.C.S. Eng. 
 
 Cases of inherited specific keratitis are so frequently met with in the 
 practice of those specially engaged in ophthalmic work, and even in 
 general medical ])ractice; and, moreover, many of these are so severe, 
 and result in such disastrous consequences to the eyes, that any 
 deviation from the usual mode of treatment which tends to mitigate the 
 severity of the symptoms, or shorten the duration of the disease, and 
 wjiich leaves the cornea free from opacities when the disease has run its
 
 774 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 course, is worthy of record. Observations extending over many years^ 
 and enquiries made of patients who have suffered severely from this- 
 affection, and wliose corneie have become more or less spoiled for visual 
 purposes by dense opacities or lenconiata, have led me to believe 
 that specific remedies have either not been employed at all, or only 
 to an extent altogether inadequate to influence favourably the course of 
 the disease. 
 
 My usual practice in the treatment of such cases, for a long time- 
 past, and that which I desire to bring before the notice of members, 
 has been to use vigorous mercurial treatment from the very onset of the 
 attack, and to keep up the influence of the drug uninterruptedly (short 
 of producing ptyalism) for a period of six weeks or two months, to 
 V)e followed by ferruginous tonics, and alternating this for some time 
 after with the specific at first used. At the same time, every attention 
 must be paid to the state of the general health, by insisting upon a 
 liberal dietary, and as much open air and exercise as the state of 
 the patient will admit of. Where treatment such as I have indicated is 
 employed, a mai-ked improvement soon manifests itself; and I have 
 noticed that the second eye (which in the ordinary course of events 
 suffers in a similar manner) either escapes altogether, or if attacked^ 
 that the symptoms are much milder than would otherwise have been the- 
 case. 
 
 I am aware that many leading authorities wlio have written on this- 
 subject have expressed themselves as averse to the use of mercurials, 
 preferring a tonic plan of treatment from the commencement, or employ- 
 ing only the iodide of potassium ; with this, however, I cannot agree, 
 and my experience leads me to regard the prompt use of mercury as of 
 the greatest importance in mitigating the severity of the symptoms, ancE 
 inducing a more rapid convalescence, at the same time that the cornea 
 is left more free from opacities and faulty curvature, and the eye there- 
 fore more useful as an organ of vision. The form of mercurial used may 
 not be of importance, but that which I usually employ is a combination 
 of the liquor hydrarg. perchlor. with the potassium iodide in full doses, 
 at the same time rubbing in the ung. hyd. co. to the temples, and 
 instilling atropine for the purpose of preventing synechiee, or in the 
 event of these having already formed (which is too often the case),, 
 breaking them by strong preparations of atroi)ine (8 grains ad. ^j). 
 
 Case T. 
 
 Miss 8., aged 7 years, was brought to see me on August 29, 18S7,. 
 and four months after the eyes were affected. The pain and photophobia 
 were so severe, that a satisfactory inspection of the eyes could only be 
 made under the influence of an anaesthetic, when V)oth cornete were 
 found covered with dense ojiacities, which rendered an examination of 
 the deeper structures impossiljle. No history of her previous treatment 
 could l^e ol)tained, so that I am unable to say whether specific medicines. 
 Lad been used. The licjuor hydrarg. ]»erchlor. and potassium iodide in 
 full doses were given, the ung. hyd. co. was rubbed into each temple, 
 and atroi)ine drojis were instilled three times daily. At the end of 
 two months a decided im])rovement had taken place, the pain and photo- 
 phobia were much less marked, and a steady convalescence ensued. The 
 girl is now fairly well in her general health, but the opacities of the
 
 TRKATMENT OF INHERITED SPECIFIC KERATITIS. 775 
 
 cornea are so dense, and the astigmatism resulting from the faulty 
 curvature of the cornea is so gx'eat, tliat for visual purposes the eyes 
 are seriously impaired. 
 
 Case II. 
 
 Maude T., aged 14, came under treatment in May 1884. The left 
 eye, which from infancy showed considerable divergence and was 
 more or less amblyopic, was attacked with kerato-iritis fourteen days 
 before. Three weeks after this the right eye became affected in a similar 
 manner, and corneal haze, with marked impairment of vision, was 
 manifest for the succeeding two months, when, after employing the 
 usual vigorous mercurial treatment, im])rovement set in, and satisfactory 
 convalescence ensued. The vision of the right eye had so far recovered 
 at the end of the following September (six months from the date of 
 attack), as to enable her to resume her school duties. 
 
 The upper incisors showed decided evidences of the specific taint, but 
 were Vjy no means typically malformed. Any doubt, however, as to 
 diagnosis, was removed by the fact that a clear history of specific 
 infection was elicited from the mother, and that a brother, whose 
 incisors showed characteristic lesions, subsequently suffered from kerato- 
 ivitis. At this date (four years after the attack), vision Oc. Dex — f and 
 Xo. 1 Jager, with the cornea apparently quite free from opacities, and 
 this, notwithstanding that one year ago the eye became attacked with 
 glaucoma of a very acute form, for the relief of which an iridectomy 
 was performed. 
 
 Case III. 
 
 Ernest T., a brother of the patient above referred to (and wdiose case 
 has already been incidentally mentioned as presenting the characteristic 
 dental lesions), was brought to me in May 1887 with kerato-iritis of the 
 left eye. The usual specific treatment was employed, when steady 
 improvement soon set in, leaving the cornea perfectly clear, and without 
 any trace of opacity — V = -^-g, and No. 1 Jjiger. On further examination, 
 the defective vision for distant objects above noted was found to be due 
 to a previously existent astigmatism. The other eye escaped altogether, 
 and up to this date remains well. In both the latter cases, the general 
 health underwent a marked improvement. 
 
 Case IV. 
 
 Miss S., set. 19, of Kyneton, was sent down to see me by her medical 
 attendant on August 29 of this year. This young lady, a person of 
 strumous habit, and markedly anaemic ajjpearance, was sufiering from 
 acute kerato-iritis of the right eye, the affection having already existed 
 for one month. The pain and jihotophobia were extremely severe, 
 making a satisfactory inspection of the cornea a matter of some difficulty. 
 Tiie cornea was found to be densely covered with haze of the usual 
 ground-glass character, the ciliai'y zone of vessels was well marked, and 
 after the a])plication of a strong preparation of atropine witli vaseline 
 (grs. viii. ad. J j), no mydriatic effect was in the least degree perceptible, 
 posterior synecliije being nearly complete. The lids and soft jiarts 
 surrounding the eyes were in a state of acute oedema, accompanied \)y 
 more or less chemosis. There was not much difficulty in making a
 
 776 INTERCOLONIAL MEDICAL CONGllESS OF AUSTRALASIA. 
 
 diagnosis, the local lesions of themselves sufficing to establish this, but 
 an inspection of the teeth removed any doubt that may have existed, the 
 upper incisors exhibiting in a marked degree those peculiarities of form, 
 &c., so frequently met with in cases of this kind. Specific medicines in 
 fiill doses were administered, the ung. hyd. co. rubbed into the temples; 
 night and morning, and a strong pre})aration of atropine and vaseline 
 (grs. viii. ad J j) was persistently used to break down adhesions to the 
 capsule, a matter of considerable difficulty. For six weeks this treat- 
 ment was persevered with, at the end of which time a marked 
 improvement had taken place, the pain and photophobia had disappeared, 
 and the iris was found to be nearly free from adhesions, one or two tags 
 of synechipe alone remaining. About this time the left eye became 
 affected, but the attack was altogether of a much milder character, and 
 at the end of a fortnight, the more acute symptoms had almost entirely 
 disappeared, leaving the cornea clear and the iris altogether free from 
 adhesions — V 12 and L — |^ and No. 1 Jjiger. 
 
 ■Case V. 
 
 Miss K., pet. 15, was placed under my care on September 28, 1888. 
 Four weeks had elapsed since the right eye was attacked. The cornea 
 was covered with a dense haze, which limited vision to mere p. 1. The 
 sclerotic zone of vessels was well marked, and pain and photophobia 
 were complained of. 
 
 Although in this case an examination of the incisors threw no light 
 on the nature of the case, the earthy physiognomy, cicatrices at the 
 angles of the mouth, and a history of infection in one of the parents, 
 ]ilaced the diagnosis beyond a doubt. After the iisual specific treatment 
 was adopted, a rapid improvement in the general health took place, and 
 the corneal haze is now represented by one opaque dot, scarcely exceed- 
 ing a pin's head, which occupies the centre of the cornea. So far, the 
 other eye has remained free from attack. 
 
 Case VI. 
 
 N. M., set. 26, consulted me on July 26, 1888. The right eye, which 
 had already been affected for three weeks, showed dense corneal haze, 
 with a well-marked sclerotic zone of vessels. There was also a moderate 
 amount of photoijhobia, with slight pain. After vigorous specific treat- 
 ment had been persisted in for six weeks, the cornea was left faintly 
 covered with haze, which, under the influence of massage with ung. hyd. 
 flava, is rapidly disa])pearing. Uj) to this date, the left eye has remained 
 free from attack. In this case, the dental lesion is characteristic. 
 
 [Dr. Jackson exhibited the cases referred to.] 
 
 Dr. SvMONS (South Australia) said two ])oints arose in his mind : 
 the possible toxic effects of strong solutions of atropine — he had never 
 used anything stronger than six grains to the ounce ; also, what is 
 the maximum age at which interstitial keratitis can occur? The oldest 
 patient he had ever seen suft'ering from it was aged 42. 
 
 Dr. Duncan (Kyneton) spoke relative to the question of the possible 
 toxic effects of using atropine in strong solution. He used it eight 
 grains to the ounce ; he had seen atropine irritation, and .sometimes
 
 OPERATIXG ON EYES IN CASKS IN WHICH MUCOCELES CO-EXIST. 777 
 
 ilryness of tlie tliroat, result, but never anything more. Witli respect 
 to the causation of interstitial keratitis, he should regard all cases as 
 specific in so far as treatment was concerned. 
 
 Mr. Syme (Melbourne) said the effect of mercury in the treatment 
 of interstitial keratitis is marked. Tlie disease can occur to an advanced 
 age. Half the cases ai-e over fifteen years ; the oldest ])atient he had 
 seen was aged 32. It was necessary to i-emember that, in cases of an 
 advanced age, there is always a possibility of tlie keratitis V>eing due to 
 aO(iuired, and not. to hereditary, syjihilis. The idiosyncrasy patients 
 exhibit to atrojnne is remarkable. In the later stages, when the redness 
 has disa]>peared, yellow ointment and massage are valuable auxiliaries. 
 Atropine should be used as a routine i-emedy in this disease. 
 
 Dr. Barrett (Melbourne) was in the habit of using atropine oint- 
 ment, eight grains to the ounce. He considered the action more 
 powerful and more safe than that of atropine used in sohition. He 
 quite agi'eed with Mr. Syme, that atropine should be used as a matter of 
 routine in all cases of interstitial keratitis. 
 
 Dr. Jackson replied to the effect that he quite agreed with Dr. 
 Barrett as to the relative danger of using atro])ine ointment and 
 atropine solution. Toxic effects might result (when the solution is used), 
 from the solution finding its way into the canaliculi and nasal duct. 
 
 THE DANGER OF OPERATING ON EYES IN CASES IN 
 WHICH MUCOCELES CO-EXIST. 
 
 By James W. Barrett, M.D., M.S., F.R.C.S. Eng. 
 
 At-sistaut Siirgeon to the Victorian Eye and Ear Hospital, and Demonstrator and 
 Examiner in Physiology in the University of Melbourne. 
 
 I believe most ophthalmologists are aware of the dangei- of extracting 
 cataract in cases in which the eye is the subject of chronic conjunctival 
 affections, and of mucocele. The fact that a slight afi'ection of this 
 nature may be quite sufficient to ruin an operation was insisted on by 
 Streatfield. 
 
 It would seem that in such cases, it is quite impossible sometimes to 
 render the conjunctival sac aseptic ; and consequently, when the eye is 
 bandaged up, micro-organisms, kept warm and moist, multiply, and 
 ultimately enter some ])art of the large cataract section, causing either 
 local sloughing, or if they j)enetrate far enough, |ianophlhalmitis. Yet, 
 apart from the cataract operation, I was not aware that there was great 
 risk in operating on such eyes. It is a matter of every day experience 
 to see performed iridectomies in cases of trachoma, and in cases of 
 rodent ulcers of the cornea. Personally, I have made more than one 
 puncture in the anterior chamber quite thi-ee millimeties long, in cases 
 of gonorrhoeal oi)hthahnia, and with good results. In these cases, 
 however, the eyes were not tied up after operation. Still, I had rarely
 
 778 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 seen unfavourable results follow iridectomies in such cases as T have 
 referred to, and I was quite unprepared for the following disastrous 
 case which, as far as I know, is without parallel: — 
 
 Mary W., set. 60, was admitted into the Eye and Ear Hospital in 
 September last, under the care of Dr. Bowen. In his absence from 
 Melbourne I had charge of his patients. She was suffering from double 
 mature catai'act, for which I determined to perform preliminary iridec- 
 tomies. 
 
 On September IS, 1888, I performed a large upper iridectomy on the 
 right eye, previously anajsthetising it with the usual aseptic solution of 
 cocaine and boracicacid. The eye was bandaged up for forty-eight hours 
 in the usual way, and at the end of that time the wound had healed; 
 the eye was quiet, and showed little reaction. 
 
 On September 22, I was about to perform a similar operation on the 
 left eye — which had been anaesthetised with a cocaine and boracic acid 
 solution, freshly made up — when I noticed on the lower lid a small 
 quantity of gelatinous mucocele fluid. I squeezed the sac, and got 
 away a little more fluid. I then examined the other eye, and found it 
 in exactly the same condition. The conjunctiva of the left eye was 
 white, and the mucocele was so slight that, as stated, it had been quite 
 overlooked. I carefully cleaned the left eye, and then washed the 
 conjunctival sac with a solution of bichloride of mercuiy — 1 in 5000. 
 An u])per iridectomy was then performed, through a comparatively 
 small incision, and without the least trouble. The eye was bandaged 
 up, and the patient put to bed. 
 
 In both cases, the knife used was the triangular sclerotome. The 
 same instruments were used by me a few minutes later for the perform- 
 ance of another iridectomy for closed pupil — a case which did well. 
 
 Twenty-four hours after the operation, the patient complained of severe 
 pain. The bandage was removed, when yellow lymph was seen in the 
 pupillary area. An attack of panophthalmitis had set in, and ulti- 
 mately the eye was desti'oyed. The iridectomy on the other eye 
 remained a success. 
 
 Here, obviously, the disastrous result was due to the infection of the 
 eye through the small puncture made with the sclerotome. I do not 
 think it at all possible that the infection was made by the instruments, 
 which were kept cleaned, and dipped in absolute alcohol prior to use. 
 In fact, the successful result of the iridectomy performed with the same 
 instruments, with the use of the same cocoaine solution, a few minutes 
 later, tends to confirm this view. The infection was almost certainly 
 due to the septic character of the lachrymal sac and conjunctiva. 
 
 I do not think further comment is necessary, but I thought I could 
 not do better than place such a case on record. If I am compelled to 
 operate on such an eye again, I shall slit up the canaliculi, and thoroughly 
 wash the sacs for some time prior to operation. 
 
 I may add that in this case, subsequent to the attack of panojih- 
 thalmitis, the canaliculi were slit up, and little or no fluid was evacuated, 
 so slight were the mucoceles. 
 
 Dr. Jackson (Melbourne) said that he had performed the cataract 
 operation on the eye of a patient who suffered from ciironic ophthalmia. 
 Suppuration set in two days afterwards, as a direct lesult of septic
 
 OCULAR SYMPTOMS DUE TO DISEASES OF THE NASAL CAVITIES. 779^ 
 
 infection of tlie wound, and the eye was lost. He should hesitate in 
 the future to operate in such cases. 
 
 Dr. DuxcAK (Kyneton) said that ho could not understand the manner 
 in which a mucocele could infect the wound. He had performed a 
 preliminary iridectomy in a cataract case in which there was no mucocele, 
 and no suspicion of septic infection; yet panoi)hthalmitis had set in, 
 and he had been compelled to excise the eye. 
 
 Dr. M. J. RvAX (Kyneton) had seen Dr. Duncan's case. 
 
 Mr. J. T. RuDALL (]\Ielbourne) said that a few years ago we were 
 taught that the entrance of microbes alone could cause suppuration. 
 He now noticed that the subject was opened up again, and that experi- 
 ments had been performed, which seemed to show that such irritants as 
 mercury and turpentine, introduced under the skin, could cause 
 suppuration in the absence of microbes. 
 
 OCULAR SYMPTOMS DUE TO DISEASES OF THE 
 NASAL CAVITIES. 
 
 By T. K. Hamilton, M.D., F.R.C.S.I., Laura, South Australia. 
 
 The sul))ect I have chosen to bring before the Section is one, I think, 
 of great interest, and of considerable jn-actical importance to the 
 ophthalmologist. I am not sure that there has been anything written 
 up to the present on this subject in our Australasian colonies, nor can I 
 find much reference to it amongst the writings of specialists in Great 
 Britain. It is from America and the continent of Europe most of our 
 information comes. 
 
 Of the continental writers, I would refer particularly to Bresgen 
 (" Der Chronische, Nasen- und Rachen-Catarrh," 1881, Band 1, and 
 " Grundziige einer Pathologic und Therapie des ISTasen-, Mundrachen- 
 und Kehlkopf-Krankheiten," 1884), who was the first to draw the 
 attention of specialists to the fact, that conjunctival catarrh is lai-gely 
 dependent upon so-called nasal catarrh, and that it will not disappear 
 until the latter be relieved ; Ziem, Dantzig [Centralblatt f. Frak. Augen- 
 heilkunde, December 1887) ; ISTieden, Bochum (Arch. OphthaL, December 
 1887 [translation] ) ; and Peltesohn, Berlin [Centralblattf. Prak. Aiigen- 
 heUkunde, February 1888). And of the American — Gruening, New 
 York (New York Medical Record, January 1886) ; Gradle, Chicago 
 [Chicago 2[edical Jounud and Examiner, March 1887, and Arch. 
 Ophthah, December 1887) ; Cheatham (America)/, Practitioner and, Neios, 
 1887), and Bettmann (Journal American Mediccd Association, May 
 1887, and Revue des Sciences Mtdicales, Fasc. I., 1888). 
 
 I have endeavoured to work out the subject as thoroughly as possible, 
 80 far as the time during which I have been making my observations 
 would allow, and I hope to be able to establish to your satisfaction a 
 very distinct and close connection between the eye and the nasal 
 cavities, as evidenced by symptoms and reflex phenomena discoverable 
 in the former and co-existent with diseases in the latter.
 
 7S0 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA, 
 
 In the first place, by way of preface, allow me to point out briefly 
 the relation these cavities (nasal) stand in to the eyes anatomically. 
 
 In addition to the direct continuation of the epithelium of the nose 
 with that of the eye, there are distinct vascular and nervous connections. 
 
 (1) Arterial. — The ophthalmic artery supplies the anterior and 
 posterior ethmoidal, which, passing through the cribriform plate of the 
 ethmoid, reach the nose and go to nourish the anterior part of the 
 septum and the lateral portions of the nasal cavities, anastomosing with 
 the nasal or spheno-palatine of the internal maxillary. In addition to 
 this, Zuckerkandl has shown that there is a direct arterial communica- 
 tion passing along the naso-lachrymal canal. The naso-pharynx has 
 likewise some arterial supply from the internal maxillary, and is thus 
 indirectly introduced into the nasal vascular circuit just referred to. 
 
 (2) Venous. — The veins of the nose anastomose extensively with the 
 ophthalmic vein through the plexus lachrymalis, and some find their way 
 into the cavernous sinus. 
 
 (3) Nervous. — The nasal of the ophthalmic supplies, through its 
 internal and external branches, the upper and anterior part of the 
 septum, and the outer wall of the nasal fosste, which nerve at the same 
 time, through its long ciliary and infra-trochlear branches, goes to form 
 part of the ciliary ganglion, and to supply various parts of the eye ; and 
 again, through this same ganglion, to give branches to the ciliary body, 
 cornea, and iris. Once more we have the spheno-palatine going to form 
 Meckel's ganglion, which in turn, through its anterior superior naso- 
 palatine and vidian branches, supplies the nose; and through its external 
 posterior and pharyngeal, with the vidian again, the upper part of the 
 pharynx. 
 
 The following is an abstract of the cases : — 
 
 Case 1. — Empyema of the antrum and unilateral hypertrophic 
 rhinitis of the left side, attended with eye symptoms : — (1) Concentric 
 contraction of the visual fields for all colours. (2) Accommodative 
 asthenopia. (3) Retinal hyperissthesia. (4) Peciiliar subjective 
 sensations of light. ' (5) Photophobia, with blepharo-spasm and infra- 
 orbital neuralgia. The evacuation of the empyema and its cure were 
 speedily followed by the disa])])earance of the eye symptoms. 
 
 Case 2. — Ecchondrosis of the triangular cartilage and chionic rhinitis. 
 This case was attended with the following eye symptoms : — (1) Asthen- 
 opia. (2) Pain in the eyeball. (3) Injection of the eyes when used 
 for close work. (4) Blepharo-spasm. (.5) Contraction of the visual 
 fields. These symptoms disappeared on the removal of the growth. 
 
 Case 3. — Spine of the bony septum, causing chorea magna. The 
 following eye symptoms were present :- — (1) Asthenopia. (2) Sub- 
 jective colour sensation. (3) Sneezing. (4) Contraction of the fields 
 of vision. These symptoms disapjieared on the removal of the spine. 
 
 Case 4. — Advanced chronic atrophic rhinitis, with middle turbinate 
 hyperplasia. The following eye symptoms were present : — (1) Asthen- 
 opia. (2) Lachrymation. (3) Puffiness of the lower lid. (4) Con- 
 traction of the visual fields. These symptoms were relieved by the 
 treatment of the nasal condition.
 
 CASE OP DOUBLE GLAUCOMA FULMINANS. 781 
 
 Case 5. — Syi)hilitic oztena. The following eye symptoms were 
 present: — (1) Asthenopia. (2) Lacliiymation. (3) Pericorneal injec- 
 tion on using the eyes. (4) Contraction of the fields of vision, which 
 was temporarily removed by the use of amyl nitrite. These eye 
 symptoms ameliorated as the nose improved. 
 
 Case G. — Polypi, nasal and naso-pharyngeal, with eye symptoms 
 similar to those recorded. 
 
 Cases of Post-xasal Growths. — In lOG cases, eye diseases co-existed 
 in 51; in 22, catarrhal conjunctivitis; in 7, follicular conjunctivitis; 
 in 16, granular conjunctivitis, and in 6, blepharitis (marginal). 
 
 One typical case of post-nasal growth, with reflex eye sym|)toms, is 
 recorded. There was asthenopia and limitation of the field. The 
 growth was removed, and the eye sym]jtoms disappeared. 
 
 A CASE OF DOUBLE GLAUCOMA FULMINANS. 
 By GuiDO Thox, M.D. 
 
 Mrs. T., set. 45, married, six children, was seized with violent pain in 
 the right eye on the early morning of the 4th of April last, attended 
 with vomiting, and followed in a few hours by loss of vision. 
 
 On the early morning of the 23rd of April, similar symptoms 
 appeared in connection with the left eye. In both cases there was some 
 conjunctival injection. 
 
 On April 2Sth, she was seen by the writer, who found the eyes small 
 and receding. The blindness was absolute, the patieiit being unable to 
 distinguish night from day. 
 
 Appearances : — Bight eye T -f- ; some conjunctival injection ; cornea a 
 little cloudy ; pupil seven to eight millimetres in diameter, immovable • 
 anterior chamber shallow ; fundus reflex, faint. Left : — Conditions 
 similar, but not so marked. 
 
 On April 30th — twenty-five days after the attack in the right, nine 
 days after the attack in the left — a doAvnward iridectom}^ was performed 
 on the right eye ; the iris was rotten ; the lens was touched with the 
 knife during the operation, on account of a sudden rush forward. Tlie 
 iridectomy in the left eye was successful. 
 
 Ultimately the wound in the right eye healed, but the eye remained 
 irritable and was ultimately excised. The left eye did well, and vision 
 was recovered to the extent of distinguishing shadowy outlines of lar^'e 
 objects, although there was an opacitj' on the anterior surface of the 
 lens.
 
 782 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 POST-NASAL GROWTHS. 
 By T. K. Hamilton, M.D., F.R.C.S.I., Laura, South Australia. 
 
 During the past twelve months, I have examined in detail the upper 
 respiratory tracts (and in many cases the larynx also) of about 260 
 individuals, between the ages of two and a half and twenty-five years, 
 with a view of forming some idea of the relative frequency of post-nasal 
 growths and enlargement of the pharyngeal tonsil in the colony of 
 South Australia. Out of this number, eighty-four had post-nasal 
 growths, and thirty-two enlargement of the pharyngeal tonsil. You 
 will notice I make a distinction between post-nosal growths and 
 enlargement of the pharyngeal tonsil. I do this more to emphasise 
 the fact that, in the former, the growths were large, irregular, and 
 distinct ; while in the latter they were regular, lobular, and more joined 
 together — in fact, only a hypertrophy of the normal lymphoid structure 
 of the naso-pharyngeal vault. There is really no physical difference 
 between the two affections ; it is merely one of degree. 
 
 About the actual locality from which these growths spring, there 
 is some difference of opinion amongst authorities. Trautmann, for 
 example, maintains that they grow only from the roof of the cavity, and 
 never from the sides ; and he says he has verified this statement by 
 post-mortem examinations. He admits, however, they very frequently 
 seem, in the rhinoscopic image, to spring from other places than the 
 roof, but this, he says, is an optical delusion. 
 
 Now, as far as I can make out, the anatomical position of the 
 pharyngeal tonsil itself is opposed to this view ; for this body, in the 
 normal condition, occupies not only the roof and upper part of the 
 })osterior wall of the naso-pharynx, but also extends laterally into Rosen- 
 miiller's fosste, and even on to the Eustachian cushions. If this be so, and 
 if post-nasal growths are only, as stated above, an excessive development 
 of this tonsil, we are not surprised to find the majority of authorities 
 taking exception to this, the view advanced by Trautmann. Molden- 
 hauer says : — " From my own numerous observations on the living 
 subject, I find that this assertion of Trautmann's requires further 
 confirmation. It has not infrequently hapjiened to me," he continues, 
 "that after the removal of the growths from the roof and the posterior 
 wall, still swellings remain which seem to spring from the fossiB of 
 Rosenmiiller, and the mouths of the tubes are more or less covered." 
 Schech sui)ports this view also ; but the most recent authority on 
 the subject is Rostanecki, who, after reviewing the existing literature, 
 and comparing it carefully with his own thorough investigations, comes 
 to the conclusion that the pharyngeal tonsil may extend to the 
 tuberosity of the tubes, and even into the ostium, and that those 
 modern authors who state otherwise are wrong. I have referred thus 
 fully to this, because the question of exact locality has a practical 
 importance, as we shall see presently, when we come to deal with the 
 removal of the growths. I myself have, in several of my cases, been 
 able to observe the growth proceeding from the lateral aspects of the 
 cavity, and by digital examination to make myself absolutely certain of 
 the fact.
 
 POST-XASAL GROWTHS. 783 
 
 Next, as to the etiology of the growths. This I think, especially to us 
 in these Colonies, is a most interesting question, and one on which I 
 trust my remarks may elicit some discussion, as I am anxious to arrive 
 at correct conclusions. Some eminent authorities, such as Bresgen, 
 Lange, and 8emon, believe they are congenital, and that they are not 
 observed until several years after bii'th, on account of their slow 
 development ; but Schech points out, that the predisposition of children 
 to the artection is not remarkable, since otiier organs, sucli as the tonsils, 
 are in childhood very often affected with hyperplasia. No dissections, 
 however, of new-born infants have confirmed this congenital theory. 
 
 According to Trautmann, ten months is the youngest age at which 
 tliey have been found to exist. The difficulty experienced in examining 
 tlie naso-pharynx in very young children will, I believe, always prove 
 an obstacle in the way of getting statistics from the living subject. 
 An attempt made by me recently to examine an infant of eight months, 
 only convinced one how difficult, indeed how impossible, it is to get the 
 index finger round the soft palate into the small cavity above. One 
 feels as if the pressure necessary to get round the corner would, if 
 persisted in, disturb some of the bony relations, and you feel irresistibly 
 inclined to desist. 
 
 The next question to decide is — Are these growths a " scrofulous ' 
 <levelopment 1 There seems to be a good deal to be said in favour of 
 tliis origin. Many authorities who live in cold and damp climates 
 (where we know scrofula prevails largely), cling tenaciously to this 
 theory, and seem to think scrofula, and it alone, is the cause. They 
 point to family tendency to these growths, and tell us that, not only 
 do they find them amongst several or all of the younger members of 
 the same family, but also that the affected individuals show other signs 
 of scrofula, especially enlarged cervical glands. Lowenburg ("Les 
 Tumeurs Adenoides," Paris, 1879), has seen in some cases transmission 
 from the parents to the childi'en, whilst Trautmann considers that the 
 children of tubercular parents are predisposed to the disease. 
 
 Again, other observers, such as Schulte, Milan (Arch. Otology, March 
 1888, p. 92), believe that the conception of scrofula can be dispensed 
 with, as tiie so-called scrofula essentially consists of nasal suppuration— 
 the latter is the cause of the growths ; and according to this theory, and 
 to the analogy of other mucous membranes, Ziem believes the growths 
 disappear entirely after the removal of the greater part, and the treat- 
 ment of tlie chronic suppuration. 
 
 From what I have been able to observe as to the original cause of 
 these growths in England and Germany, and more recently in these 
 <5olonies, I have come to the conclusion, that while constitutional 
 tendency enters largely into their causation, it is not the only cause. 
 Tliere may be in all, at any rate in many cases, a strong predisposition 
 to excess of lymphoid development in these individuals ; but there are 
 ■also, unquestionably, exciting causes to which, if these same individuals 
 be exposed, they are sure to develop the growths, and which they would 
 have probably escaped had they Ijeen more advantageously circumstanced 
 — this applies particularly to the development of post-nasal growths in 
 oiu- Australian climate. It has doubtless occurred to many of you as a 
 singular thing, that post-nasal growths should be of such very common 
 occurrence in our dry and warm climates of Australia, while other
 
 784 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 evidences of scrofulous developments are comparatively infrequently seen ; 
 e.g., enlarged cervical glands, so very common in the colder and damper 
 climates, even amongst those who are fairly well nourished, are rarely 
 seen here, at any rate in the country districts. My cases are drawn 
 principally from amongst an agricultural population, who are supposed 
 to live under more healthy conditions than those congregated in our 
 large centres ; nevertheless I find T have amongst the youth of this 
 population a large percentage of post-nasal growths. But of all my 
 cases, I can only find record of one case of enlargement of the lymphatic 
 glands in the neck, and this is the more remarkable when we i-emember 
 that a catarrhal condition of the nose so frequently exists with post- 
 nasal growths, and that there is a very distinct and direct lymphatic 
 connection between the nasal cavities and the cervical glands, most of 
 the nasal lymphatics opening into the glands, either at the parotid, or 
 those adjacent to the sterno-mastoid muscle. 
 
 I have observed closely many of my cases, and have found the growths 
 occurring in children, themselves apparently fairly robust (when the 
 growths were not in quantity enough .to cause defective development), 
 and the offspring of healthy parents ; and moreover, no sooner are the 
 growths removed (as if they, and they only, were the sole offenders), 
 than most of the cases rapidly assume a healthy appearance ; this would 
 not be so if a marked diathetic vice were the sole cause. This brings 
 me to the point I wish for a moment to dwell upon. I have endeavoured 
 to show that scrofula, or in other words, inherited constitutional 
 tendency, cannot be the only cause of these lymphoid developments, as 
 we find them so common in such climates as that of South Australia, 
 where other scrofulous diseases are of infrequent occurrence, and I shall 
 now try to point out to you what other evils are at work, as exciting 
 causes tending to bring about similar results. 
 
 To establish this theory, allow me to refer briefly to the researches of 
 Hingston Fox, and more recently of Spicer, as showing what the func- 
 tions of the faucial and pharyngeal tonsils really are. They have found 
 that the functions of the faucial tonsils are essentially those of absorbing 
 the buccal secretions and of the manufacture of leucocytes, and that the 
 pharyngeal tonsils do the same with reference to the spent nasal and 
 lachrymal secretions. 
 
 Let us confine our attention, in the first place, to the pharyngeal 
 tonsils. Many causes contribute in the general economy to alter the 
 condition of the blood, and render it impure. This in time affects 
 certain parts locally, e.g., chronic nasal catarrh is specially mentioned 
 as a result, and this catarrhal condition in turn, through the absorption 
 of unhealthy products by the lymphoid structure in question, leads to 
 an inflanunation and hypertrophy — in other words, to " enlargement of 
 the pharyngeal tonsil, and if excessive, to post-nasal growths." This 
 theory offers, according to Sjjicer, a complete and satisfactory explanation 
 of the pathogeny of post-nasal growths. 
 
 That chronic nasal catarrh co-exists with the growth in the naso- 
 pharynx, is a matter of daily clinical experience — not always, however, 
 a nasal l>lenorrhoea, nor even a hypertrophic rhinitis, for in most of my 
 cases I find, if they be at all chronic, more atrophy than anything else. 
 A very common condition is atrophy of the inferior and hypertrophy of 
 the middle spongy bones ; or again, atrophy in one nostril, and hyper-
 
 POST-NASAL GROWTHS. 785 
 
 tro])liy or a normal condition in the other. Out of thirty-five of my 
 cases in which the condition of the nostrils is recorded, I find atrophy 
 more or less present in twenty-six, and hypertro})hy only in seven. 
 
 What is the origin of this chronic nasal catarrh 1 Is there any 
 catarrh children are so liable to as nasal 1 I think not. "We frequently 
 see catarrhs originate in an attack of one of the exanthemata, and 
 become chronic afterwards. This may, in children of lymphatic 
 tendencies, be the starting-point of any lymphoid enlargemenl ; but this 
 catarrh much more frequently conies on idiopathically, as secondary to 
 derangement of the general alimentary system. This derangement has 
 its origin somewhere in the digestive tract, and secondarily affects other 
 parts of the body. Let us see how it comes about. 
 
 The excessive consumption of animal food in these colonies is 
 notorious. Even young children are allowed to eat meat at all three 
 meals, and that daily. This nitrogenous food is taken to the exclusion 
 of starchy and other foods more suitable for youthful digestion and 
 assimilation. Along with this they are given, also at all three meals, tea 
 to drink in quantities. Tea is said to delay the digestion of the proteids, 
 and the quantity imbibed must necessarily dilute the gastric juice 
 and prevent its action on the food until the excess of water is absorbed. 
 Again, the large consumption of sugar and saccharine materials amongst 
 children is injurious. Sugar is known to be eminently catarrhal, and is 
 now, by most authorities, recommended to be excluded from the diet of 
 those who have such tendenc3^ My own observation has abundantly 
 proved that an abstinence from all kinds of sugar has made those who 
 suffer from the various catarrhal conditions of the throat and nose (many 
 of which are only secondary to gastric or intestinal catarrh) much less 
 suscei)tible. There are, of course, other contributory causes — e.r/., rapid 
 or sudden changes of temperature, so common in certain seasons in our 
 climate ; neglect of cleanliness or attention to one of the most im})ortant 
 excretory oi'gans of the body — the skin ; but I cannot do more than 
 mention these here. 
 
 The analogy which has been proved to exist between the pharyngeal 
 and faucial tonsils at once explains how it is that we nearly always 
 find hypertrophy of the two co-existing in the same individual. Out 
 of 116 cases of post-nasal growths, ninety had enlarged tonsils; and 
 out of the 260 throats examined, 132 had this complication; and, 
 further, out of this last-mentioned number, there were thirty-nine cases 
 in whicli the left tonsil was larger than the right. This may be of 
 some interest to notice in passing, as we know that in the case of at 
 least one other of the double organs of the body, this also occurs. I 
 refer to the testes. 
 
 Once more, the rough condition of the posterior pharyngeal wall, 
 which invariably accompanies post-nasal growths, is only a similar 
 lymphoid hypertrophy; and hence, having the same histological and 
 pathological origin, we w'ould expect to find them, as we do, so constantly 
 co-existing, that the presence of the one on the lower pharynx almost 
 certainly implies the presence of the other higher up. 
 
 To recapitulate briefly, this then is my contention. Scrofula, or some 
 such diathetic tendency may, in many cases, exist as a strong predis- 
 posing cause to lymphoid hypertrojohy in the pharynx and naso-pharynx ; 
 but there are exciting causes whicii, in these dry climates, unfa\ourable 
 
 2e
 
 786 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 to scrofulous developments, determine the existence of post-nasal, 
 pliaryngeal, and faucial growths much more surely than diathesis alone ; 
 and these causes are principally connected with digestive derangement 
 induced by an unsuitable dietary, and one in keeping with neither the 
 climate nor the digestive or assimilative powers of the individuals. 
 
 I cannot do bettei*, in concluding this interesting part of the subject, 
 than quote the remarks recently made by Beverley Robinson (New York). 
 He says : — " Catarrhal troubles are sensitive to reflex influences, wherevei' 
 other organs are affected to any extent, and wherever the nutrition and 
 general tone of the system is interfered with. Next to local causes it 
 is a frequent source of the origin and aggravation of catarrhal trouble. 
 Chronic indigestion presents many examples of this, both through 
 reflex influences, or by its disasti'ous effects on the bodily nutrition — 
 some cases in which the condition of the alimentary canal was proved 
 to be alone responsible for the origin of the catarrhal trouble." 
 
 Signs and Symptoms. 
 
 (Jf the signs and symptoms connected with post-nasal growths, I will 
 only refer to some of the rarer ones, the others being too well known 
 to re])eat : — 
 
 (1) Noise and Difficulty in Siuallotving. — I had two illustrations of 
 this. The patient, as it were, made a double effort to swallow, sometimes 
 at the same time making a noise extremely disagreeable to those, 
 joining in the meal. 
 
 (2) Larpigismus Stridulus. — Of this I had four instances, and as 
 far as I can tell, the removal of the growths has caused these attacks to 
 cease. Hering (of Warsaw) refers to this as a symptom of nasal disease 
 {sjaasme larynge). 
 
 (3) Couyh (Useless), and Hawldng. — This is fairly constant as a 
 symptom, and, in the absence of other disease, should lead you to 
 examine the naso-pharynx before you do, what I think is nowadays too 
 often done, place the case in the category of the "neurotic." 
 
 (4) Asthenopia. — Referred to in my paper, " Ocular symptoms due to 
 disease in the nasal cavities." 
 
 (5) Epistaxis. — One does not wonder at this occurring, as the growths 
 are themselves so vascular, having a special arterial and venous supply 
 for each growth separately. 
 
 (6) Defective Nutrition. — This is extreme in some cases. One child, 
 from whom I removed both post-nasal growths and enlarged tonsils, only 
 wciglied thirty-six pounds. She was 7 years old, and in ten days after 
 the operation she had gained two pounds. It is marvellous how 
 children begin to pick up after the removal of growths, when the growths 
 have been, as they always do in cases where there are large numbers, 
 interfering seriously with their nutrition and development. 
 
 (7) Deafness. — This is one of the connnonest and most important of all 
 the concomitants of post-nasal growths. Out of my 116 cases, forty 
 complained of deafness more or less, some very extreme, and in eight of 
 these cases there was jierforation of the membrane and otorrhoea. 
 
 Tlie intimate relation of post-nasal growths to middle ear disease is 
 of great im])0rtance, as shown by Meyer's statistics ; he has found middle
 
 POS'l'-NASAL GKOWTIIS. 787 
 
 ear disease in 70 ])t'r ce)it. of liis cases of [tost-nasal growtlis ; und 
 Gradle has found tliat, in more tlian one-tifth of the children brought to 
 him for ear disease, there is hyjiertrophy of the phar^'ngeal tonsil. 
 These statistics show how important it is, that in all children who snti'er 
 from recurrent or chronic middle ear disease the naso-pharynx should be 
 carefully examined, and growths removed when they exist. 
 
 Greville Macdonald lays it down as a rule, that where deafness exists 
 the growths should always be removed, even though they be compara- 
 tively few in number and small. I removed a moderate number of 
 growths in a case like this from the nHso-pharyn.\ of a weakly lad, aged 
 12 years, who had constantly recurring though slight sujipurative 
 catai'rh. The result has been most satisfactoiy. He has not had any 
 return of discharge since their removal. 
 
 The following two cases are typical, showing the very distinct 
 connection existing between the growths and the otorrh(]ea : — 
 
 In case No. I. — The otorrhoea had been of long standing (two and a 
 half years), in ten days it is cured, and has never returned since. 
 
 In case No. II. — Double oton-luea of four years' standing, following 
 scarlatina; eleven days of treatment, after the removal of the growths, 
 sutficed to sto]) the discharge, which has never returned. 
 
 Methods of Examining. 
 A very few words as to tlie methods of examining for post-nasal growths. 
 Killian (Hartmann's " Klinik," Berlin) points out the great advantage of 
 anterior rhinoscopy in the diagnosis of growths, but says you must use 
 cocaine to i-educe the inferior turbinates, in order to get a good view. 
 The Germans all lay stress u))on this mode of examination, but I frankly 
 admit I seldom or never resort to it, as I have always found so little good 
 resulting from the examination. You may see parts of the growths if they 
 be isolated, but as to coming to any conclusion as to their number, position. 
 or size, I never could, hence either posterior rhinoscopy or the digital 
 examination are what I always practise. Posterior rhinoscopy gives, as a 
 rule, uncertain information ; it is very satisfactoiy, in one sense, to see the 
 objects you are going to remove, but on account of the great perspective 
 shortening with which the parts under examination are represented, the 
 lowest tumours only can be observed, while those lying above are either 
 quite concealed, or appear much smaller ; hence the digital examination is 
 much the most satisfactory and reliable. The correct method of pro- 
 cedure ])robably is tliis : — See what you can through the anterior nares, 
 then examine by posterior rhinoscopy. If you can get any image at all, 
 you can usually satisfy yourself from the apjjearances, taken along with 
 the symptoms of the case, whether it be one for o})eration or not. You 
 may then reserve your digital examination until you are operating, when 
 you can by a few sweeps of the linger dete^uaine accurately the condition 
 of the growths, before applying the instrument you are about to use for 
 their removal; this saves the patient the unpleasantness of on(! 
 examination with the finger, which is desirable. If, on the other hand, 
 you fail to get a post-nasal image, as you so often do in children, there 
 is nothing for it but a digital examination there and then, and of all 
 examinations it is the best. I find I can often, by a little delicate 
 manipulation of Michel's rhinoscopic mirror, avoiding carefully any 
 contact with the posterior pharyngeal wall, at the same time pressing the 
 
 2e 2
 
 788 IXTERCOLONIAL MEDICAL CONGKKSS OF AUSTUALASIA. 
 
 back of the tongue well down with a Frankel's tongue depressor, get an 
 image impossible to obtain by the ordinary mirror. The paretic 
 condition of the velum, and the semi-anfesthetic condition of the 
 posterior wall, facilitate posterior rhinoscopic examination in many cases 
 very considerably. Lastly, as to the 
 
 Methods of Removal of the Growths. 
 
 Out of the 116 cases (referred to already), I have operated on sixty-six. 
 One has to consider the age at which it is desirable to operate ; about this 
 there is no rule. I have operated on two children at the age of 4 years, 
 but there is some difficulty in children under 5 years frequently. The 
 cavity is so small, that it is not an easy matter to get yoiu- finger and an 
 instrument into it at the same time. If symptoms exist which require 
 the removal of the growths, I think the sooner they are removed the 
 better. Stoker (London) points out that physiological idleness means 
 arrest of development, and the sooner the obstruction is removed, the 
 less the deformity ; so the circumstances of each case will form the 1»est 
 guide as to when you should operate. 
 
 I have given up using any general antesthetic, as I think it is quite 
 unnecessary. Some recommend chloroform, pushed to cause complete 
 anaesthesia, and others use ether for similar purposes. As I have just 
 said, I think any anaesthetic unnecessary, and perhaps j)Ositively injurious 
 if complete anaesthesia be caused, for then you arrest reflex action, which 
 it is particularly valuable to retain, in order that the patient may be 
 able to cough up any blood which may And its way into the larynx, as 
 it often does, no matter what position the head is |)laced in. 
 
 I sometimes apply 10 per cent, solution of cocaine to the interior of 
 the nose (especially when about to use Meyer's ring knife), to the naso- 
 pharynx, into which cavity I inject a few drops (patient lying down, 
 with head low) with a small post-nasal syringe (made for the purpose 
 by Windier, Berlin) through the nostril ; and finally to the posterior 
 wall, etc., with cotton on a cotton-holder. In addition to this, I generally 
 now give the patient a large dose (gr. xxx to xl) of Ijromide of potassium, 
 half an hour })revious to the operation ; latterly, I have given or applied 
 nothing but this, and it makes the greatest possible difference in the 
 tractability of the patients, both young and old. McKeown it was who 
 recommended this in small operations on the eye, e.g., tenotomy in 
 strabismus, etc., and I find it particularly suitable for nasal and post- 
 nasal operations. 
 
 The position of the patient. — He is made to lie on a low couch, with 
 tlie head hanging over the end, and lower than the rest of the body, so 
 that the blood will flow back out of the nostrils, and not downwards 
 into the larynx ; though it is often impossible, even in this position, 
 to avoid the latter entirely. This position is by far the best, more 
 especially for the removal with any of the forceps instruments, but the 
 couch should be low, so that the operator is well above his patient. 
 This is also a most convenient position for the removal of tonsils, 
 especially in young children. If the tonsils are enlarged, I remove them 
 first ; this clears the way for gaining access to the naso-phaiynx, and 
 when the hemorrhage is ceased, I attack the growths. 
 
 Of the many instruments in use for removing post-nasal growths, I 
 find none so universally suitable as Woakes' modification of Liiwenburg's
 
 AURAL DISKASE AND EPILEPSY. 789 
 
 forceps. I generally use it, unless I find that the shape and position of 
 the growths are sucli that they can be readily included in the cutting 
 range of a Gottstein's knife. This instrument is used a good deal in 
 Germany, and the patient operated on in the erect })osture with it. 
 
 Tlie good rule laid down by Meyer is likewise now adhered to ; his 
 rule is — "no instrumental removal of post-nasal growths should be 
 attempted, unless the instrument be guided either by sight or touch." 
 I know it is not so easy to manage digital exploration with a shar])- 
 cutting instrument, still I try to combine the two as far as possible, and 
 therefore operate with Gottstein's knife, with the patient in the same 
 position as that adopted when the forceps are used. If the growths also 
 spring from the lateral aspect of the cavity, this knife is not suitable 
 for the removal of tliis portion of the tissue. You will find the forcej^s 
 come in there best. 
 
 As to Meyer's ring knife, there are many cases in which it is 
 impossible to use it. We so frequently find the nasal cavities small and 
 ill-developed, as a result of post-nasal growths, that in a large number 
 of cases they will not, even after cocaine has been used, admit this 
 knife ; or frequently you will find one nostril admit it, and the other too 
 narrow ; you can then put a curve on the instrument, and manage to 
 reach a good portion of the roof. When you get it into the cavity, it is a 
 sjilendid little insti-ument to scraj)e away all remains left after the forceps. 
 
 Trautmann's sharp spoon I have used ; but I think with it you will 
 find it hard to reach the anterior part of the naso-pharynx, as the 
 diameter of the instrument is so great. 
 
 AURAL DISEASE AND EPILEPSY. 
 By C. L. M. Iredell, M.R.G.S. 
 
 I approach the subject of the relation of aural disease and epilepsy 
 with the greatest possible diffidence, feeling, as I do, that I can only 
 "bring to bear upon it some little practical experience, tending to show 
 that the relationship is causal, but wanting those refinements of research 
 that belong more properly to pathology. 
 
 It is extremely interesting to me to trace as I can the gradual manner 
 in which the importance of aural disease in its relation to brain disease 
 has become recognised. The significance of chronic disease in this 
 region has, in fact, only forced itself into prominence during the last 
 few years — say fifteen. It was generally understood that oeca.sionall}' 
 severe inflammatory conditions of the middle ear resulted in ab.scess 
 within the cavity of the cranium, but that this occurred from, or was 
 in any way connected with, that state known simply as chronic discharge 
 from the ear, was not accepted ; and, indeed, not infrequentiv was it 
 con.5idered as the direct result of any treatment that may have been 
 adopted with a view of checking such discharge. 
 
 That all this has been changed may be best seen from the fact that 
 the larger insurance companies now positively refuse to accept any one
 
 790 IN'TERCOLOXIAL MEDICAL CONGKESS OF AUSTRALASIA. 
 
 having a discharge from the ear, though this is clearly a mistake, as 
 considerable discharge may exist without any perforation, and perforation 
 may exist for lengthened periods without discliarge. 
 
 It is, however, to the more obscure and less immediately fatal condi- 
 tions that I would now allude. Fearing always lest one should come 
 under the charge commonly made against specialism, of considering 
 every condition as Vjeing one immediately connected with one's subject, 
 I feel that I have neglected to take sufficient notice of many valuable 
 instances liearing upon this matter. So much do I feel this to be the 
 case that, while I have largely before my eyes quite a number of cases, 
 I have preferred to illustrate my paper by some three or four which 
 have come under my observation during the last two years. These, 
 which I think fairly typical, have offered themselves since 1 have more 
 particularly considered this subject. I have no doubt that much of the 
 obscurity which surrounds this class of disease arises from the difficulty 
 that exists in obtaining sections of this portion of tlie cranium. Nor, 
 indeed, has it been the custom to look at all carefully in this direction, 
 except in those cases where there has been reason to associate the cause 
 of death witii caries or abscess. It therefore follows, that much of that 
 which I have to advance is hypothetical, and open to correction by 
 further investigation. 
 
 In the introduction to I?}rom Bramwell's liook on " Intracranial 
 Tumours," I find the following :— " The lirain and its membranes are 
 favourite situations for the formation of new growths. In no other 
 situation in the body is such a great variety of tumours met with ; it 
 would almost indeed seem that the delicate and soft brain-tissue, richly 
 supplied as it is with blood-vessels and lymphatics, is as fine a forcing 
 and feeding ground for new growths, as Koch's nutrient jelly is for 
 micrococci and allied organisms." Speaking later on of growths result- 
 ing from injuries, he says: — "The explanation is probably this — that 
 the blow produces a local inflammatory lesion or contusion, which forms 
 a suitable nidus for the development of tuljercular germs, which are 
 alread}^ circulating through the system." 
 
 Now let us consider. AVe know that acute inflammation of the 
 middle ear will give rise not only to the formation of pus within the 
 cellular arrangen)ent of the temporal bone, and so sometimes by a direct 
 process of destruction to thrombosis of the lateral sinus, as may be seen 
 in a very interesting specimen shown by Professor Allen ; but it will 
 give rise, without any intermediate course of destruction, to suppuration 
 in almost any of the lobes of the brain, including the cerebellum. New 
 let us assume, for the sake of argument, the existence of an irritation 
 acting upon an otherwise healthy brain, falling short of inducing 
 supjiuration, and continuing for any length of time, or lieing repeated 
 as it would probably be in the case of chronic ear disease. What would 
 be the etiect '? Quoting again from Byrom Bramwell's book, I find he 
 says : — " Irritation of grey matter gives rise to symptoms, while destruc- 
 tion of gre}' matter is often unattemled by any external manifestations" 
 (page 9). 
 
 I am so thoroughly alive to my deficiency in the scientific knowledge 
 of these obscure aflfections that, even at the risk of weariness, I must 
 again quote from this author : — " Theoretically, a tumour or other 
 ' coarse ' lesion may cause discharge of motor gi'ey matter, either by
 
 AURAL DISEASE AND EPILEPSY. 791 
 
 'directly' irritating it, or imlii'Dctly (1) by interfering with the nutrient 
 sui)ply or (2) by refiexly irritating it. Further, Duret has shown that 
 spasms and convulsions may be })rodnced by irritating sensory nerves 
 in the dura mater ; but the spasms which are produced in this way 
 have not the well-detined and characteristic features of the localised 
 epileptiform convulsions due to irritation of the motor cortical 
 centres." 
 
 Having considered these remarks, 1 would now ])oint out a pheno- 
 menon presenting itself in the treatment of aural disease. It has 
 occurred to myself more than once, and I have frequently seen it in the 
 cliniques at home, that the simple act of syringing an ear, unprotected 
 by an imperforate membrane, will produce symptoms varying from a 
 slight dizziness to total insensibility. I would wish to say that, in the 
 latter case, the water used was always, so far as my memory serves me, 
 by inadvertence or ignorance -cold. However, there was no mistake 
 about it — the patient dropped senseless on the floor. It not infre([uently 
 happens, even after the most careful syringing with water of a ])ro]ier 
 temperature, that the patient will complain of considerable giddiness ; 
 and this will be within the experience of all of those interested in this 
 sul)ject. How does this compare with the following case 1 
 
 Case I. 
 
 On September 1.3, 1886, W. E. R., a^t. 17, was brought to me by his 
 father, a man in good position and extremely intelligent. He com- 
 plained that his son had had a running from the left ear for many 
 years, and had had various advice, but had never as yet consulted a 
 specialist. The young fellow was a fine, strong, well-grown youth, and 
 had no other ailment whatever. I syringed the ear, which contained 
 much discharge, and on examining it found a snudl polypus ; but as some 
 water remained in the ear, its definition was not good. I therefore 
 prepared, as is my custom, a probe armed with cotton wool to dry it, 
 and proceeded to do this very gently and carefully ; but immediately, I 
 noticed a tremor pass through his frame, facial muscles twitching, and 
 l>efore I could interfere, he had fallen backward in strong epileptic 
 convulsions. This seizure went through the oi-dinary phases, and in a 
 short time he was recovered, feeling somewhat weak, but with an 
 entire unconsciousness of all that had passed. The father was greatly 
 alarmed, and assured me most positively that his son had never before 
 had any symptoms of the kind ; and as I have never seen the patient 
 from that day to the present time, I have no doubt that the whole 
 thing was put down to my credit, as will probably be any subsequent 
 turn the disease may take. 
 
 Here we have an example of a condition distinctly epileptiform, 
 following upon irritation of the peripheral ends of nerves in the 
 tympanum. It is possible, howevei', that the case might bear another 
 intei-pretation. AVe know from experience, that polypus in this 
 situation is very generally associated with caries of the pars peti'osa ; 
 and Ferrier's experiments have shown that the centres for the depressoi\s 
 and elevators of the mouth correspond nearly to this portion of the 
 temporal bone. Assuming that in this case caries existed, direct 
 irritation of these centres by the carious bone may have contributed to 
 the production of the symptoms.
 
 792 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 The next case I would offer you is more iiiteresting, showing, as I 
 tliink, the benefit derived from treatment. 
 
 Case II. 
 
 On June 23, 1888, I was consulted by L. S., a little girl a^t. 13. 
 She had a polypus, and considerable discliarge from the left ear, tliis 
 discharge having existed since she had had scarlet fever, at two years 
 of age. It was for this condition that she was placed under my care : 
 but as there was also some suspicion of mental disease, she was at 
 the same time under the care of Dr. Grant, who considered her state as 
 being anything but satisfactory, and feared de^■elopment of mental 
 trouble. She had curious ideas upon many points ; had a habit of 
 counting and repeating things a given number of times, and also was 
 subject to tits of morose temper ; altogether, a state whicli, as I said 
 before. Dr. Grant feared might presage mental derangement of a more 
 serious character, but which he said was also not infrequently found in 
 the subjects of epileptic disease. The polypus was removed, and 
 subsequent treatment lessened or nearly removed the dischai-ge. Some 
 months later. Dr. Grant had a letter from the friends, who lived in 
 another Colony, saying that the little girl was very much better, the 
 discliarge from the ears had entirely disappeared, and the fits of temper 
 Avere much less frequent, and more controllable. 
 
 Very shortly after this, that is to say — 
 
 Case III. 
 
 On July 30, I was called into consultation by Dr. Willmott, in tlie 
 case of a little girl A. G., a^t. 9, with the following history : — She had 
 had discharge from both ears from the age of 2 or 3, following no 
 particulftr illness ; but during the last twelve months, the child had 
 sliowii symptoms of what they feared was mania ; and as it was 
 particularly noticed that the paroxysms always followed increased 
 discharge from the ears, while subsequently, and in the intervals, the 
 ears appeared to discharge less, or not at all, the parents concluded that 
 there was some connection between the ear trouble and the brain 
 symptoms. With this history, I proceeded to examine the ears, and to 
 do so, syringed them first with warm water. Almost immediately 
 afterwards the child became violent, trying to get out of bed, and 
 although easily restrained, was evidently labouring under intense 
 mental excitement, writing furiously and aimlessly across a copy book. 
 At tlie time, I gave it as my opinion that there must be some further 
 mischief than would be accounted for by tlie ear- disease ; at the same 
 time, I ordered such treatment as was suitable to arrest the sub-acute 
 inflammation tliat was going on within the cavity of the tympanum. 
 1 heard some time afterwards, that under this, the discliarge ceased ; 
 that the paroxysms became less frecjuent and severe, but still continued 
 until some weeks ago, since when there have been no cerebral attacks. 
 The following case, I think worth including here, as evidently bearing 
 upon the connection between the ear and the brain, but lieing 
 unaccompanied, so far as I could judge, by any active disease of the 
 former organ.
 
 AURAL DISKASE AM) EPILEPSY. 793 
 
 Case IV. 
 
 On Sept. 6, 1S8S, Mrs. L. consulted nie, coniplaiiiin<f of deafness, 
 from whicli she had sutlered for two years, immediately following an 
 attack of mumps. She had been under the treatment of other 
 specialists, but had derived no benefit. It was just one of those cases 
 where one may say, fron: certain indescribable features, the patient 
 *' looks " deaf, and one fears nerve injury. There was not much 
 difterence in the deafness of the ears, and I exaiiiined the left ear tirst, 
 finding no local changes. I then examined the right ear, and though I 
 could see the membrane partly, it was partly occluded by a small piece 
 of wax, whicli I then proceeded to wipe away, as mentioned in a 
 previous case, with a probe armed with cotton wool. This was easily 
 done, causing only a momentary Hinching, and the membi'ane was 
 ■exposed to view, and found, as the other, apparently without change, 
 but the patient complained of giddiness, and gradually became 
 insensible and convulsed. From this state she recovered in the usual 
 way, and then I heard for the first time, from herself and friend, that 
 she was subject to these "fainting tits," which were always preceded by 
 violent tinnitus, and that she suffered from frequent and severe 
 headache. 
 
 Tlie next and last case is perhaps on the whole the most interesting. 
 
 Case V. 
 
 C. C, let. 20, consulted me on the 8th August, at the instigation of 
 Dr. Bryant. His right ear had been discharging continually for 
 thirteen years, following, severe ear-aches. On the 1st Dec, 1884, 
 he had an epileptic fit for the first time in his life ; another one seized 
 him six months later, and after this he had been subject to fits 
 regularly at intervals of never more than three weeks or a month, until 
 he came to me. Early in 18(S6 he had a polypus removed from the 
 left ear by Dr. Ti'emearne, of Creswick, and at this time he joined a 
 rifle corps. Dr. Tremearne warned him that the firing was not good 
 for him, and so he found, for after practice at the butts he frequently 
 had epileptic fits, with a distinct aura, so that he was forewarned 
 some two or three minutes, during which he made preparation. I 
 have seen him from time to time, the last time being on Dec. 3, 
 1888. Under treatment the discharge from the ear has almost ceased, 
 and he has had no fit since August 7 (i.e., a period of nearly four 
 months), and feels much stronger and better in his general health. 
 Beyond the local treatment, I have been giving him strychnia and 
 bromide of potassium, but I may mention that he had taken con- 
 siderable courses of bromides before he came under my care. 
 
 Now here is a group of cases, all coming under the observation of 
 one practitioner within a short period, in which chi'onic disease of 
 the middle ear existed in conjunction with epileptic or epileptifoi*ni 
 conditions — that is, with the exception of Case IV. The continued 
 irrita,tion produced by this sub-acute inflammation of the middle ear 
 Avould seem to be all that can be desired to establish the connection 
 between the symptoms, and would comply with all the requirements of 
 this form of l)rain disease. As time goes on, fresh observations in this 
 field will no doubt correct or verify these statements, but at any rate
 
 794 INTEUOOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 they are sufficient to demand the investigation of the subject -from 
 those who have the opportunity of watching these cases, for it must he 
 remembered that in practices such as mine it is only those cases in 
 which the ear symptoms are the most urgent tliat epilepsy comes under 
 observation, and I therefore anticipate that my function chiefly lies in 
 directing the attention of medical men generally to the advisaljility, in 
 all cases of epilepsy, of seai'ching out any history of ear disease, even if 
 such be not immediately presenting, and especially to consider the 
 serious necessity of attending to chronic otorrhcea wherever found. 
 
 THE VALUE OF REDNES8 OF THE HANDLE OF THE 
 MALLEUS AS A SYMPTOM IN DISEASES OF THE 
 MIDDLE EAR. 
 
 By James W. Barrett, M.D., M.S., F.R.C.S. Eng. 
 
 Assistant Surgeon to the Victorian Eye and Ear Hospital, and DeuKnistrator and 
 Examiner in Physiolof^y in the University of Melbovuiu'. 
 
 I liave been unable to obtain precise information as to the ^■alue of 
 redness of the handle of the malleus (seen through the auditory meatus), 
 as a s^'mptom in diseases of the middle ear. I had been told that it 
 sometimes co-existed with perfect hearing power, and with a healthy 
 tympanum, and was not of necessity a pathological appearance. The 
 object of the investigation I have made was to determine whether 
 redness of the malleus, seen on examination of the membrane, is, or is 
 not, a pathological appearance in all cases. 
 
 (a) The first step taken was to examine a large number of 
 membranes, in persons whose hearing, was perfect, and in whom there 
 was no middle ear disease existent. In none of these examinations 
 (oA'er fifty in number), did I find a membi'ane with a red malleus. In 
 all, it was wliite in colour. 
 
 It is well kno^\'n, that syringing the ear, or the impact of a blast of cold 
 air, produces a redness of the malleus, wliich usually passes oft' in a few 
 hours. Temporary redness from the first cause, I have seen frequently; 
 from the second, once or twice. 
 
 (h) Next I made careful examinations of those cases in which the 
 malleus was red, and, when possible, kept them under observation. 
 
 The following table gives particulars of fifteen of the cases. By 
 way of ]>reface, I may say that a healthy adult, 25 years of age, usually 
 hears the watch I employ at about 100 inches distant. Healthy persons 
 over 50 years of age hear it at distances varying from thirty-six inches 
 to nil. Old persons, hearing it at one inch or less, often possess 
 perfect hearing power for conversation. My observations are not yet 
 complete, but I do not think the acutenessof the hearing for the watcli 
 diminishes greatly till at least the 40th year is reached. Where the 
 redness was well marked, the malleus is referred to as being red. Where 
 it was not well marked, the colour is described as reddish.
 
 VALUE OF REDNES.S OF THE ir.VNDLE OF THE MALLEUS. 
 
 795 
 
 
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 796 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 An examination of the cases recorded show : — (1) That in all cases 
 the red appearance was co-existent with deficient hearing power. 
 (2) That in cases 1, 2, 4, 11, and 15 (cases which were kept under 
 obsei'vation), improvement in hearing was coincident with disappearance 
 of the redness. It seems to me that these observations warrant the 
 ■conclusion that the redness is indicative of an inflammatoiy condition 
 of the tympanum, which reduces the hearing power, and that it is 
 distinctly a pathological sign. 
 
 Case 1 furnishes a type to which attention must be called. There 
 had been for two years positively, and probably for a much longer time, 
 •chronic inflammation of tlie middle ear, which had steadily reduced the 
 hearing power. On the disapj^earance of the redness under treatment, 
 the hearing improved from two to ten inches right, and from three to live 
 inches left — a considerable improvement. But yet this result was pool'. 
 That is to say, the previous attacks had reduced the hearing to about 
 ten inches right and live inches left. The redness was due to an 
 additional attack of inflammation, from whicli the ear recovered. 
 
 The table shows that redness is a hopeful sign to some extent. When 
 the malleus appears i"ed, the hearing power may generally be somewhat 
 impi'oved. 
 
 PHLYCTENULAR CONJUNCTIVITIS IN ERYTHEMA 
 
 NODOSUM. 
 
 By Leonard W. Bickle, L.R.C.P., M.R.C.S., Mount Barker, 
 South Australia. 
 
 At the July meeting of the South Australian Branch of the British 
 Medical Association, I read a short paper detailing the features of nine 
 cases of erythema nodosum which had occurred in my practice since 
 January 1884. In seven of these a condition of phlyctenular conjunc- 
 tivitis was noticed, a number far too great to be a mere coincidence. 
 Almost immediately after this paper was read, I met with a tenth case 
 in a married woman, who had, in addition to the E. nodes on the leg, 
 a well-marked erythema papulatum of the forearms, the rash being 
 perfectly typical. In this case the same eye condition cropped up, and 
 I was glad to avail myself of the services of a lady ai'tist, resident in 
 tlie town, to sketch the condition. This sketch I now show, as it leaves 
 no doubt as to the nature of the afliection. It is not a little curious 
 that the symptom has not been noticed in South Australia as far as I 
 can ascertain, and also, that it should occur in eight out of ten cases. 
 
 Is the att'ection of E. nod. commoner out here than in the old world 'i 
 The proportion of cases to those of general skin disease is intinitely 
 greater in my experience than that shown by McCall Anderson's and 
 tlie Amei'ican Dei-matological Association's statistics, and yet rheu- 
 matism is undoubtedly rarer in Australia than in the older countries. 
 
 The symptom is an interesting rather tlian an important one, and 
 presented no difliculties in treatment, tlie dusting in of calomel, and
 
 NASAL CALCULUS FHOM A OIRL AGKD TIOX YKAHS. 797 
 
 a weak tonic lotion, causing a cure in a few days. It took place in 
 patients of all ages, from ten }^ars to sixty years. The time of 
 api^earance varied, in some cases coming with, in others later than, the 
 rash. 
 
 EXHIBITS. 
 
 Dr. LiNDO FERCiUsox, F.R.C.8., of Duuedin, N.Z., exhibited tlie 
 following specimens : — 
 
 (a) Aspergillus niger. 
 
 (b) Instrument. — A two-edged scissors for dividing the capsule. 
 
 NASAL CALCULUS FROM A GIRL AGED TEN YEARS. 
 
 By C. MoKTON AxDERSOX, M.R.C.S. Eng., Sydenham, 
 Christchurch, N.Z. 
 
 This patient was brought to me on Sept. 17, 18i>7. She was then 
 suffering from an exceedingly offensive purulent discharge from the 
 right nostril, which she had had for about one year. She was thin and 
 pale, had a bad appetite, and was in very bad health. Up till a year 
 preWous, she had enjoyed good health and spirits. I learned that she had 
 been under medical treatment for about nine months, but apparently 
 with no benefit. It was absolutely impossible to examine the nostril 
 carefully, owing to the excessive (quantity and thick tenacious character 
 of the discharge. I ordered a mixture of syrvip of iodide of iron with 
 calumba, and a lotion (boric acid, gr. x in Jj) to syringe the nostril 
 out with frequently. On Oct. 3, as the discharge had not improved 
 so much as I had hoped for, I ordered the following lotion : — R. acid 
 carbolic, Sj ss : acid tannic, gr. xij ; glycerini, ^j ; aq. ad. J xij, m. ft. 
 lotio. 
 
 Oct. 11. — The discharge was somewhat less copious, and not so 
 offensive, but I still could not make a satisfactory examination. I then 
 prescribed a mixture of liq. arsenicalis and dec. cinchona'. 
 
 Nov. 5. — Considerable improvement in discharge and general 
 health. 
 
 Nov. 8. — Fancied the disease was located in inferior spongy bone, 
 flopped this over with ecjual parts of carbolic acid and glycerine. 
 
 This was repeated on tlie 12th, 15th, 21st and 24th Nov. On the last 
 occasion I felt certain that I could feel some dead bone at the posterior 
 border of the inferior spongy bone, and on firm pressure with a probe 
 it appeared to move slightly. I then told the girl to come on 
 Nov. 26th to have this removed, and that I would give her chloroform, 
 as the nose was exquisitely sen.sitive, and a strong solution of cocaine 
 seemed to have very little influence. 
 
 I might here remark that, on the first occasion that the girl was 
 brought to me, I had inquired most particularly as to whether she had
 
 798 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 ever put anytliiiig up her nose, sucli as a pebble, a cherry or pluui 
 stone, &c. But tlie child was quite positive on this point that she had 
 not, and she seemed so clear and intelligent, that I accepted her denial. 
 
 Nov. 26. — Chloroform having been administered, I proceeded to 
 remove, if possible, this supposed piece of dead bone ; and after some 
 <lifficulty, and the exercise of a considerable degree of force, I succeeded 
 in removing the desired object, which, on further examination, j^roved 
 to be a nasal calculus, with a cherry stone for a nucleus. After this, 
 the discharge soon ceased, and the girl regained her usual health and 
 spirits. 
 
 I have been induced to exhibit this specimen principally on account 
 of the rarity of nasal calculus, bvit also partly on account of some other 
 important features in the case. 
 
 • In the tirst place, the amount of constitutional disturbance was very 
 ^'reat, and although, no doubt, this had been carefully treated, still she 
 continued to go from bad to worse, till tlie local lesion was taken in 
 hand. 
 
 Secondly, the girl denied having ever put a cherry stone up her nose; 
 and this I am inclined to believe, as from tlie formation of her nose, 
 and the great difficulty I experienced in removing the object, I do not 
 believe she could have put one there in situ had she tried. Then how 
 did it get there 1 The theory which appears to me most feasible is, 
 that about a year ago, when eating some cherries, she must have 
 coughed, or more probably sneezed, and that this effort had forced a 
 cherry stone (which she was probably trying to swallow) up into her 
 right nostril, and tixed it tlrmly at the ^josterior part of the inferioi- 
 spongy bone. Here it remained, and in due time the calcareous 
 concretion formed on it. 
 
 The child's mother informed me that, at the outset, the girl used to 
 complain of pain in her nose, and denied having put anything into it, 
 but that they had not sought medical advice for a few weeks, till the 
 offensive discharge appeared and the health began to fail. 
 
 Possibly, some will recollect having been overtaken with a fit of 
 sneezing when in the act of swallowing ; and if such has been accom- 
 panied witli a piece of potato or bread crumb being driven up into the 
 nares, they will probably have a lively recollection of the trouble they 
 had to get it down again. 
 
 MICKOSCOPIC SPECIMENS OF GLIOMA OF RETINA. 
 
 From C. Morton Anderson, M.R.C.S. Eng., Sydenham, Christchurch, 
 
 New Zealand. 
 
 No. 1. — Portion of glioma of left eye from Mrs. S.'s infant. 
 No. 2. — Portion of glioma of right eye from Mi's. S.'s infant. 
 No. 3. — Complete section of left eye from JNIrs. S.'s infant. 
 Nos. 4, 5 and G. — Sections of right eye of Albert H. H. 
 Sections 1, 2 and 3 were prepared for me by Dr. T. L. Bancroft 
 ■vvlien lie was House Surgeon at the Cliristchurch Hospital.
 
 MICROSCOPIC SPECIMENS OF GLIOMA OF RETINA. 799 
 
 No. 2, from tlie right eye. This globe was lirst noticed to be 
 diseased wlieii the child was 32 days old, and I excised it on the 35th 
 day (from birth). The left eye at that time was apparently healthy, 
 and a careful examination with the ophthalmoscope failed to reveal any 
 trace of disease. Tlie child made a rapid recovery from the operation, 
 without a single bad symptom. Date of operation, November 7, 1887. 
 
 On November 30, I was again called in to see the child to examine 
 its left eye, as the parents thought they detected a yellowish reflex. 
 Examination showed that their fears were only too well founded, but 
 I declined to operate on this eye without a second opinion as to the 
 desirableness of so doing. 
 
 Accordingly, on December 7, Dr. H. Lindo Ferguson, of Dunedin, 
 ■was consulted, and he corroborated my diagnosis, and advised the 
 operation as the only chance of saving the child's life, and also to save 
 it from the great pain it would suffer if the disease were left to run its 
 course. The parents then decided to try what "faith healing" would 
 do, but after several days, as the eye grew steadily worse, they made 
 up their minds to have the operation performed ; and on December 17, 
 T excised the (left) eye, at the same time removing about half-an-inch 
 of the optic nerve behind the globe, together with some of the 
 suri'ounding tissues. The child recovered almost as rapidly from this 
 operation as from the first. 
 
 iSome months afterwards, the child had one convulsion, but it was 
 then teething, and had been given some plum cake by one of the other 
 children. A warm bath and some castor oil soon restored it, and up to 
 the present time (November 1, 1888), the child has been remarkably 
 healthy, and both sockets look as well as could be wished. 
 
 Family History. — Both parents are pale and delicate, and they are 
 cousins. All the children, with .the exception of this baby, show 
 evidences of struma. One boy has had hip joint disease, but has 
 recovered with shortening of the leg. Two children have died of tabes 
 mesenterica. There is no evidence whatever of syphilis, and no 
 previous history of consumption on either side of the family so far as I 
 have been able to discover. One aunt on the mother's side suffers from 
 some mental affection, and Mrs. S. has shown some symptoms of the 
 same after two of lier confinements. No history of any eye affections 
 in family. 
 
 Sections 4, 5, and 6. — Albert H. H., aged 11 months. I first saw 
 this child on August 25, 1888, and excised the globe (right eye) on the 
 following day. The cliild was a very fine healthy boy, and made a quick 
 recovery. When I last saw him in the early part of October, the socket 
 looked healthy, and otherwise he appeared to be in vigorous health, and 
 of a remarkably cheerful disposition. I regret that I could not obtain 
 any history in this case. The child is, I believe, an illegitimate one, 
 and has been put out to be nursed. I only saw the mother once for a 
 few minutes before the operation, and she appeared to be a fine healthy 
 young woman.
 
 800 INTERCOLONIAL MEDICAL CONGRESS OF AUSTKALASIA. 
 
 ON THE NATURE AND CAUSES OF DIPHTHERIA 
 AND ITS RELATION TO CROUP. 
 
 By James Jamieson, M.D. 
 
 Lecturer ou Medicine, Melbourne Universitj*. 
 
 Few subjects in practical medicine liave greater interest and 
 importance than that of diphtheria. Various causes, and especially 
 the occurrence of rather severe outbreaks in dift'erent parts of this 
 colony, have given it a special interest at the present time. It has 
 been thought desirable, therefore, that any discussion which may arise 
 should have point given to it by a preliminary statement, with 
 reference to some points in connection with the nature and cause of the 
 disease, and its relation to croup. It must not be said that questions 
 of this kind are of merely theoretical interest, since it cannot fail to he 
 the case that a man's views as to treatment, and the deliniteness 
 and thoroughness with which he carries it out, will dejDend greatly 
 on the opinions he holds about the nature of the disease. If he 
 believes it to be primarily a local disease, he will inevitably lay great 
 stress on the use of local remedies ; and even in his choice of these, 
 he cannot fail to be influenced by his pathological opinions. If his 
 pathology is bad, his treatment will also be bad, or at best, tainted 
 with uncertainty ; and most of us, who have had experience of the 
 disease, must be convinced that it is one in the management of which 
 active measures are called for. No apology is therefore needed for an 
 attempt, however imperfect, to state some points which I believe to be 
 of fundamental importance. 
 
 So far as published records show, the first cases of diphtheria, 
 oliserved in Victoria, occurred in the end of 1858, and cases were 
 reported from Tasmania about the same time. The disease spread 
 rapidly, so that in 1859 the deaths registered as caused by diphtheria 
 and croup numbered 509, and in 1860 no fewer than 792 — a higher 
 mortality than has been observed in any year since. In grouping- 
 together the deaths registered as due respectively to diphtheria and 
 ci'oup, I by no means wish to prejudge the question about the identity 
 or dissimilarity of the two affections. I only wish thus to indicate that, 
 to get a correct notion of the mortality from diphtheria, it is necessary 
 t» take account of the deaths from croup, since eveiyone admits that 
 many, if not most, fatal cases of croup are instances of diphtheria 
 affecting the larynx. 
 
 There need be no hesitation in saying, that all authorities are now 
 agreed in liolding that diphtheria belongs to the class of infective 
 diseases, owing its origin to the introduction into the system of some 
 virus. I tiiink it may be taken as further agi-eed, that this virus 
 is not only possessed of specific properties, but that it owes its acti^■ity 
 to the presence of bacterial organisms, even though there is not yet satis- 
 factory evidence that the particular bacterial form has been identified. 
 But, in addition to being infective, there is clear proof that diphtheria 
 is a contagious disease, spreading fi-om person to person, eitiier 
 directly by personal intercourse, or indirectly, as by the agency of 
 infected rooms, or articles of food, clothing, or furniture. Of course
 
 NATUUK AND CAUSES OF DII'UTllEiaA : ITS RELATION TO CUOUP. 801 
 
 there are very many cases in which it is difficult, if not impossil)le, to 
 trace the source of contagion, and the same difficulty is often found in 
 tracing tlie mode of origin of cases of other diseases whose infectious or 
 contagious nature is undoubted, such as measles or scarlatina. But 
 that diphtheria spreads by contagion is sliown, not merely by its 
 extension from one member of a family to another, but exen more 
 clearly by the not unconnnon instances of medical men having become 
 infected by the throat discharges of patients on whom they were 
 attending. 
 
 While there is thus clear enough proof, then, that the disease may 
 and does spread from person to person, it must also be allowed that the 
 cases are very numerous, in wliich it is hard to believe that there could 
 have been conveyance of the virus from a previous case. It is 
 necessary, I think, to admit that the poison finds a lodgment, and 
 probably a breeding place, in foul heaps, neglected drains, cesspits, &c. 
 
 As regards its mode of spread, indeed, diphtheria seems to have 
 many points of resemblance to typhoid, in wliich some outside source 
 of infection has often to be assumed, whatever we may think about its 
 specific nature. Speaking from my experience of the disease, both 
 in town and country, I can say that I have been often strongly 
 impressed with the influence of local conditions, of the kinds referred 
 to, in favouring the .spread of diphthei'ia in a locality. That insanitary 
 conditions are not necessaiy for its admission into a locality, and its 
 spread tlu'ough the members of a family, is doubtless true. But that 
 such conditions favour its spread in many cases, must at the same time 
 be acbnitted, though we are not yet in a position to explain the exact 
 mode of operation. That sore throat, not distinctly diphtheritic, is 
 often caused by sewer emanations, is a matter of common observation ; 
 and the possibility is that the poison which causes common ulcerati\'e 
 sore throat may undergo some process of intensification, whereby it 
 becomes capable of producing the more serious disease, which is 
 then transmissible directly from person to person. But till we have a 
 fuller knowledge of the essential constituent of the virus, it will not be 
 possible to speak more definitely. We do know that the specific virus 
 is very persistent, and that it may remain long attached to clothing, 
 articles of furniture, and even walls of buildings, while still remaining 
 capable of exciting the disease in susceptible subjects ; and this should 
 always be borne in mind, before we dismiss the possibility of contagion 
 in any particular case. 
 
 W^hether any special susceptibility, local or general, is necessary, may 
 perhaps be doubtful ; but the data collected by Hirsch (" Handbook of 
 Geographical and Historical Pathology," vol. iii, p. 100) go to show 
 that the disease is most pre\"alent in cold, damp weather, though there 
 are many marked exceptions to the rule. The most reasonable sup- 
 position is that the influence of cold and damp, and of changes of 
 weather generally, in favouring the occurrence of diphtheria, is due to 
 tlieir liability to produce sore throat of a catarrhal kind, thus allowing 
 a readier inlet for the specific poison. That susceptibility of some 
 kind, and probably local, is of importance, is strongly suggested by the 
 frequency of instances in which only one member of a family sufters, 
 as compai'ed with what happens when measles or scarlet fever finds 
 admission into a house. 
 
 2f
 
 802 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 A question more difficult, but not less important than these 
 etiological ones, is that about the relation between the local and 
 constitutional symptoms ; whether, that is to say, diphtheria is or is 
 not primarily a local disease. To put it otherwise, the great dispute is 
 whether we are to look on the throat atiection as a mere localisation of 
 the effects of the poison (like the angina of scarlet fever), or to regard it 
 as the tirst stage of the whole process — the constitutional symptoms, 
 and the affections of remote parts, being secondary results in some way 
 of that local affection. Now, while I have no wish to ignore the 
 ditHculty of the question, and am free to admit that the opposite view 
 has some evidence in its favour, I am unhesitatingly of opinion that 
 the doctrine of the local nature of the disease primarily is the true one, 
 and that which is best in accord with the history and course of the 
 disease, and with the results of treatment. The first point in favour of 
 this doctrine is that, in patients who can differentiate their symptoms, 
 the first thing visually complained of is more or less sore throat. The 
 throat affection need not, to begin with, be severe, and hence in 
 children it is readily overlooked ; but in the case of adults, it will 
 always be found, I think, that some pricking or slight difficulty of 
 deglutition is experienced, before any other symptoms have become 
 developed. It is true that in scarlatina the sore throat is also a very 
 early symptom, but at the same time I doubt if anyone could say that 
 it ever comes on before the rigor, feverishness, headache, vomiting, or 
 other signs of constitutional implication in that disease, while in 
 diphtheria this is not uncommon. And there are a good many mild 
 cases of diphtheria in which there never are marked constitutional 
 symptoms at all. 
 
 Even more conclusive are the cases, not of course common, in whicli 
 the disease begins in some other locality than the throat, as the result 
 of inoculation. The following cases (" Memoirs on Diphtheria." K. 
 Syd. Soc. Trans., pp. 181-84) give the strongest possible support to the 
 view that the disease is primarily a local one : — (1) Dr. Herpin was 
 treating a child by means of cauterizations, when some coughed-up 
 matter was thrown on the orifice of his left nostril, and was not at the 
 time washed or wiped off. A few days after there was snuffling on the 
 left side, and nasal voice ; then suddenly painful pharyngeal angina, 
 the tonsils and uvula being found next morning completely enveloped 
 in a white incrustation of false membrane. There was slow recovery, 
 with development of marked paralytic symptoms. (2) In a school, a 
 large number of children were attacked with diphtheria in the ordinary 
 form. One child, suffering from excoriated chilblains, who was allowed 
 to mingle with the others, wetted one of its feet in a little pool of sputa 
 on the fiooi', and in it an excessively painful ulceration between the 
 toeis, and covered with false membrane, was the result. (3) Trousseau 
 (loc. cit. p. 261) relates the case of a child suffering from fatal 
 diphtheritic sore throat, whose mother suckled it all through its illness, 
 with the effect that her breast was soon afterwards attacked with the 
 specific inflammation, and became covered with false membranes. 
 Many cases of such localisation, as the result of inoculation, might 
 be collected, and others, indeed, will be referred to further on. 
 
 Another point, which seems to me to tell in favour of the primarily 
 local nature of diphthei'ia, is the shortness of the incubation period,
 
 NATUKK AM) CAUSKS OF Dll'lllll KKIA : ITS IJKLATIOX TO CKOUP. ^03 
 
 ill oases where its (liu-atioii i-aii be elearly ascertained. It is conimonly 
 put by authorities at two to li\e (lays, but it certainly is often even 
 less than the shorter of these periods. The following are very 
 interesting illusti-atioiis of this fact : The first case came under my 
 own observation some years ago, when I was in practice in a country 
 town in this colony. Two children came in to church, from an isolated 
 house about a mile from the town, and went for a short time to a 
 house to see the body of another child which had died of diphtheria, 
 there being other cases under treatment tliere at the same time. The 
 same night, after returning home, one of these two children was taken 
 ill, and died of the disease a few days after. Knowing all the par- 
 ticulai's as I did, there seemed to me to be no room for doubt as 
 to where and when the contagion had been ac(|uired. The otlier case 
 is that of tlie late Prof. C. O. Weber, of Heidell)erg, as told by himself 
 C' Pitha and Billroth's Chirurgie," Bd. 1, ]i. ."598) in the following 
 terms: — '"On Api'il 2o, 18(54, I perfor)ned tracheotomy, though too 
 late, on account of croup, in a l)oy of four years. As the child vomited 
 during the operation from an emetic whicli had previously been given, 
 blood passed thi'ough the canula into the trachea. To prevent the 
 danger of suffocation, I sucked out the blood with my mouth, and 
 naturally got with it in my mouth some of the croup membrane, mixed 
 Avith mucus and pus. Though 1 immediately washed it out with 
 vinegar, on the evening of the same day I felt pain on swallowing. 
 Se\"ere angina came on, which a few days after passed on to violent 
 croupous intlammation of the larynx. The fact that tliere had been 
 contagion was confirmed by the circumstance that my assistant, Dr. A. 
 Mcens, also acquired a sore throat, which, however, passed otf more 
 easily." It is very remarkable that three or four years after. Prof. 
 Weber again acquired diphtheria in exactly the same way, and died of 
 the effects ; two assistants who helped him in the operation, and 
 also tried to suck the tracheotoiny tube, being likewise affected. 
 
 The following extract fi'om "Trousseau's Clinical Lectures" (N. Syd. 
 Soc. Translation, vol. ii, p. 497) illustrates not only the risk of 
 contagion, but the liability to a very rajDid course: — '"Very recently, one 
 of my provincial colleagues liad a case of diphtheria and croup in which 
 he was obliged to resort to tracheotomy. During the opei'ation, a fear 
 of suffocation arose, from 1)lood getting into the trachea, whereupon, 
 in dismay, my imprudent colleague applied his mouth to the wound in 
 the neck, to suck out the blood from the air passage ; he inoculated 
 himself with the disease. Like Valleix, he died in forty-eight hours of 
 malignant sore throat." Tt is needless to insist on the absolute proof, 
 which these cases supply, not only of the contagiousness — the actual 
 inoculability — of the disease, Ijut also of the rapidity with which 
 the symptoms, and above all, the local symptoms, become manifest. 
 Now it is this which marks the difference between diphtheria and the 
 general diseases, of which scai-let fever may be taken as the type. In 
 that disease the incubation period may be taken as lasting four to 
 seven days, or possibly long<!r, and in measles pei'liaps seven to ten 
 clays. The difference is not owing to different modes of production, 
 because, when these diseases have been imparted Ijy inoculation the 
 period elapsing befoi'e the development of distinct sym2:)toms was found 
 to be also about seven days. T am awai-e that it has been stated that 
 
 2f 2
 
 804 INTEKCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 tlie incubation period of scarlatina may not be more than twenty -four 
 or thirty-six hours, but the evidence is distinctly meagre, the case 
 narrated by Trousseau ("Lectures," vol. ii, p. 163) being constantly 
 referred to. Trousseau himself says that the duration of the period of 
 incubation in scai-latina cannot be rigorously determined ; and certainly 
 tliere is liability to fallacy in determining it, which prevents the few 
 pul)lished cases of veiy short incubation from having anything of 
 the demonstrative character of those of diphtheria just quoted.* So 
 far as we have gone, therefore, it does not appear as if, in our seai'ch 
 for diseases with which to class diphtheria, we sliould find them in the 
 group of the acute exanthemata. 
 
 But I think the argument may be developed a little further ; and for 
 that purpose, the course of an ordinary case of diphtheria has to be 
 considered. When the throat is examined at an early enough stage, 
 there may readily be seen, with perhaps some dittuse redness, merely a 
 small white patch on one tonsil. This slowly increases in size, so that 
 twenty-four or thirty-six hours may elapse before it begins to transgress 
 on tlie soft palate, or before anything of a similar kind can be seen on 
 the other tonsil. Several days may easily elapse l)efore symptoms of 
 croup develop, showing that the disease has spread to the larynx. All 
 this time the false membrane, as it extends, may be seen to have a 
 distinct well-detined margin. This is altogether a ditl'erent process 
 from that observed in the angina of scarlet fever, where there is uniform 
 diftusion of the inflammation from the tirst, and symmetrical formation, 
 with rapid and uniform development of membrane formation, when 
 tliere is such formation at all. If there is to be comparison of diph- 
 theria with other diseases at all, the resemblance would rather be to 
 the progressive development of a disease like erysipelas, which has 
 tnken origin in, and extends from, some breach of surface on which the 
 virus has been inoculated accidentally or for experimental purposes ; 
 or with hospital gangrene, or other phaga?denic process, affecting a 
 wound or ulcer. I cannot help thinking that this want of symmetiy in 
 tlie tirst localisation of the diphtheritic process in tlie throat, with its 
 continuous extension, in a widening circle, from the first observed seat, 
 is the strongest evidence in favour of the disease Ijeing at the outset of 
 a strictly local nature. 
 
 But if it be held, as I do hold, that the constitutional symptoms and 
 the affections of remote organs are secondaiy to, and results of, the 
 local pi'ocess set up by the implantation of the virus, and the changes 
 produced by it at the seat of implantation, I may be asked to account 
 for those cases in which severe constitutional symptoms are observed 
 before the throat symptoms have become marked ; or for those in 
 which it has been alleged that fatal general symptoms, such as lieart 
 failure, came on rapidly without any sore throat at all. Tt certainly 
 is not very uncommon for croup to come on and prove fatal, in cases 
 where no affection of the tonsils, fauces, or pharynx is observed. In 
 most of these latter cases it is certain, I think, that there had been 
 some faucial affection at an early period, which disappeared spontane- 
 ously, or under the influence of treatment ; and this, indeed, has often 
 
 * The fullest discussion of this question of the incubation period of scarlet fever, 
 ■which I have met with, is contained in the article on that subject in Pepper's 
 " System of Medicine," by American authors, vol. 1.
 
 XATURK AM) CAUSKS OF DIPIl'lH HKIA : ITS KELATIOX TO CKOUP. 805 
 
 been noted. But if it is insisted tliat death from constitutional symp- 
 toms, such as collapse, comes on in cases where there is no local 
 diphtheritic process at all, I can only say that I have never ol)served 
 any cases of the kind ; and a very careful post-mortem examination 
 would be required to prove that false membrane was absent, not only 
 on parts easily seen, but in the recesses and deep parts of the naso- 
 pharynx, or on some other mucous surface. 
 
 It must be admitted, of course, that constitutional symptoms of the 
 se\"erest kind may occur in cases where the local symjitoms were slight, 
 and that albuminuria not infrequently is found early in the course of 
 the disease. The explanation may be that, in some cases — as, for 
 instance, where the disease took origin on a raw surface — absorption 
 of poison may take place quickly ; and it may easily be the case that 
 it is absorbed from the lining of the lacunje of the tonsils, at a time 
 when little is to be seen on the surface. There can be little doubt, I 
 think, that severe constitutional symptoms may have a double origin, 
 and be due either to admission of the speciiic virus into the system, or 
 to the absorption of putrefactive products from the seat of the local 
 lesion. These two modes of systemic infection may, of course, be 
 combined in varying measure ; but it certainly is matter of observation, 
 that severe constitutional symptoms of any kind come on, as a rule, 
 about the height of the local affection, and are in proportion to its 
 intensity. If there is an explanation to be got of the more or less 
 anomalous cases already referred to, which are certainly rare, it should 
 be sought in some hasteiiing, or other modification, of the ordinary 
 sequence of events, rather than in the assumption of some quite 
 different course. 
 
 <)ne more point in connection with the pathology of diphtheria, which 
 is in favour of its primarily local nature, is that an attack does not 
 giA-e protection from subsequent ones, thus further emphasising the 
 diffei'ences between it and the acute exanthemata. 
 
 I venture, further, to say that the results of treatment are distinctly 
 in favour of the view, that diphtheria is primarily a local disease. 
 Every one who has given fair and full trial to the system of treatment 
 with antiseptic and disinfectant agents, nmst have seen cases cut short 
 in a way that gave complete contradiction to the doctrine tliat throat 
 affection is a mere manifestation of a general constitutional condition, 
 like the angina of scai-let fever. I do not ])ropose to enter on details 
 of treatment, but after trial of many methods, I am clear on the subject 
 of the benefits to be got from local treatment of the kind mentioned, 
 with the proviso, that it must be carried out in an efficient way; and 
 efficiency means, above all, persistence with the use of the remedy 
 selected, carbolic acid, or another, using it in moderate strength, and 
 at short intervals, and in a way to cause the minimum of mechanical 
 injury to the ])arts, i.e., by insufflation, or spraying, rather than 
 by rougher modes of cauterisation. And it is in this tliat the 
 great importance of correct views of the nature of the disease lies ; 
 for no man will carry out, in other than a half hearted way, a 
 system of local treatment for a lesion, which he looks on as little more 
 than a manifestation of a general disorder, or at most a troublesome 
 symptom, to be palliated ])erhaj)s by the swallowing of ice, or the 
 application of hot or cold T)acks to the neck.
 
 806 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA, 
 
 There is anothei- point in connection with diphtheria wliich deserves dis- 
 cussion, and that is its relation to croup, in its true or membi-anous form. 
 Since Bretonneau, nearly all the leading physicians of France have held 
 to the identity of the two affections. More recently, the same view has 
 been steadily gaining acce])tance both in Great Britain and Germany, 
 and is now, I think, generally held. With all who yield deference to 
 authority in such matters, it cannot fail to have gi-eat weight, that Sir 
 William Jenner, who formerly considered membranous croup to be a 
 distinct form of disease, has now formally withdrawn that opinion. It 
 is admitted at all hands, that diphtheria frequently proves fatal by 
 extending to the larynx ; and even those who deny the identity of the 
 two aftections not only allow this, but admit further, that it is not 
 possible to distinguish, with anything like certainty in the individual 
 case, the croup which is diphtheritic, from that form which has been 
 called idiopathic, but is now by preference known as sporadic membranous 
 croup. While pathologists distinguish in the anatomical way between the 
 "diphtheritic" and the "croupous" membranes, they all allow that both 
 forms may be met with in the same case of diphtheria, though the former 
 is especially seated in the fauces or pharynx, and the latter on the 
 mucous surface of the respiratory tract. And further, it is certain that 
 no evidence has ever been supplied, showing that the membrane found 
 in the larynx is difterent, in the croup due to the extension of faucial 
 diphtheria, from that which is found in supposed idiopathic croup. 
 Basing an opinion on my own observation and ex])erience, I am strongly 
 inclined to adopt the doctrine of the identity of the two affections, and 
 practically, it certainly is the safer view to hold, either from the point 
 of view of prevention or treatment. As an article of faith then, I favour 
 the identity doctrine, but I am not prepared to assert it dogmatically, 
 and these are some of the grounds which compel me to hesitate a little. 
 
 Diphtheria, as we are all familiar with it, was not recognised in this 
 colony till the end of 1858, in which year it was reported to have 
 caused 6 deaths; the number increasing to 280 in 18.59, and to 636 in 
 1860. But, from the time when accurate returns were kept, there were 
 always deaths registered as due to croup — 72 in 1854, 53 in 1855, 69 
 in 1856, and 56 in 1857. With the a|)pearance of epidemic diphtheria, 
 the deaths from croup of course rapidly increased to 102 in 1858, 229 
 in 1859, and 156 in 1860. What was the nature of this disease called 
 " crouii," which caused 72 deaths in the year 1854, when the 
 population of the country was less than one-third of what it is now, 
 and the number of births less than one-fourth 't In fact, in proportion 
 to population, moi'e deaths were ascribed to croup in 1854 than in any 
 year from 1880 to 1886, when many were certainly of diphtheritic 
 origin. Is it conceivable that, during the years 1853 to 1857, diphtheria 
 was actually a common disease, but that for some mysterious reason it 
 was not recognised, tliough from 1858 onward there was no difficulty 
 experienced in its diagnosis ? If this be the case, however, tlien the 
 disease must have shown a very special })redilection for the respiratory 
 surface, and it can never have been very prevalent in any one place. Of 
 course it is now known that there had been local outbreaks of malignant 
 sore throat in Gi'eat Britain previous to 1857, though the disease took 
 on the epidemic form, and was generally recognised, only in that year. 
 This may be true of this colony also, for during the years 1854-5S
 
 NOTES OX DIPHTHERIA. 807 
 
 scarlatina was more or less prevalent, and deaths really due to 
 diphtheria may have been ascribed to it. There is perhaps coutiriiiatioii 
 of the same view in the circumstance that, in the same years, a good 
 many deaths were registered as due to "quinsy," which is not recognised 
 as at all a fatal disease now. The number was not absolutely, though 
 it was relatively, great — 53 deaths from '' quinsy " being registered in 
 the 5 years 1854-58, as against 51 in the 5 years 1882-86. I do not 
 think it is possible, in the present state of our knowledge, to give 
 a positive answer to the question, " Is croup always merely diphtheria 
 affecting the upper part of the air passages," the evidence derived 
 respectively from clinical observation, pathological anatomy, and vital 
 statistics, being of a rather inconclusive kind. But at the same time 
 I must repeat my own opinion that croup, as we see it now, in its true 
 membranous and fatal form, is almost always a diphtheritic atl'ection. 
 I have seen a good many cases, and I am not sure that there was one of 
 them, whieli I had not grounds for considering to be of that natuie. 
 And it is important, in my opinion, that this view should be held ; 
 for, just as experience has convinced me that local treatment of an 
 energetic kind can alone be relied on in faucial diphtheria, so I am 
 convinced that treatment of a similar kind is most useful in crou[), 
 though for manifest reasons it can never be depended on to be so 
 successful. 
 
 NOTES ON DIPHTHERIA. 
 
 By Dr. A. Jarvie Hood, Maclean, Clarence Eiver, N.S.W. 
 
 During the last four years, we have had an epidemic annually, each 
 one occurring about the same time of the year, viz., during the months 
 of April and May, and a few cases in June. It has been my lot to 
 attend seventy-tive cases during those ejndemics, and I purpose to give 
 a short resume of tliose cases, giving special reference to etiology and 
 treatment. 
 
 Etiology. 
 
 (1) Dampness and bad ventilation 
 
 Is usually mentioned as a prime factor, but that could not possibly 
 obtain in the epidemics 1 refer to, as three of them occurred in times of 
 great drought, while the other occurred in anything but a wet season ; 
 moreover, the ventilation was only too tliorough, most of the houses 
 being built of timber, which, shrinking within a few months after being 
 put up, left a series of air-passages, in some instances large enough to 
 blow out a candle at a few yards' distance. In one island in the river, 
 diplitheria is endemic, and in one house alone it recurred thrice in three 
 years. 
 
 (2 1 Tnsufjicient feeding and dotlnnr/. 
 
 Bad feeding and i)Oor clothing had no share in the causation, for in 
 only one or two cases were the patients in anything like poor circum- 
 stances, and strange to say, no deaths occurred in the members of those
 
 808 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 families so circumstanced. Almost without exception all the cases 
 happened in well-to-do farmers' houses, where fresh food, including eggs, 
 milk, butter, meat, etc., were in abundance. 
 
 (3) Diathesis and occurrence during or after diseases of other nature. 
 
 A fair number occurred in tubercular families, and one case occurred 
 in a patient suffering from chronic phthisis, with a fatal termination. 
 Out of eleven deaths, five occurred in families of distinctly tubercular 
 inclination, viz., in whose families deaths had occurred from phthisis or 
 tubercular meningitis. 
 
 Two cases followed an attack of frequently recurring spasmodic 
 ci'oup, both being fatal. One case occurred immediately after an attack 
 of scarlatinal albuminuria, and, strange to say, recovered. About 10 
 per cent, of the cases occurred in children who had enlarged tonsils 
 following quinsy, which I may state is endemic in some parts of this 
 district, and almost identically the places where diphtheria is so bad. 
 One case occurred during an attack of whooping cough, with recovery. 
 Tlie remainder occurred without reference to other diseases. 
 
 (4) Agt. 
 
 Age as a factor was most peculiar. Whilst the usual age is stated as 
 some time between 2 and 1 years (with of course exceptions), the cases 
 I now refer to differ very much in their ages. Two cases occurred in 
 infants under 6 months ; three between the ages of 6 and 12 months; 
 six between 12 and 24 months; twenty -one between 2 and 4 years; 
 twenty-seven between 4 and 10 years; six between 10 and 20 years; 
 ojie at 21 ; two at 23 ; one each at 26, 30, 36, 37, 39, 40, 54 ('?). This 
 differs considerably from the usual ages given. Of these, five were 
 suckling, which is a somewhat rare occurrence ; and although we hear 
 occasionally of cases occurring in adults, and sometimes with a fatal 
 issue, as evidenced by the sad and sudden death of Dr. H. M'Ewan, of 
 Glasgow, one of the most promising membei's of the profession, which 
 took place a few months ago, it is somewhat rare, whei'eas in my 
 cases there were thirteen out of seventy -five above the age of 15, and 
 ten over 20. 
 
 (5) Locality. 
 
 As the last of the probable causes, and to me the most important one 
 in this instance, I will mention locality. 
 
 As a few of you may know, the district of the Lower Clarence lies in 
 a low basin, with mangrove-lined creeks and low banks. The shores are 
 very sloping, and covered with mud and decaying and decayed vegetable 
 matter, forming a suitable nidus for the luxuriant growth of the 
 mangrove. The river is studded with islands (99), many of which are 
 inhabited and cultivated, but which, in their interior, are often below 
 tide level, consequently they contain swamps of brackish water which, 
 in many instances, is simply river water filtered through a medium of 
 mud and dead organic matter. 
 
 The chief supply of drinking water is obtained from wells, dug in 
 many instances in close ])roximity to these swamps, and the result is 
 that the people are drinking, esj)ecially in dry weather, poisonous
 
 \OTES ON DIPHTHERIA. 809 
 
 matter in varying, but probably large, quantities. Added to this, tlie 
 banks, whicli are low and muddy, as before stated, are left uncovered 
 ■while the tide is low, and as the tide is influenced on the river to a 
 great extent by the rainfall, during the drought there is of course a 
 much greater tract of bank exposed, and necessarily, the poisonous 
 emanations being greater, the malai-ial effects are gieatly increased. The 
 epiilemics were of varying degrees of virulence, the last two being by 
 far the worst, Tioth as to fatality and the number of adults affected, and 
 it is worthy of notice that both the seasons were very dry. The disease 
 recurred in one famil}' in three consecutive years, carrying off one victim 
 each time. 
 
 When a death occurred in one house, usually one or more victims in 
 same family went. The disease was, in nearly all cases, asthenic in type, 
 and very rapid. One child at the breast was to all appearance well one 
 day when I saw him ; the next day I was called to see him, when I 
 found his pharynx covered with the membrane. He was cyanosed, 
 choking, and jnilseless. In twenty-four hours he was dead. His little 
 brother was seized next day, and was dead in four days. The day he 
 ■was buried his mother showed signs of it, and although she had a severe 
 attack, in nine days she was up on a chair. Person aftei* person who 
 visited the house contracted the malady, and in all eight peo})le were 
 affected, with however no more fatalities. To show the virulence of the 
 attack, one girl of 18, who came to see her aunt who was just recovering 
 from an attack in the same house, was down with the disease twenty- 
 four hours afterwards. Her's was the worst case of all which recovered. 
 The fauces, [)alate, ixvula, base of tongue, part of pharynx, and probably 
 the larynx, were one huge mass of greyish-white membranes. Time after 
 time they were destroyed, but only to return, and when she did recover, 
 she was ill and paralysed for nearly six months. Her mother, a woman 
 over 50, came to nurse her, and was stricken down, and one began to 
 wonder where it was going to end, avid who would go next. Fortunately, 
 the epidemic came to an end soon afterwards. I made strict enquiries 
 where the drinking water was taken from, and was sliown a well near 
 the creek bank, at the bottom of which stood some water, nearly a foot 
 below the level of the water in the creek, which was just a few feet 
 distant. We had the well closed, and tank water, whicli had been filtered, 
 used, and no more cases appeared in that house. I had the water 
 examined under the microscope, and found it contained fungi in the form 
 of spores and mycelium in great quantity, besides a lot of amorphous 
 substance. This I put down as the prima causa in this house's trouble. 
 Nearly every house where the disease showed itself was built on the 
 edge of a creek, and this made me almost certain that the epidemics 
 ■were due to malarial influences, or to bad water, or both. In cases where 
 there was a fatal result, it was A'ery rapid, only one living six days (an 
 infant of six months), and he suffered from a relapse. Tlie majority died 
 within three days after the appearance of membrane. The only compli- 
 cations in all these cases were albuminuria, epistaxis, and diphtheritic 
 paralysis. The first of these occurred in six cases, two having a fatal 
 termination, the others being recoveries. Epistaxis occurred only twice, 
 once in the young girl of 18, whose case I siiecially referred to 
 previously, and ahvays followed an attack of vomiting — vomiting 
 being a prominent symptom in her case all through. The other
 
 810 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 case in which epistaxis occuri-ed was that of an adult — a young man of 
 26 — who walked to my consulting-room at the time at which the last 
 epidemic was at its height, and who stated that his nose had bled all 
 night, and that his thfoat was sore. On examination, I found a 
 diphtheritic patch on his i-ight tonsil, which quickly spread to the fauces, 
 and then to the other tonsil. He made a good recovery. 
 
 Diphtheritic paralysis occurred more or less marked in five, two only 
 being severe. The first case was that of a child whom I was called to 
 see, her father, when he came to see me, telling me that his daughter, a 
 child of eight, was unable to walk, or use her arms, or even to swallow. 
 After seeing the child, on enquiry, I found that about ten days before 
 they noticed any loss of power, she had complained of a sore throat, and 
 her mother on looking down the throat, saw a white patch, to which 
 she ap])lied p>owdered sulphur repeatedly till it disappeared, and the 
 child apparently was all right in a few days. Not till some days after- 
 wards, did she complain of inability to walk, and then to swallow, as 
 when she tried to swallow it made her cough ])aroxysmally, almost to 
 the verge of choking. She was almost completely ])aralysed ; she was 
 unable to speak, to swallow, to hold her head up, and if it were held up, 
 it would fall forward on her chest. The upper and lower limbs were 
 almost quite powerless, the urine escaped involuntarily, and the bowels 
 had not moved for days, and to crown all, she was quite cyanosed. 8he 
 ultimately recovered. 
 
 The other case is the one T have referred to so frequently, viz : — that 
 of the young woman of 18, who had such a severe attack, with vomiting 
 and epistaxis. Early in the course of the disease she had great difficulty 
 in swallowing, and if anything solid were attempted, she would cough 
 till she was almost asphyxiated. Tliis increased so rapidly, that all food 
 had to be stojiped by the mouth. 
 
 Treatment. 
 
 In speaking of treatment, I have no intention to go into the different 
 methods of treatment advocated by different authorities on the subject, 
 but will simply give in detail the methods I adopted in different cases, 
 with the apparent results, giving failures as well as successes. 
 
 When I began to attend diphtheria, I did so with the unfortunate 
 feeling, that to give perchloride of iron and chlorate of potash internally, 
 and apply perchloride of iron and sulplnirous acid locally, meant a 
 certain cure, and I entered comfortably on such treatment. This feeling 
 one conceived from seeing records of men in ai)parently honorable 
 positions and lai ge practices, such records being published with the view 
 of showing that diphtheria was in the hands of such men a simple affair, 
 in fact, tfiat if other men lost cases, they were morally guilty of 
 culpable homicide. 
 
 One man recorded 300 cases without a death. Lately, we have seen 
 recorded sixty or seventy or eighty cases without a loss. Could one 
 believe this possible, diphtheria would cease to be the dread disease 
 which every conscientious physician believes it to be ; but when one sees 
 records such as these, tliey either doubt the recorder's veracity or his 
 diagnosis. In all cases, the treatment generally was what every one 
 naturally resorts to.
 
 NOTES OX DlPIITriKlilA. 811 
 
 (1) Internal Medicines. 
 
 Large doses of potass, clilorate and tinct. ferri. perchlor. were given 
 internally, where it was possible to get it swallowed, but this was 
 impossible in at least one-fourth of the cases, viz:— in children of very- 
 tender years, and a few older ones, who struggled so violently that it 
 was considered inadvisable, after one or two attempts, to force them to 
 take the medicine. 
 
 (2) Diet. 
 
 The diet was in all cases, from the moment of seeing them, of the 
 most nourishing kind. Milk, strong beef tea, chicken soup, and jelly, 
 oysters, especially in adults ; and lastly, cream was administered in a 
 number of cases where beef tea and chicken soup could not be taken, 
 without causing nausea. Fortunately, as I stated before, the cases were 
 nearly all in households where all these forms of nourishment were in 
 abundance, and I feel certain that, had they been otherwise, I would 
 have had a greater number of fatal terminations. I should have 
 mentioned that switched eggs, with milk and brandy, were used freely. 
 So fa»', the treatment mentioned is what is done by almost every medical 
 man who is called to see a jtatient suffering from diphtheria ; but it 
 is better to give every detail of treatment, so that the diff"erent parts of 
 the treatment will have their own share of credit or discredit. 
 
 (3) Local Applications. 
 
 The first few cases in the first epidemic, I also treated by local 
 applications to the diphtheritic patches and throat generally of liq. ferri. 
 |)erchlor. and glycerine, one to four ; but although only two deaths 
 occurred out of the eight so treated, I had the feeling that had I not 
 used it in one of those two cases, it would have recovered also. The 
 application caused such intense congestion and catarrh of the pharynx, 
 spreading thence to the larynx, that I stopped it altogether in three 
 cases after a few ai)plications ; and one strong girl of 12, who certainly 
 was in a very low state before the last application, died from asphyxia 
 thirty minutes after the application, her mouth and throat being full of 
 frothy mucus. 
 
 I then resorted to the local treatment advocated by Dr. Roliert 
 Bell, of Glasgow, who claims to have had few, if aiiy, deaths in several 
 hundred cases, viz., glycerin, acid, carbolic c liq. ferri perchlor. and acid 
 sulphurosum. This did well in some cases, but did not pi-event death 
 occurring in a case in which the treatment was carried on from the start. 
 It also had the objection noticed in the perchloride application, causing 
 intense congestion of pharynx, and profuse mucous catarrh. I then 
 tried the application of carbolic acid. This I applied pure with a glass 
 brush, painting the patches whenever they appeared in adults, and equal 
 parts of glycerine and carbolic acid in cases of children ; then sprayed 
 the throats every two or three hours with the following : — R Acid, 
 carbolic. Jj, glycerini ^iv, aq. ad. jxij. 
 
 The results were excellent ; where the case was seen early, and the 
 patches destroyed at once, the disease was very much shortened, and in 
 several cases the patches did not reappear. In fact, in two adults, the 
 attack was to all intents and purposes aborted, that is to say, the pain
 
 812 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 in throat, ear, and neck disappeared ; they picked up strength in a day 
 or two, and were going about their usual occupations in a week. This 
 last form of treatment I used almost as a matter of course for a good 
 nximber with the nourishing diet referred to, and for a while with good 
 results ; but at last one fatal case, followed by another, showed that even 
 though excellent results from it were obtained, still that it was by no 
 means to be looked on as a specific. It was at this time that I was 
 attending the young woman referred to so frequently before. It was a 
 most virulent attack, the fauces, tonsils, pharynx, &c., being, as I stated 
 before, one mass of dirty greyish looking patches. I destroyed the 
 patches with carbolic and glycerine, equal parts. The usual stimulating 
 diet was ordered, and the spray of carbolic acid, glycerine and water 
 ordered every two hours. Persistent vomiting set in, accompanied b}' 
 epistaxis, and next day she was distinctly worse, dyspnoea being marked, 
 and the face pale and anxious. The membrane had reappeared worse 
 than ever, and she was soon in a critical condition, no food nor drink 
 being retained by the stomach. I immediately resorted to nutritive 
 enemata every two hours, the bowels to be cleared out once a day 
 by an enema of pure warm water, each enema to consist alternately 
 of two ounces of peptonised milk and beef-tea, with a dessert- 
 spoonful of brandy in each. In desperation as to further local 
 applications to the throat, and as tracheotomy would not be per- 
 mitted, I thought I would try the solvent action of zymine, so 
 I altered the spray as follows: — R Zymine 3ij, sodte bicarb. 3 ijj 
 aq. ad. ^ iv, to be sprayed every two hours alternately with R Acid. 
 carbolic ^j, glycerine Jj, aq. ad. J xij. Twenty -four hours afterwards, 
 one would hardly have known the girl ; the throat had cleared to a great 
 extent, leaving however extensively sloughed surfaces. The face was 
 easy, and breathing much better. The vomiting and epistaxis had both 
 stopped, and she was able to retain the enemata, which I ordered to be 
 continued for other twenty-four hours. The spraying was to continue as 
 before. Before giving up the enemata, the next day I tried if she could 
 swallow, but she rather alarmed me by nearly choking and coughing 
 paroxysmally. Soon afterwards, other symptoms of diphtheritic paralysis 
 supervened, and I continued the enemata for about a week, adding liq. 
 stryehnise m. v, three times daily. She was weakly, and not able to do 
 mucli for over six months, but is now well and strong. 
 
 This treatment of applying zymine locally, alternately with carbolic 
 acid and glycerine, I have tried in eighteen or twenty cases, and in none 
 of them was there a fatal termination. Whether this result was simply 
 ]y)st hoc or propter hoc, I cannot say, l)ut theoretically zymine should be 
 valuable in diphtheria, and certainly deserves a fair trial. 
 
 Tlie other case of diphtlieritic paralysis I only saw after it had 
 developed, and she seemed to me to be in extremis. I resorted to the 
 same treatment, and she, after lingering for a little, slowly improved. 
 
 (4) Inhalation of Steam and Eucalyptus. 
 
 As to steam inhalations, I tried them in at least a dozen cases ; but 
 from the cause I referred to before, viz., draughty houses, I was unable 
 to continue them. The apparatus for employing the inhalations 
 (which all contained eucaly})tus) was very imperfect, and no trained
 
 NOTES OX DII'lITHEIUA. 813 
 
 nurses being obtainable — consequently the orders for giving them not 
 being correctly carried out — I was forced to desist. 1 would find the 
 atmosphere in the room damp, the bed clothes damp, everything in the 
 I'oom in fact damp, from rajnd condensation due to the quite too free 
 ventilation. 
 
 Tkaciieotojiv. 
 
 Referring to tracheotomy, I only performed it on two occasions — one 
 successfully, the other with a fatal issue. The first one I performed on 
 the fourth day of the disease, and resorted to rectal alimentation every 
 three hours, and the child was well in a fortnight. In the other case 
 referred to, I was not permitted to do the operation till the child was 
 choking ; even then the relief was so great that the parents regi-etted 
 their obstinacy in not permitting it before. He lived twenty-four 
 hours. 
 
 I find that there is a great prejudice existing in the [)ublic mind, at 
 least in the country, against tracheotomy. The parents generally say, 
 " If my child is to die, it will die, but don't give it any more pain than 
 it has already," and one cannot reason them out of it. This, I dare say, 
 does not apply to the people in the city quite so much, for as a rule 
 they have more education, and are more able to comprehend the increase 
 of hoi)e of the child's life hy an early operation, compared to leaving the 
 question of operation till the child is almost moriI)und. 
 
 Summary. 
 
 In summing up this rather fx-agmentary contribution, I shoidd like to 
 draw your attention to the following points, which I consider the salient 
 ones : — 
 
 ^6- to Etiologi/. — I believe that in certain districts of this colony 
 diphtheria is endemic. I ha^e pointed out already that it is endemic 
 in my own district, and notably in some parts of it. I also have 
 pointed out that it occurred in a much greater percentage of adults 
 than is generally appreciated, and this I put down to the cause just 
 mentioned, viz., endemicity. 
 
 In purely epidemic di{)htheria (and I suppose this holds good in some 
 other infectious diseases) very few adults are affected ; but oppositely, 
 where the disease is endemic, I am convinced that adults run almost as 
 great a risk as the children. Certainly their powers of resistance are 
 greater ; and if diphtheria arises in the districts referred to from bad 
 water, or malarious influences, the only difference in their susceptibility 
 is their power of resistance, and the same, I think, accounts for there 
 being no deaths among the cases in adults referred to. 
 
 As to Season. — The four epidemics all occurred in autumn, when 
 everything was burned up after the summer heat ; when the rivers were 
 low, and their muddy banks were exposed to a hot sun ; when the air 
 was dry and non-refreshing, full of dust, and probably particles of 
 decayed matter ; and, which I think is, perhaps, more important than 
 either of those just mentioned, when everybody was worn out by a long 
 hot summer, leaving their staying powers very much below par. 
 
 Two points in Treatment are worthy of note : — (1) Early rectal 
 alimentation which is medicated by the addition of doses of liq. strych.
 
 814 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA, 
 
 suitable for tlie patient ; and m this, I think, we have the means of 
 savino- many lives, especially in young children who won't swallow 
 medicine, and won't swallow food for fear it contains medicine. This I 
 would earnestly ask some of you to give a trial. 1 2) The local applica- 
 tion of zymine as a solvent of the diphtheritic membrane. I am 
 persuaded that, in the cases I have recorded, it did act as a solvent 
 of the membrane when I could not get rid of it otherwise. The numbei- 
 of cases I have tried it on are too few to pei-mit one to dogmatise ; but 
 I would suggest that it may be a very valuable adjuvant to our para- 
 phernalia of diphtheritic applications. As to the abortive treatment, by 
 applying pure carbolic acid to the patch in the early stage, I fully 
 believe that in a case seen early you can, in certain instances, shorten 
 the duration of the disease. 
 
 DISCUSSION ON DIPHTHERIA. 
 
 Dr. Hayward (Adelaide) did not think that the constitutional 
 symptoms were always secondary. He had seen the constitutional 
 symptoms precede the local changes. With regard to treatment, anti- 
 septics were necessary, but he preferred to give them internally. 
 
 Dr. Nicholson (Benalla) did not think the disease was a local one. 
 He had seen a case of diphtheria located in a boarding-house 'full of 
 boarders ; he had sucked up the false membrane, and he did not regard 
 the disease as being very contagious. The presence of albumen in 
 the urine was no criterion in diagnosis. 
 
 Dr. Appleyard (Tasmania) commented on Dr. Jamieson's paper. 
 
 Dr. Curtis (Semaphore) said death rarely occurred in the tonsillar 
 cases, but nearly always occurred in the laryngeal cases. He used 
 turpentine internally and externally. 
 
 Dr. Scott (Warmambool) regarded diphtheria as just as contagious 
 as small-pox or gonorrluea. He strongly I'eeonnnended the use of 
 eucalyptol or turpentine in the form of sprays. He feared that the use 
 of carbolic acid tended to [)roduce pai-alysis afterwards. 
 
 Dr. JosKE (Melbourne) had sucked up diphtheritic membrane in a 
 tracheotomy case. Tiiree days afterwards his fauces and tonsils were 
 inllamed and covered with false membrane, and he suffered from fever. 
 He was ill for eight days, and recovered in fourteen. 
 
 Dr. Hudson (Nelson, N.Z.) regarded diphtheria as a local disease. 
 Membranous croup and diphtheria are identical. At the same time 
 we must remember that it is not always easy to distinguish croup from 
 forms of laryngitis. He preferred sulphurous acid as a remedy. 
 
 Dr. WooLDKiDGE (Melbourne) said if croup and diphtheria were 
 identical, then diphtheria had existed for a very long while. He 
 was in the habit of removing the membrane mechanically. 
 
 Dr. CoANE (Melbourne) believed that the local spread of diphtheria 
 can be prevented by the application of a nitrate of silver solution, 
 twenty grains to the ounce.
 
 DISCUSSION ON DIPIITIIEKIA. 815 
 
 Dr. B. J, Adam (Beaufort) used inhalations of eucalyptus oil in 
 his practice. 
 
 Dr. Newman (Geelong) referred to the strength of oil used. 
 
 Dr. Spkingthokpe (Melbourne) said a large number of cases of 
 "diphtheria" sent into the Melbourne Hospital turned out to be 
 epidemic influenzal sore throat. Locally there was a deposit of mucus, 
 simulating false membrane. In those cases in which the catarrh invades 
 the tonsillar and epiglottidean regions, the resemblance was marked. 
 It is probable that such cases, and also cases of simple catarrhal 
 laryngitis, are called diphtheria in practice. 
 
 Dr. J. W. Barrett (Melbourne) said it was quite obvious, from 
 the remarks of speakers, that a distinction must be made between 
 diphtheria and such affections as follicular tonsillitis on the one hand, 
 and between diiihtheria and forms of laryngitis, attended with mucoid 
 exudation (but not with formation of false membrane), on the other 
 hand. Dr. Jamieson had related cases in which the inoculation of 
 the diphtheric poison had pi-oduced diphtheria. Dr. Joske had related 
 his experience in the matter, and he (Dr. Barrett) knew of a case 
 in which a medical man succumbed to diphtheria brought on by sucking 
 false membrane out of the trachea in a tracheotomy case. It seemed to 
 him absurd to endeavour to refute the conclusion based on the exact and 
 definite evidence adduced by Dr. Jamieson. This conclusion was that 
 di])htheria could be produced by local inoculation ; the facts did not 
 prove that it could not be produced in any other way. 
 
 Dr. Jamieson, in rejjly, said that there were forms of laryngitis and 
 of tonsillitis which are not diphtheria, but which are often difficult 
 to distinguish from true diphtheria. These affections, probably, 
 predispose to diphtheria.
 
 SECTION OF PSYCHOLOGY. 
 
 PRESIDENT'S ADDRESS. 
 
 By F. N. Manning, M.D. 
 
 luspector-General of the Insane in New Soutla Wales, and Lecturer on 
 Psychological Medicine in the University of Sydney. 
 
 In taking this chair, I have first to acknowledge the courtesy and 
 consideration which induced the Council of the Congress to select as the 
 President of this Section, the senior officer of the Lunacy Department 
 of the mother Colony, and next — it being my good fortune to occupy 
 this position — to express my personal gratification at presiding over the 
 First Session of the important Section of Psychological Medicine. 
 
 The choice of a subject on which to address you required some thought 
 and consideration. I could scarcely hope to say anything very new or 
 very interesting on the more abstract and scientific questions pertaining 
 to our specialty ; and remembering that this is our hundredth birthday, it 
 occurred to me that I might, with interest to you and possibly with 
 interest and advantage to those who may come after us, review our 
 present position in regard to lunacy matters in Australia ; set up in fact 
 a sort of mile-stone on which to record our i)Osition and progress ; and 
 then, if time permits, indicate some of the steps which it behoves us to 
 take on our path onward. 
 
 I shall trouble you as little as possible with statistical details, beyond 
 what are necessary to bring out and make clear the more salient and 
 important facts, and shall relegate to an appendix various tables and 
 returns, which are of considerable interest, and for the means of compiling 
 which I am indebted to my confreres and co-workers — the heads of the 
 Lunacy Departments in the various Australasian Colonies. The returns 
 from New Zealand are given separately. It is much to be regretted, 
 that the statistics from Western Australia are so imperfect as to be useless, 
 except on one or two main points ; but I felt that I could not trouble 
 Dr. Barnett for more details, after his statement in reply to my second 
 letter of enquiry, that his "asylum work was merely an item of his 
 general duties, and that he had no assistant." 
 
 The first point I shall notice is, the proportion of insane to population : — ■ 
 
 On December 31, 1887 (and I may mention here, that all the statistics 
 I have collected go to the close of 1887), the population of the 
 Australian Colonies was 2,951,590, and the number of insane, 8,435.
 
 president's address — SECTION OF PSYCHOLOGY. 817 
 
 There was, therefore, 1 insane person in every 349, or 2-86 jier 1000 ; 
 the proportion of insane men being 1 in 330, and that of women 1 in 
 377 (Table I). 
 
 There was considerable ditt'crence in the proportion in the different 
 colonies (Victoria, 1 in 21)4 ; Western Australia, 1 in 351 ; New South 
 Wales, 1 in 369 ; New Zealand, 1 in 380 ; Tasmania, 1 in 399 ; 
 Queensland, 1 in 419 ; South Australia, 1 in 431), Victoria heading the 
 list with 1 insane person in every 294, and Queensland and South 
 Australia closing it with 1 in 419, and 1 in 431 respectively. The 
 proportion in New Zealand was 1 in 380. The reason why lunacy is 
 more prevalent in Victoria than in the other colonies, I must leave for 
 your discussion, merely suggesting that the returns seem to point to a 
 somewhat over stringent registration — patients on leave of absence 
 being retained on the books for long periods. In the case of Queensland, 
 there has been hardly time for the full accumulation of chronic cases — 
 a process which takes some years. 
 
 How does the proportion of insane in Australia compare with that 
 in Great Britain and Ireland'^ On December 31, 1887, the proportion 
 in the mother country was 1 in 342, or 2'92 per 1000 ; the range being 
 from 1 in 316 in Ireland, to 1 in 346 in England (Table II). So that 
 at present the burden of insanity in Australia is somewhat less than in 
 the United Kingdom (1 in 349 in Australia, as against 1 in 342 in 
 Great Britain and Ireland). 
 
 Is insanity in Australia increasing in proportion to the general 
 }»opulation ? I must answer this question in the affirmative, and add 
 that the increase has during the last 10 years been only a slight one, 
 and would appear to be due to the accumulation of chronic cases, and 
 not to any })roportional increase in the rate of " occurring insanity." 
 On December 31, 1877, the proportion of insane to population was 1 i]i 
 356, or 2-80 per 1000, as against 1 in 349, or 2-86 per 1000 ten years 
 later, b}' no means a large increase, and mainly in the younger colonies. 
 In the older colonies there was even some decrease. In Tasmania, the 
 proportion decreased from 1 in 317 in 1877, to 1 in 399 in 1887. In 
 New South Wales there was a slight decrease. The proportion in 
 Victoria was practically unchanged. South and Western Australia and 
 Queensland showed an increase — greatest in the latter colony (Table I). 
 
 The admissions in proportion to the population, which show the ratio 
 of "occurring insanity," were in 1878, 1 in 1550 ; and ten years later, 
 1887, had dropped to 1 in 1738 ; the average for the 10 years being 1 
 in 1690 (Table III). 
 
 The nationality of the insane at present under care is of interest now, 
 and will be of equal, if not of greater interest, to those who may examine 
 our statistics some years hence. These statistics are not as exact as 
 
 2o
 
 818 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 they might be, owing to imperfect returns from Victoria and Tasmania, 
 in which the nationality of a considerable number is returned as 
 " unknown " ; but they show several important facts, the chief among 
 them being, that only 23'12 per cent, of the insane now under care were 
 born in Australia, and that the larger proportion of our patients there- 
 fore are of other than Australian nationality. Upwards of 26 per cent, 
 are from Ireland, 23 per cent, from England, 6 per cent, from Scotland, 
 2 per cent, from Germany, and 2 per cent, from China ; whilst xmder the 
 heading of "other countries and unknown," nearly 14^ per cent, are 
 tabulated. Of these, about 5 per cent, come from countries other than 
 tliose already specified, and include stray specimens of nearly every race 
 and nationality. Those tabulated as " unknown " in the Victorian and 
 the Tasmanian statistics, are evidently of foreign as opposed to 
 Australian nationality, and by far the larger proportion should be 
 credited to England, Scotland, and Ireland, and go to swell the already 
 large percentages from these countries (Table IV). 
 
 The proportion of patients of Australian nationality is, as might be 
 expected, much greater in the older than in the younger colonies, and 
 ranges from 12 per cent, in Queensland to 32 per cent, in Tasmania. 
 No detailed census has been taken since the year 1881, and it is not 
 possible therefore to fix accurately the relative proportion of the insane 
 with regard to nationality; but there can be no doubt that the 
 proportion of insanity is, throughout Australia (as it was in New South 
 Wales in 1881), much greater among the foreign than among the native 
 born. At that time, in New South Wales, the proportion of insane 
 per 1000 among persons of British nationality, was 8-03, and among 
 foreigners G'87; whilst among Australians, it was only 1-22 per 1000. 
 
 The comparatively small proportion of insanity among Australians is 
 partly to be accounted for by the fact that fully one-third of these are 
 children, whilst insanity is mainly a disease of middle life and old age; 
 but there are some reasons which I have not time to detail, which lead 
 to the pleasant conclusion, that Australians are less subject to insanity 
 than people of other races living in Australia. 
 
 Turning now to the question of the recovery and death-rate of insane 
 persons under treatment and cai-e, it is satisfactory to find, that with 
 all the imperfections of Australian asylums, and the difficulties with 
 regard to management which beset us, but from which the medical 
 officers in English asylums are happily free, our recovery and death-rate 
 compare not unfavourably with those in asylums in the mother country. 
 Taking the decennial period from 1878 to 1887 (and statistics on these 
 points are apt to be misleading unless they include quinquennial or 
 decennial periods), the recovery rate in Australian asylums was 42-09 per 
 cent., whilst in addition 6 "97 per cent, were discharged as relieved, as com-
 
 president's ADDKESS — SECTION OF I'SVCHOLOfiY. ^19 
 
 pared with a recovery rate of 40-04 j)er cent, in English asylums for tlie 
 corresponding ten years. The recovery rate in Scotch and Irish asylums 
 averaged a little below 40 jier cent, for the same period. 
 
 It should be noted, however, that whilst the statistics of Australian 
 asylums include idiots — a very incurable class — these are eliminated 
 from the English statistics, and the Australian returns are therefore 
 even better than they would at first sight appear. 
 
 The death-rate in Australian asylums for the decennial period above 
 mentioned was 7"09 per cent., whilst in England it was 9"58, and in 
 Scotland 8-~)0. The death-rate in the various colonies was as follows : — 
 Queensland, ')-S2; New South Wales, Gw2; Victoria, 7*11; Tasmania, 
 8'00; South Australia, 9-00. The New Zealand death-rate was 5'94 
 (Table Y). The returns from Western Australia are incomplete. 
 
 The small death-rate in the young colonies of Queensland and New 
 Zealand -is interesting in connection with the rapid increase of insanity 
 in these colonies, and the difference between the Australian and English 
 rate goes far to account for the somewhat rapid growth of insanity in 
 all the Australian colonies as compax'ed with the mother country up to 
 very recent years. The warmth and equability of our climate, which 
 render our patients much less liable to pneumonia and other chest 
 afiections than the insane in Great Britain, have, I think, more to do 
 with the low death-rate than any other causes, and it is interesting to 
 observe that, with one exception, the warmer and more equable the 
 climate, the lower the asylum mortality. 
 
 With regard to the classification of the insane, it ap])ears that of the 
 total number 9 "So per cent, are suffering from undevelojied intellect — 
 are, in fact, imbecile or idiotic ; 3"07 per cent, are under criminal dis- 
 abilit}' ; nearly 1 per cent, are still at the charge of the Imperial 
 Treasury — the relics of a by -gone regime — and 86 '59 per cent, belong 
 to the ordinary class of the insane who have had intellect and lost it, 
 and who are under no criminal ban (Table VI). Only 1188 of the 
 total number of 8435, or 14-08 per cent, are deemed curable ; so that 
 the large mass of our asylum population consists of chronic and incur- 
 able patients (Table VI), The differences in the proportion of the 
 various classes in the different colonies as shown in Table VI are 
 interesting, but I have not time to discuss them or their probable 
 causes. 
 
 I should have Ijeen glad to discuss the question, •' Does insanity, as 
 seen in Australia, differ in its forms and types from insanity in other 
 countries 1 " but on this point I must content myself with placing before 
 you one or two facts relative to general paralysis, a most interesting and 
 typical form of insanity, which has only been fully known and recognised 
 in modern times, and which is undoubtedly increasing in frequency. 
 
 2g 2
 
 820 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 This peculiar affection is at present muck less common in Australia 
 than in England. The proportion of general paralytics admitted to 
 Australian asylums in 1887 was I'S per cent, of the total number 
 admitted, whereas the proportion admitted into English asylums for the 
 same year was 8-6 per cent. (Table VII). 
 
 Again, the proportion of general paralytics admitted to the New 
 South Wales asylums for the quinquennial period 1883 to 1887 was 
 3'4 per cent., whilst the proportion admitted to English asylums for the 
 same period was 8*4 per cent. (Table YIII). This disease already 
 appears more common in the older than in the younger colonies, and it 
 will be intei'esting to observe if it increases in all. 
 
 I may note in passing that as yet epilepsy is decidedly less common 
 in Australian than in English asylums (Table YII). 
 
 Time will not peimit of any lengthened notice of the lunacy laws of 
 the Australian colonies, Ijut this is a subject which I cannot pass over 
 altogether in silence. 
 
 Each colony has its own Lunacy J^ctn, [)assed at various dates, com- 
 mencing with that for Tasmania in 1858, and ending with that for 
 Queensland in 1884, The foundation of all of them is English law and 
 precedent. The superstructure varies with colonial needs and expediency. 
 The scattered population, the paucity of qualified medical practitioners, 
 the enormous distances, and various other matters, have had to be taken 
 into account, and legislation adapted thereto. 
 
 In all the colonies (except in the case of indigent patients committed 
 by Justices in Tasmania and South Australia, where one medical 
 certificate is accepted) two medical certificates are required before 
 patients can be admitted to hospital. In all, patients can be admitted 
 at the " request " of relatives or friends, if such request is accompanied 
 by two medical certificates. In all there are stringent provisions, that 
 the persons signing the " order," " request," and certificates shall be 
 independent and nnassociated persons. In all there are provisions for 
 the rejection of imperfect certificates; and in all, except Tasmania and 
 South Australia, where there are special arrangements, the medical 
 officer of the hospital must give a separate and independent certificate of 
 insanity within a brief period after admission, or the patient cannot be 
 detained. There are also in all abxmdant provisions for inspection by 
 inspectors, commissioners, official visitors, or other authorised officials, 
 and the interests of the patients are as fully guarded with regard to 
 discharge as to admission. 
 
 On the whole, the lunacy laws of the Australian colonies appear to be 
 satisfactory, sufficient, and well abreast of the time. They are in no 
 way behind, and in some respects ahead of the legislation in Great 
 Bi-itain, tlie United States, Canada, and the principal European countries.
 
 PRESIDENTS ADDRESS — SECTION OF PSYCHOLOGY. 821 
 
 111 the provision of receptiou-liouses in New Soutli Wales and Queens- 
 land, and of lunacy w;ird.s in })ublic hospitals in Victoria, for the 
 treatment of insanity in its early stages, the Statutes are decidedly in 
 advance of those of Great Britain. 
 
 During the year 1887, the Master in Lunacy in New South Wales 
 ap])lied to the English Courts for the payment to him of money 
 belonging to a patient in one of the hospitals of the colony, and in 
 delivering judgment* Lord Justice Cotton thus expressed himself : — 
 " We have been referred to the Lunacy Act of New South Wales, and 
 undoubtedly that Act contains provisions which make it practically 
 ini[)ossible that anyone should be in an asylum without sufficient 
 reason." Whilst Lord Justice Bowen said : — " I desire most emphati- 
 cally to add my voice to what has been said by the Lord Justice as to 
 the provisions of the Colonial Ijegislature, being above all comment and 
 criticism as regards these insane patients. We have the most ample 
 confidence, not only in the legislation, but in the officers who administer 
 the law, and the patient is surrounded by all the protection and safe- 
 guards that could reasonably be invented for the purpose of taking c^re 
 of herself and her ])roperty." 
 
 What is here said of the lunacy laws of New South Wales might, 1 
 believe, be said with but little reservation of the lunacy laws of all the 
 Australian colonies. The newer Acts are, as they should be — the 
 better. Our younger sister, Queensland, has been able to see the few 
 weak points in the legislation of the older colonies, and avoid them. 
 
 Whilst I am on this subject, I may mention that during the last three 
 or four years there has been in England an outcry for the reform of the 
 Lunacy Acts, and so-called reformers have advocated three I'adical 
 changes : — 
 
 (1) That no }>atient shall be sent to an hospital or licensed house, 
 unless examined and committed thereto l)y a judge or magistrate. 
 
 (2) That all such committals shall be for a definite time — say one or 
 two years, and shall l)e renewed if necessary. 
 
 (3) That all medical certificates shall be signed by specially a]ipointed 
 medical practitioners or exjierts. 
 
 I think there is reason for the strongest objections to each and all of 
 the.se proposals. It is clear that they would widen the breach between 
 the care and treatment of diseases of the brain and diseases of other 
 organs, which for years all the teaching, all the endeavours, and all the 
 wisdom of modern science has been endeavoui'ing to close and annul, and 
 did time permit, I should, I think, be able to show that such legislation 
 would be a retrograde step, and be able to give good and sufficient 
 reasons for its rejection. 
 
 ' Law Report, Chanceiy Div., Part 12, 1887.
 
 822 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 As yet there is no special legislative provision for idiots and imbeciles 
 ill any of the Australian colonies, and the English "Idiot Act of 1886,"^ 
 entitled "An Act for giving facilities for the care, education, and 
 training of idiots and imbeciles," might with advantage be adopted. 
 
 In Great Britain, there are various methods of providing for the 
 insane. Besides State institutions for criminals, and for the insane of 
 the military and naval services, there are county, district, and parochial 
 asylums, as well as lunatic wards in poor houses, under the management 
 and control of local authorities, and the inspection of Government 
 Officials ; lunatic hospitals under trustees, in which the excess payments 
 of the well-to-do are used for the support of those less favoured of 
 fortune ; private asylums, which receive j^atients at rates suited to 
 almost all classes of paying jiatients ; a system of payment to relatives 
 towards the support of the insane ])oor ; and in Scotland and other 
 ])laces " boarding-out " with strangers who have no connection with, or 
 interest in, the patients, except the monetary one. 
 
 In Australia, with the exception of private asylums in New South 
 Wales and New Zealand, the whole of the institutions for the insane are 
 under State control, su})ported l)y funds provided by Parliamentary vote, 
 and managed directly bv the Government, and there is no established 
 system of payment to relatives, or " boarding-out." 
 
 In Great Britain, with an elaborate system of local government, the 
 result of long experience, the local or district provision for the insane 
 leaves little or nothing to be desired. In America (where local govern- 
 ment is less completely organised), whilst the State asylums are 
 admirable, the institutions under local or municipal control are for the 
 most part dismal failures. The fifth report of the State Committee on 
 lunacy of the Commonwealth of Pennsylvania, published only a year or 
 so ago, contains the following statement: — "The entire arrangement 
 and government of many of the county institutions are such that 
 the insane poor cannot be otherwise than neglected and cruelly 
 wronged, and the treatment of this unfortunate class in poorhouses 
 has been simi)ly that of continued neglect." The details given in this 
 and other reports, from Pennsylvania, New York, and other States, 
 aro simply horrible. 
 
 [ see nothing in the present state of local government in Australia 
 wliich leads me to think that municipal or county authorities would be 
 any better guardians for the insane than they are in America, and I 
 think our insane fortunate that they are, so far, wards of the State. It 
 would lie well, however, if our State institutions were supplemented by 
 others, like the lunatic hospitals at home, managed liy trustees for the 
 good and profit of the ))atients only, and bearing the same relation to the 
 sick in mind as our general hospitals do to the .sick in body.
 
 PRESIDKNT's address — SECTION OF PSYCHOLOGY. 823 
 
 As yet, private benevolence lias not stepped in to assist in tlie 
 maintenance and care of the insane in Australia. We have no insti- 
 tution.s like the Maclean Hospital in Massachusetts ; the Pennsylvanian 
 Hospital for the Insane at Philadelphia ; the Hospital at Cotoii Hill, 
 near Stafford ; Barnwood House, near Gloucester ; the Friends' Retreat 
 at York ; St. Andrew's Hospital, Northampton ; the Holloway 
 Sanatorium at Virginia Water ; Murray's Asylum at Perth ; the 
 Crichton Institution at Dumfries ; or the several Royal Asylums at 
 Edinburgh, Montrose and Glasgow, and other cities. I mention these 
 as types of many others in Great Britain and America, all of them 
 magnificent institutions, built or endowed by private benefiuence, for 
 the care of patients who are not able to meet the charges for main- 
 tenance. In tiie small New England State of New Hampshire, 
 upwards of <£54,000 has been bequeathed for the benefit of the patients 
 in the State asylums, and the interest is now expended by the 
 trustees for their benefit. This is by no means an exceptional instance 
 in America ; whilst, so far as I am aware, not one penny of private 
 means from subscriptions, donations, or legacies, is available for the 
 maintenance of insane persons in this great continent. 
 
 I trust that such an opprobrium will not long continue, and that 
 ere long, the sick in mind may share with the sick in body in the 
 contributions of the benevolent. I know no way in which the surplus 
 wealth of the rich can be better expended. I know no way in which 
 more real solace and comfort can be afforded, and a truer charity 
 exerci.sed, than in placing in a position of comfort the minister of 
 religion, the physician, the artist, or the teacher who would, except for 
 such aid and assistance — owing to the loss of all means through a 
 cruel malady — be left to the charity of the State, and have to herd 
 with the vagi-ant and the pauper, though still retined, still cultured, still 
 with tlie instincts of a gentleman. 
 
 Again, though I am no advocate for private asylums, I think these 
 institutions — for the richer classes — have a useful place in an asylum 
 system, and can make provision for those who cannot he so adequately 
 cared for under the, perha[)s necessary, restrictions as to outlay in 
 Government institutions. 
 
 Until within the last few years, all the hospitals for the insane in 
 Australia received all classes, and wei'e in no way specialised ; but with 
 the growth of population, the wi.sdom, nay, the necessity, of providing 
 .separate acconnnodation for criminals, for idiots and imbeciles, and for 
 the large class of chronic in.sane, has been recognised. 
 
 New South Wales, Victoria, and Tasmania have already, practically, 
 distinct institutions for criminals. In New South Wales there is a 
 sepai-ate hospital for idiots. In Victoria and Tasmania these classes aie
 
 824 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 placed in cottages — separate from, though in connection witli, the 
 hospitals — and the Victorian Government, to its great honour, has 
 lately made a distinct step in advance, and commenced a system of 
 special education and training, after English and American models, 
 for this feeble-minded class. 
 
 The much-debated subject of the separation of the acute and chronic- 
 insane, by placing them in different institutions, has found a practical 
 settlement. At Parramatta in New South Wales, Sunbury in Victoria, 
 and Ipswich in Queensland, buildings erected for other purposes, and 
 uiisuited for the more demonstrative classes of the insane, have been set 
 apart for chronic cases, and there can be little doubt but that this 
 arrangement will be more fully carried out in tlie future, as tending to 
 economy and more systematic classification. 
 
 The system under which all patients who are brought to our hospitals 
 in all the Australian Colonies are admitted, whether there is room or 
 not, is one that, so far as I am aware, obtains in no other country— 
 certainly in no other English speaking community. In Great Britain, 
 in the United States, in Canada, a standard of accommodation is fixed, 
 and no patient is admitted in excess of this. In Great Britain, the 
 numbers in excess of the accommodation in local asylums are accommo- 
 dated temporarily in the asylums of other districts, in licensed houses or 
 poor-houses. In Canada and the United States, the temporarv accom- 
 modation ])rovided is in poor-houses, or other receptacles, and the 
 patients must await their turn for admission, should the State asylums be 
 full. Our system has one advantage, it gives us our patients in an early, 
 and in many cases curable, stage of their malady ; but it has disad- 
 vantages which outweigh this. It does not allow us to do our best for 
 them when we have got them. Our accommodation (I speak from 
 twenty years' experience) is seldom or never in advance of our needs. 
 It is often grievously behind them ; and the over-crowding consequent 
 on this is .subversive of all order, cramps, if it does not paralyse, the best 
 efforts of our medical officers, and is too often fatal to the mental health 
 of our patients. 
 
 If this system of admission is to be continued, it should be in connec- 
 tion with one for providing more sjieedily, and under less restrictions 
 than at present, ample and suitable accommodation — and this, gentlemen, 
 I fear, will never be until the management of our asylums is placed in 
 the hands of persons (a Commission it might be — these are the days of 
 Commissions) who will have more weight, and be more listened to by 
 the Government, than any single head of a department, even if an 
 embodied importunity, can hope to be. I think I have riot been remiss 
 in urging the claims of the insane in New South Wales ; but the 
 accommodation in that Colony is still far short of what is necessary to
 
 president's address — SECTION OP I'SYCIIOLOGY. 825 
 
 give 600 cubic feet per patient — the least space necessary for liealtli, 
 quiet, antl efficient atlministratioii ; and I gather that tlie same condition 
 of things exists in other colonies. 
 
 Some of the buildings in use for housing the insane in Australia are 
 strangely diflferent to what they sliould be, and require improving off 
 the face of the Continent. Thei-e are some in Tasmania, in Victoria, 
 and in New South Wales, which are heart-breaking tg those having 
 oliarge of them ; but it is to be hoped that these will soon be things of 
 the j)ast, and the line piles at Kew in Victoria, at Parkside in South 
 Australia, at Callan Park in New South Wales, at Toowoomba in 
 Queensland, and at SeaclifFe near Dunedin in New Zealand, are 
 evidences of a large and wise liberality, and an earnest of advancing 
 civilisation. 
 
 The number of medical officers to patients in Australian asylums is 
 at present far below what it should be. In the United States, it is 1 to 
 every 160; in Ontario, the foremost State of the Dominion of Canada, 
 1 to 209 ; in Great Britain and Ireland, 1 to 250 ; in Australia, 1 
 to 325. 
 
 I understand that arrangements have been made in South Australia 
 to commence this year with one additional medical officer, and the New 
 South Wales Parliament has provided n)eans for the employment of two 
 in addition to the present medical staff. 
 
 Under disadvantages, some of which I have indicated, we may, I 
 til ink, be proud that non-restraint in the treatment of otir patients is' 
 our rule — restraint the occasional exception. From the returns fur- 
 nished to me from all the Australian and New Zealand asylums, it 
 appears that restraint is on an average used only in 1 out of 300 or 
 400 cases, and then chiefly for surgical reasons, or to guard figainst 
 suicide. 
 
 Thus much as to our present position. And now, turning from the 
 present to the future, what are to be our further onward steps in the 
 care and treatment of the insane, and in the advancement of Psycho- 
 logical jNIedicine ? To the amateur alienist — at all events in Victoria— 
 the great desideratum would seem to be the leplacing of what are some- 
 what unfairly called barrack buildings by cottages ; and if one is to trust 
 newspaper reports, the Government of Victoria is aViout to take the 
 astounding step of housing some 1500 insane patients in cottages, 
 and placing this •' City of the Simple " at some distance from the 
 metroi)olis. 
 
 The objections to this sclieme have been so ably set forth by Dr. 
 Barker, an officer of the Victorian Lunacy De])artment, that it is 
 perhaps not necessary for me to go fully into the subject. Something, 
 howevei', I must say on this point.
 
 826 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Whilst I am very decidedly of opinion that cottages should form a 
 part of every Hospital for the Insane, I am also of opinion that tliey 
 cannot be very largely used, and that for three-quarters, if not nine- 
 teuths, of the insane under hospital care, cottages will be found alto- 
 gether unsuitable. They are costly to build, costly to work, difficult to 
 administer and supervise, and add little or nothing to the comfort and 
 well-being of the patients placed in them. The truth is, that the Iarg& 
 majority of patients when fit for cottages are fit for discharge. For 
 convalescents, for certain of the chronic insane - especially the steady 
 workers who do so much to carry on the farm and garden operations of 
 all hospitals — cottages afford a comfortable and suitable home. For 
 the sick they are unsuitable, as withdrawing them too much from 
 efficient medical supervision ; for a great majority of acute cases, for the 
 excited, dangerous, and turbulent, they are unsafe ; and for the chronic 
 dements, the dirty, the paralytic — who make up so large a part of all 
 asylum population — they involve too much expense, and too extended a 
 supervision, without any commensurate re.sult. Let us have cottages as 
 part of our hospitals by all means. 80 far as the hospitals under my 
 su[>ervision are concerned, I could wish for a decidedly larger proi)ortion 
 of this class of accommodation, but I do not anticipate any great 
 amelioration of the condition of the insane by this means, and if the 
 official programme is to be carried out in Victoria, I fear it will be a 
 costly mistake. The truth is, that no one form of building can meet all 
 the needs and requirements of the insane. Cottages alone will be as 
 unsi\itable as " barracks " alone. What is required is variety in the 
 construction, arrangement, and position of the buildings of an asylum, 
 so as to allow of judicious segregation, and to provide for the wants of 
 [nitients of difterent classes. If I am to indicate briefly what I consider 
 the best form of asylum ; what it is desii'able that the Psychopathic 
 Hospital of the future should consist of— I should stipulate for a central 
 lK)Sj)ital for the sick and for acute cases, surrounded by pavilions or 
 blocks of varying form and construction for different classes, and 
 supplemented by cottages for the convalescent, the quiet, and for certain 
 chronic cases. The buildings should stand on a large estate, and be 
 spread over a considerable area. They should contain abundant space^ 
 with light, airy, cheerful day rooms, large verandah.s, and well-ventilated 
 dormitories. It is essential that a quarter, at least, of the total 
 accommodation should be in the form of separate or single rooms. It is 
 important — at all events in our climate— that the day rooms should all 
 lie on the ground floor, so as to afford direct and easy access to the 
 verandahs and the open air. It is even more important that the blocks 
 or divisions should be comparatively small, so as to preveiit too large an 
 aggregation of patients, and sufficiently numerous so as to allow of a
 
 PRESIDKNT'.S ADDKESS — SECTION OF PSYCHOLOGY. 82T 
 
 varied classification. These are our main requirements, ;ind I would 
 point to the Eastern Hospital for the Insane at Kankakee, Illinois, as 
 perhaps the best existing model. Special architectural forms or styles 
 are but of secondary importance, but T would plead for space as against 
 outside ornamentation, which is too often only a mockery of the misery 
 within. 
 
 The boarding-out of pauper children has been so unqualified a success^ 
 that it has been assumed that the boarding-out of pauper lunatics is 
 likely also to have good results. The lunatic colony at Gheel, the 
 boarding-out at Kennoway and other places in Scotland, are each in 
 their way interesting and encouraging experiments. The system, as 
 tried to a very limited extent around the Sussex County Asylum, and 
 at other places in England, has not been without good results; and it 
 must not be forgotten that there are in England upwards of GOOO out-door 
 pauper lunatics, or upwards of 7 per cent, of the total number of the 
 insane, mostly living with relatives, and i-eceiving weekly relief from 
 the guardians out of the poor rates; but that it will ever be in Australia 
 a method of providing for any large number of the insane, I very much 
 doubt. I do not propose to discuss the question at length, as it is the 
 subject of separate notice in a paper by Dr. Beattie Smith, but I would 
 point out that with children there is increasing growth, increasing 
 usefulness, increasing intelligence, to appeal to the feelings of their foster 
 jtarent; whilst with tlie lunatic, there is none of these things, and the 
 conditions are altogether different. 
 
 To subsidise, assist, and encourage the friends of the chronic insane to 
 keep them at home, or to i-emove them from hospitals when fit for such 
 removal should. I believe, be part and parcel of our asylum system, and 
 in time I believe a very considerable number will be kept in their homes 
 by means of State, parochial, or municipal aid; but whilst wages are 
 high, and there is much scope for active employment, the number will 
 not be large. 
 
 The antecedent conditions which have rendered Gheel and Kennoway 
 possible — a large waste of poor land, and a miserably poor proprietary 
 who are glad of the added pittance to eke out their want of means — are 
 things which none of us can wish to see in Australia. The well-to-do 
 condition of our working classes renders the boarding-out of the insane 
 (by which I mean paying strangers to receive and take care of them in 
 their homes), at present at all events impracticable, even if it were 
 desirable; whilst the absence of village life, the isolated dwellings, the 
 sparse population, the special dangers and ditiiculties of " bush " life, and 
 the impossibility of effective medical or parochial supervision, all stand 
 in the way of an adoption of the system, except in very special and 
 occasional cases.
 
 828 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 The separation of the idiotic and imbecile from the insane, both by 
 legislative enactment, as T have already indicated, and by the provision 
 of special institutions in which they can be trained and taught, is a 
 matter of very considerable importance, and will, I have no doubt, be 
 undertaken in all the colonies as soon as the number of these patients in 
 each justifies the expense necessary for the special provision. The 
 memorandum of the Committee of the Charity Organisation Society, 
 agreed to at meetings held in London in 1877, has been virtually 
 adopted bj^ all who have thought on, and worked at, this subject. 
 
 In a few more years, when the number of the criminal insane has 
 increased, the wisdom of making provision for this class in sei)arate 
 buildings, if not in separate establishments, will, I have no doubt, be 
 acknowledged and acted on in all the Australian Colonies, as it has been 
 in England, Scotland, Ireland, in the State of New York, and in New 
 South Wales, and provisionally in Victoria and Tasmania. The further 
 question arises, whether such provision should be in connection with the 
 Lunacy or the Penal Department. Those patients who are acquitted on 
 tlie ground of insanity, who are insane first, and whilst insane and 
 irresponsible, commit criminal acts, may faii'ly and properly be placed 
 in wards or establishments in connection with the Lunacy Department ; 
 but so far as I can understand there ai-e no valid reasons why -arrange- 
 ments should not be made for the treatment of those who become insane 
 whilst undergoing sentence — who are criminal first, and insane after- 
 wards — in connection with the Penal Department. When prisoners 
 undergoing sentence suffer from bodily ailment, they are treated in 
 properly provided hospitals in the prisons. Why should not provision 
 be made in ^^I'isons also for those suffering from mental ailments and 
 brain diseases 1 Suitable buildings should not be difficult to provide. 
 The prison surgeon should be as well qualified to treat diseases of the 
 In-ain as of other organs, and the gaol warder has special qualifications 
 for dealing with this special class. The transfer and re-transfer of these 
 patients from the Penal to the Lunacy Department is a constant 
 difficulty and ti'ouble, the system leads to malingering and to numerous 
 other difficulties in both departments, and it tends to make our asylums 
 into prisons. The practical wisdom of the Scotch has solved the question 
 by establishing wards for criminal lunatics in connection, not with an 
 asylum, but with the general prison at Perth ; and an interesting 
 experiment at Woking Prison in England, where all the insane convicts 
 have been kejjt during the last 11 years, has been reported on at length 
 by Dr. Cover in an apj^endix to the report of the Director of Convict 
 Prisons for 1885-86, and has proved a substantial and gratifying success. 
 
 The most desirable and necessary onward step, as it appears to me, is 
 a more extended, largei-, and more accurate scientific study of insanity.
 
 pkksident's addrkss— section of psychology. 829 
 
 More extended with regard to the medical profession at large. Larger, 
 more accurate and scientific, so far as those especially engaged inasylnm 
 work are concerned. I think I am not over-stating the <juestion when 
 I say, that not half of the medical pi'actitioners in Australia — aye, and in 
 Great Britain also for that matter — have ever attended a lecture on, or 
 made any study of, mental diseases. In the great Medical School forming 
 part of the University of Edinburgh, although there is a lecturer on 
 insanity — in every way a master in his specialty — ^attendance on his 
 lectures is not compulsory, and he is not permitted to set a single 
 question in the examination papers for the degrees granted by the 
 University. Most of the London Medical Schools have lecturers, but 
 attendance as at Edinburgh is voluntary, and the licensing bodies make 
 psychological medicine no part of their examination. It is quite natural 
 that with so many things a student must know, he holds in light esteem 
 those things about Avhich he may or may not troiible himself at his 
 discretion, and the study of mental phenomena occupies the attention, 
 tlierefore, of only a few of the more thoughtful students. At some 
 medical schools, no provision is made for teaching the subject, and the 
 result is, that the overwhelming majority of medical practitioners can, 
 and do, obtain their diplomas to practise without having attended a 
 lecture, or answered a question on the subject of mental diseases, seen 
 the inside of a lunatic asylum, or examined a person of unsound mind, 
 except in connection with some physical ailment, as in the delirium of 
 fever. It is only a necessary consequence of this, that abnormal mental 
 pi'ocesses in their beginnings, slight deviations from mental health — 
 insanity in its most remediable stage — are too often unrecognised and 
 untreated ; and when i-ecognised, too often regarded as disorders of the 
 intellect rather than diseases of the brain, and held to be beyond the 
 ordinary resources of mental science. It is a consequence also, that the 
 medical profession as a body takes but little interest in insanity, and 
 that medical practitioners as a rule consider their duty with regard 
 to it to consist in the somewhat perfunctory signature of medical 
 certificates. But more important than all, a host of neurotic indiA'iduals 
 become insane, who under proper care need never pass the boundary 
 line, and numerous individuals who under proper advice might 
 keep sane, break the laws of mental health, with disastrous results 
 to themselves and their offspring. The young Universities of Sydney 
 ai^d Adelaide have very Avisely insisted that the study of psychological 
 medicine shall form a compulsory part of the curriculum for their 
 degrees, and that all candidates shall be examined in this subject. The 
 University of Melbourne has, as yet, taken no steps in this direction, 
 but I cannot believe that its medical graduates will much longer be 
 untaught and unexamined on this important branch of scientific
 
 830 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA 
 
 medicine. In this connection, and for other reasons wliich I cannot 
 now enter on, I regard the proposal to remove both the hosjntals for tlie 
 insane from the neighbourhood of Melbourne, and therefore from the 
 neighbourhood of the University, as wanting in wisdom and forethought. 
 The Metropolitan Hos])ital for the Insane should be in a manner 
 affiliated to the University, and should be a school of practical teaching, 
 and believe me such teaching will be fraught with the highest good, not 
 only to the students, but to the medical officers of the hospital ; will 
 give them a renewed interest in their work, and will lead to a moie 
 accurate and systematised knowledge of their subject. I believe that 
 the time is not far distant when all the medical officers of our hospitals 
 for the insane will be engaged in clinical teaching and demonstration, 
 and when arrangements will be made for the assistant-medical officers' 
 appointments to l^e held for limited periods by our newly-fledged 
 graduates. There is yet another step — and one I have for some years 
 held in hopeful view — to complete a system of alienistic medical training, 
 so as to procure an adequate supply of competent and efficient can- 
 didates for the various positions in our asylums and other medical 
 offices in the public service, as well as to advance practical psychiatry 
 and to diffuse a better knowledge of insanity throughout the profession 
 of medicine, and this is the establishment in connection with our chief 
 hospitals for the insane of a system of clinical clerk or assistantships. 
 These positions, corresponding to those of " interne " in continental 
 hospitals, should have a tenure of from six to twelve months, and cany 
 with them residence, with adequate provision for board and attendance. 
 Such a system is in force in several of the hospitals for the insane 
 in the United Kingdom, notably at Bethlem, the West Riding, and 
 at Edinburgh. It has been tried, with great })romise of public utility, 
 under the administration of Dr. Workman, in Ontario ; and the 
 Minister for Public Instruction in Italy, to his honour and to that of tlie 
 Italian Government, some time ago initiated a complete and liberal 
 scheme of this kind in connection with the University of Modena, 
 under the direction of Professor Tamburini, the medical director of the 
 asylum of Reggio Emilia. 
 
 In advocating a larger, more accurate, and scientilic study of insanity 
 by all specially engaged in asylum work, I am bound to point out that 
 we have hitherto, at all events till lately, worked too much within the 
 trammels of a somewhat narrow specialism. We liave regarded insanity 
 as standing apart from other diseases, we have gravitated so to speak 
 round psychology, and it is only of comparatively late years that we 
 have recognised that diseases of the cerebrum are only a part of the 
 great subject of diseases of the nervous system. The very name of this 
 Section of our Congress is in a measure evidence of this; and I would
 
 PRESIDKNTS ADDRESS — SECTION OP PSYCHOLOGY. 831 
 
 isnggest that at our future meetings a Psychological and Neurological 
 Section would be a more fitting appellation in relation to the ground 
 which we desire to cover. By the study of general paralysis, which is 
 A disease not only of the brain, but of the whole nervous system, by 
 the ascending course of some diseases of the spinal cord, by which ataxic 
 ami paraplegic subjects V)ecome dements, by examples of general sclerosis 
 of the nervous tissue and other affections, we are being shown the 
 intimate correlation of disease ; and the study of cause and effect is 
 demonstrating to us that if a large jtart of our insanity is not a.bsolute]y 
 caused by diseases of other organs, there is no single part of the 
 economy, lesions of which may not bring about psychical disorder in 
 pre-dis])osed subjects. We are beginning to understand, but as yet we 
 are far from an accurate and scientific knowledge of what may be called 
 the alternations of neuroses, that though neurotic manifestations may be 
 different in the individual, and interchangeable by inheritance from 
 generation to generation, they are practically of one family and essence. 
 In truth, as has been well said by a recent writer, " We have crossed 
 the threshold of the great temple of mind, but we know little of the 
 inner sanctuaries." This knowledge can only come by adding to our 
 empirical work and observations a scientific comparative study of the 
 homologies of disease. 
 
 That the study of insanity has not heretofore been as scientific and 
 accurate as is desirable, is not the fault of the medical officers of 
 hospitals for insane in Australia. They are overweighted and over- 
 burdened with other work, and until their number is increased in 
 proportion to the patients under their charge, they cannot undertake the 
 pathological, the microscopical, and the scientific thei'apeiitical work 
 which should be steadily progressing in every hospital. 
 
 I believe that the large majority of those engaged in the care and 
 treatment of the insane are duly impressed with the advantage, nay the 
 necessity of systematic and varied amusements as an aid in curative 
 treatment; and the increasing pei'centage of i»atients actively and 
 usefully employed in our asylums shows that the value of employment 
 towards the same end is duly appreciated. 
 
 The importance of a generous dietary, indeed of a wise liberality in 
 the matter of food is fully recognised, and not a few of us are disciples 
 ■of the " gospel of fatness," so ably and eloquently preached by Dr. 
 Clouston ; but I believe there are some curative agents which are neither 
 as fully nor as wisely employed as they should be, and which it behoves 
 us to use with greater accuracy, greater care, and greater method. And 
 first, as to drugs. Medical men, and those practising our specialty in 
 common with the rest of the profession, have become only too often 
 sceptics in medicine, as well as in religion ; and to quote a distinguished
 
 832 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 American alienist, they " give tlieii* physic as they say their prayers — 
 without expecting any immediate or any literal answer." Now I would 
 deprecate this mental attitude, aud urge a more liberal and more 
 accurate, and in some cases a more continuous employment of drugs. 
 Considering the immense importance of sleep, do we study sufficiently 
 the old vegetable neurotics and their alkaloids, and the newer chemical 
 compounds, in regard to their action and their dosage with the view of 
 pz'oducing sound and yet harmless sleep? Do Ave not fail in many of 
 the cases in which we do employ sedatives, because we measure out 
 inadequate quantities to calm the excitement of mania, or the distress of 
 melancholia? Considering the marked trophic changes in many forms of 
 insanity, do we employ the alteratives, such as arsenic and the milder 
 mercurials, the alkaline salts, and the nervine and vaso-motor tonics and 
 stimulants, with sufficient discrimination, and for sufficient periods of 
 time ] Considering the marked dryness of hair and skin, and the 
 malodorous character of the cutaneous secretions, is our knowledge or 
 our practice of hydro-therapeutics either creditable or satisfactory 1 Is 
 the Turkish bath employed either as frequently or as fully as it might 
 and should be, and is our use of simple or medicated baths carried out 
 even to the full scope of the means at our command 1 The physical 
 inaction of a number of the insane, especially in some of the forms of 
 mental stupor and dementia, points to massage as a curative agent, as 
 }'et too little used and understood in our specialty. The obvious relation 
 of electricity to nervous force, and the extreme sensitiveness of our 
 patients to electrical change, as evidenced by increased excitement and 
 noise, and by more frequent and severe epileptic fits during times of 
 electrical and atmospheric disturbances, are well known. The influence 
 of electricity on some of the more obscure nutritive changes is recognised, 
 and the treatment of some forms of insanity by the continuous current 
 has been more than favourably reported of. But has gahanism been 
 with us thus far, except in a few instances, much more than a scientific 
 toy? 
 
 There is surely much for us to do in this and in other directions I 
 have indicated, towards the scientific treatment of insanity. Among 
 other things, our hospitals should be great fields for brain surgery, the 
 brilliant results attending which are of the highest interest and 
 importance. Another direction in which I anticipate progress, is the 
 systematic tiaining of attendants and nurses for their special duties. This 
 training should include a knowledge of general, as well as special 
 nursing, and to this end the general hospitals should render us assistance 
 by receiving for definite periods our attendants and nurses for training 
 on their Staff. So far, the system is as yet in its infancy in these 
 colonies ; but Dr. Sinclair and Dr. Ross, who have been working for
 
 )00 
 
 }00i 
 
 )00 
 
 (/, ov oht JJecemher, 1887. 
 
 PROPORTros OF Insane to Popilatiok. 
 
 \ in 370, or 
 69 per 1000 
 
 )00,| 
 
 )00, 
 
 •00,1 
 
 1 in 326, or 1 in 346, or 
 
 3-06 per 1000 2-88 per 1000 
 
 1 in 343, or 
 
 291 per 1000 
 < 1 in 316, or 
 {3-16 per 1000 
 
 I 1 in 342, or 
 
 292 per 1000 
 
 • • puBxSna 
 
 9881 
 
 i88t 
 
 If-^.T^siiv u.iaisajW i88I 
 91'1 Binnras^X i88I 
 
 <-^\ pifB^suaanf) t I88I 
 
 Sir • • -Buo^DiA A88t 
 li^AV ^'V^'^'& A^^K i88I 
 
 {tin 
 
 •HvaA. 
 
 Ovg[ 07m i>un 
 
 ^g the liecovei 
 
 For tlie year ( 
 Dee. 31, 188^ 
 
 For the year 1 
 1 Dee. 31, 188: 
 ' For the year ■ 
 1 Dec. 31, ISS: 
 
 For decennial 
 [ ending Dee. 3 
 1 For decennial 
 ( ending Dec. 3 
 f For decennial 
 ( ending Dee. 3 
 j For the year > 
 I Dee. 31, 188: 
 ( For decennial 
 ( ending Dec. 3 
 
 PERCEN"TA(;t;. 
 
 .lale. 
 
 Female. 
 
 Toi 
 
 7-31 
 
 10-40 
 
 8- 
 
 0-65 
 
 8-08 
 
 9- 
 
 4-01 
 
 12-15 
 
 13 
 
 6-31 
 
 9-06 
 
 7- 
 
 8-80 
 
 7-64 
 
 8- 
 
 8-98 
 
 21-42 
 
 19 
 
 9-32 
 
 9-39 
 
 9 
 
 5-76 
 
 12-92 
 
 14 
 

 
 ,,„ 
 
 SItl uH^mto'lSW. 1 ilt?*^mb«r!'^7t' "" Bit DwmiUr, l»7. * Oft IteWBbtr, ^K^. 
 
 C.U,,,. 
 
 Ihlf. nuM,. T«l»l ] Mn)» [F.mia* 
 
 w j «.,., ; i^.».. 1 To.^. I »«!. 
 
 P.I.I.I.. j Tutal 
 
 1T*1 - Sow South Wslet^ 
 
 5TJ.D1S 408.HU7 ' 1.013,1110 : l.TSfi 1.D80 
 650,1150 48Q,0G0 I.O^lG.llO 1,866^1.638 
 
 3U.5SI 1 i.-.2,«o auo.nio m 330 
 
 71.7^4 j r,5.0Hl l«-,..8« 1 IDS 167 
 
 3.831 
 3,610 
 
 3-42 per 1000. 3-35 iier 1000. 
 350 per 1»00, 3-19 per 1000. 
 
 3'58 per 1000. 3-41 pvr 1000, 
 »-18 per 1000. 337 per 1000, 
 
 2-71 per 1000. | H-13 p« 1000. 
 
 3-30 'i«r 1000. 3'68p°rl000. 
 
 1 in 294 1 1 iu 371 
 3-31 pur liXK). ' 3-11 per 1000, 
 
 3-38 por lOOO. , 3'03 per 1000, 
 
 2-50 per I'oOO. 3-7» per 1000. 
 1 in 309 1 I ii?3Ul 
 
 1 iu Jll 
 
 3-7G pur 1000, 
 2-01 per 1000, 
 3-15 'per 1000, 
 
 T.„,. .. 
 
 1.006,530 ! 1.;MS.070 2.051.3W , 4.868 3,507 
 
 8.435 j 
 
 303 per 1000, 305 per 1000, 
 
 3-68 pM 1000. ; SWt per lOOO. 
 
 2-53 per lOOO. 
 
 9-80 per 1000, 
 
 1 ""■ ' '''""""°" ■■ 
 
 3iT,!t08 , 297.933 | iU5,H;M I.U'.a 042 
 
 -1 
 
 3-03 per 1000. 2-16 per 1000, 
 
 3lia per 1000, i 217 p*r 1000. 
 1 in 330 1 1 iD 101 
 
 1 in 603 
 
 lE™ 
 
 Shoiping the I'roj-orliou of Intanf to I'cj.Hialum i„ En^tam/, SaAlaml, and Ii-e/iind, on 3t»l Dttimber, 1387. 
 
 r«,.«.o,. ^- ,„„, 
 
 P™k,.». 
 
 „, „,„,„„„. 1 
 
 1 «... 
 
 FUD>I>. TcUI. link 
 
 1S.04S 
 5d.7«l 
 
 M.M9 
 15,303 
 
 liD3I(l,or 
 »p.,ll)0O 
 
 linSa6,or 
 
 ilSt 
 
 EngUnd' .. 18.931,593 
 Ireland: „| 
 
 u.m.m 3».^,Mi «r.floi 
 
 Tor*!. .. .. .. 87,157,655 ' 30,720 
 
 109,513 
 
 TABLE III. 
 Sin tie Pol ul t\o f tfie A tt al a C h m (/ \ nher of Patirult admitted to ihc Anjlum, and t/ie ProporlloH of AdmiMcms to Population for llif 10 i/iart. 1S7S to 1S87 imtui 
 
 ».«, » 
 
 » 
 
 ,1 
 
 ii *.»•""■ 
 
 T.^.,u. 
 
 »»™,A„.,„„. 
 
 <ani.t 
 
 Smltm AaitnU*) 
 
 lATtl 31 SHJ 
 
 Is : 
 
 11=1749 9M0611 
 
 
 3oJ:400 1 195 llnllsSO 3171861 I 138 \Z\]tw 
 il»,im 1 207 , l.n l,.-.ii. .;!'j,^.M jii. 1 ,M I..'.7I 
 
 1.231,005 
 
 H 
 
 1 in 2,493 
 
 '\r 
 
 i 1= 
 
 L 
 
 3,0811.012 
 
 3,831>,7ir-. 
 3,900,lu^ 
 
 31,813.487 
 
 1.311 lit) 1,650 
 1.400 1 ill 1.633 
 
 U.G80 ; 1 in 1,690
 
 1 A-Jimu /or tht Yenr ISST, 'lii:l fir llu Dmuttinl 
 
 ! IhtuJm, 1SS7. 
 
 ^^ 
 
 " 
 
 ,-Jt„ 
 
 ■33 
 
 87-60 
 
 il-U 41 
 
 »« 
 
 2'fl9 
 
 3-18 3 
 
 33 
 
 43-70 
 
 61-31 46 
 
 ■79 
 
 8-111 
 
 5-10 7 
 
 72 
 
 e-57 
 
 3-26 7 
 
 41-00 57-W 
 
 46-99 
 
 49-6 00-00 
 
 40-01 
 
 4-3-C3 48-U8 
 
 45-(IO 
 
 3-60 5-47 
 
 4-22 
 
 46-19 6-1-40 
 
 i9-i-> 
 
 6-87 0-OU 
 
 fl'68 
 
 0-42 4-93 
 
 S'83 
 
 0'59 53-16 45-W ' 4fl-8H JBS 
 1'06 { 43-64 43-00 i i9-\S 44-11 
 5-58 1 9-04 0117 I 7-57 108 
 
 New South IVulce 
 
 TABLE VI. 
 'till/ l/u Clasiijica'Mn »/ the huaiie in (/«• AiMmlian Coloints on 32st Dfcen^i; 18S7. 
 
 
 'lU-40. S'GO 
 I 8-08 
 no I 14-01 1 13-16 
 
 , 1«-B5 I 8-08 I 0-4 
 
 760 0-32 0-30 1 9-85 
 340 lS-76 : 13-02 14-00 
 
 
 ^ 
 
 "■"--l 
 
 78 
 11 
 36 
 
 10 
 
 -909* 
 
 60 
 
 47 
 
 19 
 
 2-06 0-48 I 
 18-52 6-57 I 
 106 1 0-62 
 
 ..r- 
 
 I i 
 
 00-31 0118 S54 1 
 83-85 n-U 193 ' 
 7e-19 ; 52-80 ' 70 I 
 
 I 10-75 ' 7fi0 I 
 43 I 12-2S 307 i 
 I 12 ; 0-91 lOfl • 
 
 1.188 114-08 7:^: 
 
 Shumn'j th. uiiuiber of Bpilej}(ic4 uitJ Urmral I'aral-jd-:* o.imitUd Inio Auflmiiau ,l«y»HW .hirin.j ihr Ytar JUS?, 
 <iiul into EwflUt AtyluiM duviny lite ytar ISSG, va'iUt f/te I'rojiortion (per ant.) t<i tlu: lotal mirnhtr admitttJ. 
 
 
 1 
 
 
 
 
 
 
 
 Pwiw 
 
 iundw 
 
 Tw'Sl 
 
 
 ^-^.v 
 
 licnl t 
 
 
 -— =— 
 
 0, Trao l.™..u „ P.„™ A,,.,„«,x 
 
 
 
 
 
 
 
 
 
 General FaraljUm. \ 
 
 
 97 20 17 
 6 19 
 
 
 
 \ 
 
 
 ilOT4 
 
 gniMl*.! Ttrtnl. 
 797 1 1,891 
 
 Male 
 
 J 
 
 9 
 
 i 
 
 1 
 
 8-4 
 
 
 F«>D«le. 
 
 :: 
 
 0-9 
 
 
 1887 1 SoulU AnVtrda" '.'. '.'. 
 
 1887 WMtern A<i8lt»ii'ii '.'. '.'. 
 
 uopt Woetuni Austrolift) . . 
 
 
 isr]E..u,^:.- .7^7 .. 
 
 
 6,919 ||3,694 
 
 9 _ 8 1 18 
 
 11 
 
 1 
 
 ^ 
 
 197 
 
 TABLE vm. 
 mim numWr of PatUiita, aiut tiuiiiljtr of Gtitei^ 1 „i - , . „ - , i - ,. 
 
 Pamll/lix admilUd fir Jit! jm,-., ;«*« (o ISST 'VMioini; «umlj,r ,,j folunl, ■ml niimbtr .,J (,rii 
 
 iiiclurivt, to Inaitationl fir Ifir /itsant, Srvi South I fir Jive yiari, ISUJ tn ISSil tHClutire, tti 
 
 Wain. 
 
 ■iml iiiimbfr ./ Oeiirral J'-imluliet « 
 XmiliJ, Atilli'm 
 
 '""' 
 
 i',;s-™ ^"/,.U'A-j;s^- 
 
 '"""SKSS"""- It«,.„,p.„^*»,„... ■i«...»o».j^.;.....v„.. „„i™>?S:uS» 
 
 1 "■"• 
 
 1M4 i |M 
 5 yearn [ 1,581 
 
 '»"-j '"•'■'»-- "-^ 
 
 ,«.! 
 
 ».!.. k«.,., Tou, 1 ,„, 1 r„^ 1 ,,^ ,^ 1 „„,^ ,.„^ „^, 
 
 «,^!-t- 
 
 178 [ ISO 16 . S 
 97ll9*69| 80 1 8 
 
 ~ 
 
 fi.j ! '■* ; ^t i^^ "■"** 1 "-"IS 13.581 998 I 988 1,151 1 18-8 
 
 S.i ' A". ^'3 ! '*^ '■''" 7.441 1 14,458 918 1 912 l.IO*' ' 18-1 
 
 tn 1 7=1 i'l 1 ^**' '-**75 , 7.*3S 1 14.808 980 200 1.192 18-9 
 
 5-8 ! i-5 1 1-2 IS 1 !■")" ! "■"' '»■'«" »=" "^ '■!" ' i"'" 
 ^ji^ ^^Ki^ ^9JI^ Iggi; ^ 0.712 1 6.912 [ 13.824 904 213 1.177 14-8 
 
 6-0 ] 0-8 1 3-4 11 6 j™,| 33,819 ;86J)17 '69.129 4.743 1 1,113 .,,835 140 
 
 3-8 ! 8-6 
 '^ 'J 
 
 i:;|n 
 
 8. , 8-
 
 eiiiale. Total. 
 
 i' 
 
 3 ,S-12 8-91 
 
 7 
 
 3')(r87 52-.52 
 
 lU-97 
 
 1 
 
 31-20 
 
 1 
 
 s-65 
 
 1 
 
 31I-S5 
 
 3 4-40 
 
 0-13 
 
 1 4-l('. 
 
 ] 
 
 5-94 
 
 Total. 
 
 300 Sl-oB 2,8'21 
 200 90-93 3,ol9 
 750 
 874 
 350 
 121 
 
 .551 73-40 
 
 : 7hO H9-24 
 
 ;307 N7-71 
 
 ;i()9 90 08 
 
 j247 85-91 1 8,435
 
 PRESIDENTS ADDRESS — SECTION OF PSYCHOLOGY. 833 
 
 two years at Gladesville, are more than gratified with the result, wliich 
 to my mind is most satisfactory. The effort to improve the qualification 
 of those in immediate attendance and care of patients, promises great 
 lienefit to the insane ; and I am making no rash prediction in saying 
 that, within another decade, no attendants nor nurses will be employed 
 in State Hospitals for the insane in these colonies, except as probationers, 
 who have not gone through a systematic course of training and instruc- 
 tion in their duties, and received certificates of their fitness for their 
 special work. 
 
 Did time permit, I might go on to indicate some of the hindrances, 
 the troubles, and difficulties which are known only to those who are 
 engaged in lunacy work, but I should serve no practical purpose. 
 Insanity, though a most interesting, will always be an unpopular subject, 
 and one in which little or no outside interest will come to our aid. 
 Most of the progress which I have indicated must come from within 
 rather than from without, and though I believe that the care and 
 treatment of the insane, and our knowledge of insanity, will steadily 
 improve, and a more intelligent interest arise in our work, especially 
 among the members of the medical profession, we shall in the future, 
 as in the past, in only too many cases, and for some years to come, have 
 to do perforce of circumstances what is expedient or possible, instead of 
 what is right and best, and to be content, or as content as we can, with 
 an attainable good, instead of an unattainable better. 
 
 See Tables. 
 
 2h
 
 834 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 A CASE OF SPORADIC CRETINISM, WITH REMARKS. 
 
 By F. Norton Manning, M.D, 
 
 Inspector-General of tlie Insane, N.S.W., and Lecturer on Psychological Medicine 
 at the University of Sydney. 
 
 The case I am about to describe is one of a somewhat rare disease — 
 rai-e, at all events, in Australia, since it is the first and only one I have 
 seen in an experience of twenty years, and not very common in Great 
 Britain, though I have been able to find more or less full notes of 
 twenty-six cases. In addition to these, I find two cases described bj^ 
 M. Baillarger as having occurred in France. 
 
 S. G. was admitted into the Hospital for Idiots and Imbeciles at 
 Newcastle, N.S.W., in April 1888, and I obtained the following 
 history from her father, who I may mention is a somewhat squat 
 ugly Irishman, of quite average intelligence, and comes of decent stock 
 in the West of Ireland : — He did not leave home till he was thirty 
 years of age, and knew his own and his wife's people i;p to the grand- 
 parents on both sides. He states confidently that there has been no 
 insanity, idiocy, or epilepsy on either side, and describes his wife, who 
 died about three months before the patient's admission to hospital, as a 
 "very fine healthy woman." The patient is the last but one of six 
 children, all the rest of whom are well-formed, healthy, and show no 
 mental failure, and three of whom are married. The father describes 
 himself as a sober, steady man, and I have no i-eason to doubt his state- 
 ments.. There is no history of syphilis. The patient was born in 
 Armidale, N.S.W., and is now eighteen years of age. She appeared 
 healthy at birth ; at all events, the parents were not conscious of any- 
 thing wrong with her. At eight months old, she was thrown out of a 
 perambulator. After this convulsions commenced, and continued occa- 
 sionally till she was nearly three j'ears old. They were not frequent, 
 and were probably due to dentition. Tliere have been no fits since. 
 The idea that there was something the matter with the child appears to 
 have dawned very gradually on the parents ; but they were fully aware 
 of her deficiencies before she was three years old, and the probability is 
 that the malady, if not congenital, commenced early. She has lived for 
 tlie last ten or twelve years in a suburb of Sydney, and was taken care 
 of by her mother and sisters till the death of the former. 
 
 On admission. — She was an excellent and characteristic specimen of 
 a cretin, or cretinoid idiot — a case of true sjioradic cretinism. Her 
 height was thirty-five inches, and her weight fifty-six pounds. The 
 chest girth was twenty-eight inches. The figure was broad and squat, 
 and there was considerable development of fat. The abdomen was 
 protubeiant, and the legs bowed and twisted. The arms measured 
 fourteen inches from the tip of the acromion to the finger ends, and 
 the hands were large and wrinkled, and aged-looking. There were no 
 signs whatev(!r of sexual development, the breasts being undeveloped 
 and the pubes liairless. So far as could be ascertained, the thyroid
 
 / 
 
 « 

 
 A CASK OV Sl'OKADlC CKKriM.SM. Wl'lll KHMAKKS. S^O 
 
 gland was al)sent, and above tlie clavicles were the peculiar fatty 
 protuberances usually seen in these cases. The circumference of tlie 
 head was twenty-two Indies, and the vertical measurement from the 
 insertion of one ear to the othio', twelve inches. In shape it was brachy- 
 cephalic, with considerable occipital protuberance. The face was flat and 
 broad ; the cheeks hanging and jowl-like, and the eyes set somewhat 
 far apart; the mouth was always partly open, and tlie point of a 
 large smooth Habby tongue visible ; the lips were thick, and the nose 
 flat and ill-formed. The palate was not markedly abnormal, and the 
 tet^tli, though ill-shaped and decayed, were fairly regular. The ears 
 were wing-like and large. The com])lexion was earthy and sallow, and 
 tlie skin could not be pinched up from the subcutaneous tissue. The 
 pulse was eighty-eight, and the temperature normal. The patient could 
 walk, though in a peculiar waddling fashion, and could use l)oth hands. 
 The senses all seemed good, but perception was very slow. The speech 
 was slow and monosyllabic, and indistinct, but she could .say a number 
 of words and tell the names of all ordinary articles about her. She 
 recognised a ]ienny, but called all silver coins without distinction a 
 sliilling ; and though she knew that money would buy sweets, peaches 
 and bananas, had no idea of relative value. She could count up to four 
 only. Could tell her name and age, but no other particulars of her 
 history. She was cleanly in habits, and attentive to the calls of nature, 
 but could not dress herself. She was exceedingly amiable, easily 
 amused, and .strongly imitative. 
 
 The experience of some months has shown that she is teachable 
 in only a very minor degree. She cannot be got to count above four, 
 but she knows the routine of the establishment, and can tell the hours 
 foi- meals, etc., if asked, and is very appreciative of kindness and fond of 
 those who take notice of and pet her. Altogether, the intellectual 
 development is extremely low in class. 
 
 Cretinism has been described as characterised by a lesion of the 
 intellectual faculties more or less analogous to that observed in idiocy, 
 and with which is associated a characteristic vicious conformation of 
 the body — an arrest of development of the entirety of the organism. 
 
 These sjioradic cases certainly conform to this definition, and to any- 
 one who has travelled in the cretinous districts of Switzerland or 
 the Himalayas, or has seen isolated cases of endemic cretinism in 
 French or Italian hospitals for the insane, • the resemblance of the 
 sporadic to the endemic cases is most striking, and is such as to make 
 them recognised at once as belonging to the same family. The more 
 marked physical peculiarities of these cases are the arrest of develop- 
 ment, which seems to occur generally at the period of the first dentition, 
 but in one or two cases has been postponed until the seventh or eighth 
 year, so that at 18 or 20 years of age they are physically children of 
 from 5 to 7 years, and never attain to any sexual development — the 
 peculiar squat conformation, the pallid earthy complexion, the wrinkled 
 skill (especially of the hands), the brachy-cephalic crania, flattentid 
 noses, widely set eyes, thick lips and large flabby tongues, and lastly, 
 the presence of supra-scapular swellings and the absence of the thyroi<l, 
 which latter is difficult to diagno.se during life. The mental condition 
 is that of idiocy. The patients are extremely placid and good tempered, 
 have often a sense of humour and fun, and are very imitative, but are 
 
 2h 2
 
 836 IM'EKCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 teachable only to a v'eiy limited extent. The speech is generally slow,, 
 thick, and nionosyllabic. By attention and care, most of the cases can be 
 made cleanly in habits and attentive to the calls of nature. The fatty 
 tumonrs of the neck consist of general enlai'gements of the fatty 
 deposits in this region ; but they are not as a rule defined or encapsulated, 
 but send out processes under the sterno-mastoids and clavicles. There is 
 nothing peculiar in their constitution. They are simj)le fatty growths, 
 and since they disappear in exhausting diseases and emaciation, are 
 apparently a reserve .stock of ordinary fatty material. They are rather 
 in fact an anatomical curiosity, than interesting pathologically or 
 l^hysiologically, but at the same time they are \ery distinctive, and in 
 some cases, notably in two described by Dr. Hilton Fagge, are most 
 marked and peculiar, so as to constitute an absolute deformity. They are, 
 with the absence of the thyroid, a constant distinctive feature between 
 sporadic and endemic cretinism, being almost always present in the 
 former, and never yet observed in the latter affection. 
 
 Before turning to the literature of the subject, it may be well to insist, 
 tirst, that the disease is not related to either rickets or scrofula, though 
 in some cases the limbs of the subjects have been bowed ; second, that 
 it is not inherited syphilis ; and third, that it is not markedly the out- 
 come of heredity, the parents for the most part being healthy folk, in 
 no way consanguine. From the cases which have been published, it 
 would appear that it may be, and indeed usually is, congenital, Ijut tliat 
 it is usually fix'st noticed during the first dentition, though, as in cases 
 I'cported by Dr. Fagge and Dr. Langdon Down, it occasionally, though 
 rarely, seems to commence at a later age. In most of the reported cases 
 there lias only been one in ;v family, the other children being healthy ; 
 but three of Dr. Fagge's cases occurred in one family, the remaining 
 children being quite free from the afliection. 
 
 The first notice of the affection which I have been able to find is a 
 paper in the "Med. Chir. Transactions for 1850," by Mr. T. Blizzard 
 Curling, entitled, " Two cases of absence of the thyroid body, and 
 symmetrical swellings of the fat tissue at the sides of the neck, with 
 defective cerebral development." Mr. Curling gives the post-moi-tem 
 api)earances in both these cases, and in his brief remarks says, "'It is 
 liighly probable that the abnormal secretion of fat was de])endent on the 
 absence of those changes, which result from the action of the thyroid, or 
 from some imperfection in the assimilating process consequent on the 
 want of tlie gland." In the " Med. Chir. Transactions for 1871 " is a 
 jiaper Ijy Dr. Hilton Fagge, on "Sporadic Cretinism" occurring in 
 England, in which four cases are described ; and in the " Pathological 
 Transactions for 1874" Dr. Fagge gives the post-mortem appearances of 
 one of these four cases, and of a fifth case which came under his 
 observation. 
 
 Dr. Langdon Down, in his recently published work " On the Mental 
 Afiections of Childhood and Youth," mentions that between 1850 and 
 1887, he has had twelve cases under his care, and M. Baillarger has 
 f)laced on record notes of two. Dr. Fletcher Beach of the Darenth 
 Asylum, has had .seven or eight cases under his care; and in the 
 "Transactions of the Pathological Society for 1874 and 1876" and 
 the " Report of the International Medical Congress for 1881," has 
 published the results of microscopic examination of five cases. I
 
 A CASE OP SPO]{ADIC CKETIMSM, WITH I{P:MAKKS. 837 
 
 had an oppoitunity of examining two of the cases under Dr. Fletcher 
 Beacli's care, in tlie Darentli Asylum, in 1887. In addition to these 
 cases, instances of the disease have been mentioned by several 
 writers. In all Dr. Fletcher Beach's post-mortems, the thyroid was 
 absent, the tumours of the neck consisted of lobulated fat, and the 
 convolutions of the brain were as a rule described as coarse, and their 
 structure simjile. On microscopical examination, the nerve-cells were 
 somewhat large, rounded, or ])3-ramidal in form, with round, oval or 
 irregularly angular nuclei. Many of the cells had no processes, some 
 only one or two, often three or four, but these stunted. The spaces 
 around the cells were large, so as to produce a curious honeycombed 
 jippearance. 
 
 It is now advisable to ask, what is the essential character of this 
 jittection, and what is its cause 1 From the fact of almost all the cases 
 first recorded, or at all events a large proportion of them having 
 occurred in or near London, in the valley of the Thames, some 
 telluric, miasmatic or climatic influence has been suggested ; and it has 
 been thought that a London lane or court, with its high walls, its 
 want of light, its stagnant and vitiated atmosphei'e (bearing some 
 resemblaiice to a narrow Swiss valley between the mountains), combined 
 with poverty, bad food, and other causes (also common to the dwellers 
 in Swiss A-alleys), may have determined the peculiar form of the 
 degeneration ; but certain of the cases, and among theni the one I 
 have described to you, have not been subject to these conditions. 
 
 Dr. Langdon Down states that, in the majority of the cases under 
 his care, there was reason to believe that they were procreated during 
 the intemperance of the father, and adds, " some of the later ones could 
 not have been procreated under any other condition." In one or two 
 other cases on recoi-d, it is stated on the authority of the mother, that 
 the father was drunk at the time of the connection. Though drunkenness 
 on the part of the father during procreation is a recognised cause of 
 idiocy, there seems no reason why the idiocy should take this special 
 form ; and indeed, as a rule, it most certainly does not, and l^esides in 
 some of the cases on record the pai-ents were absolutely temperate 
 people, and there was every reason to believe there liad been no 
 drunkenness during coitus. 
 
 M. Baillarger seems to regard the essential and primary part of the 
 disease as residing in the generative organs, and opines that the 
 inactivity of the generative system is i-esponsible for tlie general 
 condition. 
 
 Virchow Ijelieved that he had found the capital abnormality of the 
 cretin in all his varieties in the premature ossification of the spheno- 
 l)asilar bone, or to put it in his own words. " the premature synostosis 
 of the two parts of the sphenoid bone, together with the basilai- 
 process," whicli jirevents the elongation of the base of the skull, and 
 consequently the development of the Ijrain : and his articles in periodi- 
 cals, and liis separate woi-k on this subject, ai-e as solid and unamusing 
 reading as you can tind in medical literature. 
 
 Drs. Hilton Fagge and Fletcher Beach have, in their necroscopic 
 examinations of sporadic cretinism, found that tliis peculiar pi-emature 
 ossification exists, but that it is the essential or capital abnormality is 
 more than doubtful.
 
 838 IN'TERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 The most marked, constant, and distinctive peculiarity is the absence 
 of the thyroid gland. This absence is total and complete, and has been 
 found post-mortem in every case, except one of Dr. Fagge's in which 
 the cretinoid condition was late in developing, and in this case the 
 gland, though present, was extremely small and atrojihied. We have 
 no means of knowing whether this absence is accidental, primary and 
 congenital, or is due to some changes, either intra-uterine or soon after 
 birth, in the troj)hic centres, which prevent its development or lead to 
 its eai-lv and complete absorption ; but, as Dr. Fagge remarks, " it may 
 be interesting to speculate whether this absence can possibly be the 
 cause of the other changes which make up the morbid state." 
 
 In this relation, the disease known as myxtedema is interesting, since 
 in every case of this there is atrophy of the thyroid, and an almost 
 complete annihilation of the proper gland elements, which are replaced 
 by a delicate fibrous tissue, this change being due either to a compres- 
 sion by the mucin deposited, or to disease of the trophic centres of tiie 
 thyi'oid in the medulla. In this affection, as in sporadic cretinism, 
 there are marked changes in the general nutrition, and the patients 
 attain — in time — a colour, a general aspect, a condition of skin, and a 
 tiabbiness, which bear a peculiar resemblance to those of the cretin, 
 whilst at the same time there are pecidiar mental changes — a loss of 
 mental power, a slowness of nervous perception and of speech, and a 
 dull lethargic dementia, which has led some writers to .speak of this 
 condition as adult cretinism. So marked, indeed, is the resemblance 
 between spoi'adic cretinism and myx<edema, that the Committee of the 
 British Medical Association, presided over by Dr. Ord, have come to 
 the conclusion " that a general review of the symptoms and pathology 
 leads to the belief that the disease described vmder the name of myx- 
 ( edema, as observed in adults, is practically the same disease as spoi-adic 
 cretinism when aff'ectiiag children, and that a very close affinity exists 
 l)etween myxtedema and endemic cretinism."' 
 
 I would point out that the mental clianges frequently accompanying 
 Basedow's or GraAes' disease — exophthalmic goitre — in which there is 
 enlargement of the thyroid, with vascular turbgesence of that body, are 
 also of interest; and I would also direct your attention to tlie physical 
 changes in the rare disease known as acromegaly, two cases of which 
 are described in the report of a meeting of the Clinical Society, held 
 on April 13, 1888. In these cases, with enlargement of the thyroid, 
 due to cystic disease in^ohing its proper structure, there is an extra- 
 ordinary disturbance of nutrition, as shown by a remai'kable overgrowth 
 of some parts of the bony skeleton, particularly of the bones of tiie 
 face, the ends of the clavicles and ribs, and the small Ijones of the 
 hands and feet, and also by a thickening of the sul)cutaneous fatty 
 tissue, an inci-eased coarseness of tlie skin itself, impairment of .s^^ecial 
 senses, and marked genei'al feebleness. The idea that absence of the 
 tliyroid is the starting point, or at all events the main pathological 
 factor in sporadic ci-etinism, is further strengthened by the facts made 
 known by Professor Koclier, of Berne, that after removal of the tliyroid 
 a coiulition grachially supervenes, which is called 1)V him " cachexia 
 struniiiiri\a, " and by Re^"erdin " myx(e(Ieme operatoire,"' and which 
 resembles adult cretinism: and also by the appearance of symptoms 
 resembling those of rnvxciHlema aftei- remoxal of the thvroid in monkeys
 
 A CASE OF SPORADIC CUKTIMSM, WITH KEMAUKS. 83& 
 
 l)y Professor Horsley. Whilst absence or atrophy of the thyroid is a 
 constant feature in sporadic cretinism, the fact of the association of 
 ciideniic cretinism with tlie opposite condition of goitre is interesting, and 
 as goiti-e is as a rule simple hypertropliy, or cystic fibroid, or filiro-cystic 
 enlargement of the gland, some hypothesis by which the peculiar 
 discrepancy can be explained is necessary. To this explanation Dr. 
 Hilton Fagge devotes some attention in his paper in the " Medico-Chir. 
 Trans, for 1871," which 1 Iiave ali'eady mentioned. He points out first, 
 that though goitre and cretinism co-exist in many cases, they bear no 
 fixed pi'oportion to each other. In the worst cretins, the thyroid body 
 is often no larger than usual, wliilst persons with enormous goitres are 
 frequently well developed both mentally and physically; and he suggests 
 that goitre is the earlier efiect of endemic influence, and that cretinism 
 only appeal's when this influence is intensified, and acts through more 
 than one generation; that with little intensity the sole effect is goitre, 
 but with great intensity, oi" after acting through successive generations, 
 it produces cretinism as well as goitre. " It appears to me," he says, 
 '" that there is a certain antagonism between goitre and cretinism. 
 When a large goitre exists, it may possibly have the power and effect 
 of protecting against the more severe effects of endemic influence, and 
 thus cretinism and goitre only co-exist when the exciting cause is 
 present in intense degree, or has acted tlu'ough several generations." 
 
 Accepting this explanation, the discrepancy vanishes. AVe have but 
 to suppose that the healthy thyroid body is capable of so controlling 
 nutrition, and of counteracting moi'bific climatic, miasmatic, or telluric 
 influences that in most parts of the world — at all events, where the 
 causes of endemic cretinism act only with a low degree of power — these 
 c.-iuses are held in check, and we can see why a form of cretinism sho"\\'s 
 itself when the thyroid is atropliied or absent. We know so little 
 positively of the physiology of the thyroid, that we can only speculate 
 as to whether sporadic cretinism is due simply to the absence of this 
 body, and some impei'fection in the nutritive or assimilati^■e processes 
 consequent on such absence ; or to the absence, plus some miasmatic or 
 other morbific influence which, if present, it would have the power to 
 counteract, as Dr. Hilton Fagge suggests ; but arguing from my x( edema, 
 and from Professor Kocher's observations, it seems probable that the 
 former is the case. Under either supposition, sporadic cretinism is 
 interesting pathologically, and in its physiological bearings.
 
 840 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 A CONTRIBUTION TO THE STUDY OF SPORADIC 
 
 CRETINISM. — SIX CASES OCCURRING IN SOUTH 
 
 AUSTRALIA. 
 
 By E. C. Stirling, M.A, M.D. Cantab., F.R.C.S. Eng. 
 
 Surgeon to the Adelaide Hospital, and Lecturer on Physiology in the 
 University of Adelaide. 
 
 Some years ago, I was consulted in reference to the two children 
 whose cases stand first on the list which follows. I was at the tiine 
 struck with the resemblance of the affection in many respects to 
 myxcedema, with which I had become familiar through seeing in the 
 fiist place some of the cases on which Dr. Ord's description was founded. 
 And, in fact, I called the affection of these children myxojdema, though 
 I had iiever heard of it occuri^ing in such young subjects. On looking 
 up the matter, I became acquainted with Dr. Hilton Fagge's paper on 
 " Sporadic Cretinism occurring in England," in vol. liv. of the " Trans- 
 actions of the Medico-Chirurgical Society ;" but, being unable, as a 
 medical adviser, to suggest either cause or remedy, I lost sight of the 
 children until I heard from my friend Dr. F. Norton Manning, of 
 Sydney, that he had a similar case wliicli lie intended bringing before 
 tlie Intercolonial Medical Congress. 
 
 On this, I sought permission of the parents of the children in 
 question to make a further study of them, as well as others of the family 
 Avho were affected, which was readily granted. The following paper 
 embodies the result. For the opportunity of investigating the last 
 case on the list I am indebted to Dr. Yerco, who was kind enougJi 
 to bring it under my notice : — 
 
 The fact of five of the affected cliildren being members of one family, 
 obviously makes all questions of heredity of special importance. I there- 
 fore preface my report of the cases with an account of their parentage. 
 
 Tlie father, a^t. 43, is a rather sliort, but compactly built, strong, 
 healthy and intelligent man of good social standing, occupying with 
 ability a responsible position of trust. He has never suffered from any 
 illness except periodic attacks of liay-fever, which affect him severely. 
 Tliere is no question as to his habits, which are at all times strictly 
 temperate, and there is no history whatever of syphilis. He was one 
 of a family of eleven, of whom two are dead. His father died at 
 .seventy-two of some bladder complaint, and his mother is still alive, 
 being still well and strong at the age of seventy-one, but with some 
 liability to rheumatism and bronchitis. 
 
 The mother, jet. 40, a native of South Australia — one of a family of 
 eight, of whom two are dead — is a particularly bright, intelligent and 
 cheerful woman of ordinary stature. Yery spare and thin in her 
 youtli, slie now inclines a little to a full habit. She has had no serious 
 iHness. Her father and uncle suffered from epilepsy, of wliich tlie 
 former died. Both her grand-parents lived to a good old age. 
 
 These parents of the family now under consideration are not related, 
 and have been married for twenty-three years, during which time 
 eleven children have been born to them. There have been no 
 miscarriages, no instruments were in any case employed at delivery, 
 and none of tlie labours wove difficult. Recovery afterwards was in
 
 A CONTRIBUTION TO THE STUDY OF SPOHADIC CRETINISM. 
 
 841 
 
 all cases very favourable, .-uul there is no account of any shock or 
 frii^ht durin<; pregnancy. All were born at the full term. 
 
 The following table indicates, in tabular form, the order, sex, 
 and ages of their family, the affected members being indicated by the 
 prefix of an asterisk, and as the family consists of two distinct types as 
 regards the colour of the hair and eyes, I add these particulars also : — 
 
 No. 
 
 Sex. 
 
 Age. 
 
 Colour ok Haik. 
 
 Colour of Eves. 
 
 1 
 
 Girl 
 
 22 yrs. 
 
 Auburn, inclined 
 
 to red 
 
 Greyish blue 
 
 2 
 
 Boy 
 
 Died from accident, 
 would have been 20. 
 
 Dark brown 
 
 Dark brov.n 
 
 *3 
 
 Girl, L. M. 
 
 1 9 yrs. 
 
 Brown 
 
 Blue 
 
 *4 
 
 Girl, E. 
 
 17 yrs. 3 mths. 
 
 Dark brown 
 
 Blue 
 
 5 
 
 Boy 
 
 15 yrs. y mths. 
 
 Dark brown 
 
 Dark brown 
 
 *6 
 
 Bov, C. H. 
 
 13 yrs. 6 mths. 
 
 Dark brown 
 
 Brown 
 
 •7 
 
 Girl, J. L. 
 
 11 yrs. 1 mtb. 
 
 Dark brown 
 
 Greyish bine 
 
 8 
 
 Boy 
 
 8 yrs. 1 mtb. 
 
 Auburn, inclined 
 to red 
 
 Greyish blue 
 
 •9 
 
 Girl. A. A. 
 
 6 yrs. 6 mths. 
 
 Bed 
 
 Blue 
 
 10 
 
 Girl 
 
 3 yrs. 9 mths. 
 
 Very dark brown 
 
 Blue 
 
 11 
 
 Bov 
 
 1 yr. 4 mtbs. 
 
 Very dark Ijrown 
 
 Very dark brown 
 
 No peculiar features of any kind can be distinguished in the 
 unaffected members of the family, who appear perfectly bright and 
 healthy in every way. 
 
 Between all those who ai'e affected there is such a strong generic 
 resemblance, that it will only be necessaiy for me to describe in detail 
 the case of the eldest of the series, girl No. 3 in the preceding table, in 
 Avhom the physical symptoms are most marked, though in respect of 
 mental condition she stands at a higher level of intelligence than either 
 the sister who immediately follows her, with whom, fi"om the approxi- 
 mation of their ages, she can best be compared, or No. 9, who of course 
 is much younger. I will then, in the case of the other affected 
 members, merely state those particulars in which there are differences 
 observable between them and the one (No. 3) recorded in full. Where 
 no particulars are given, it is to be understood that the description of 
 the first case applies. 
 
 Case I. 
 
 L. M., female, jet. 19 (the third child in the family series). 
 
 History. — 8he was born at the Reed-beds, a sandy l)ut sometimes 
 partially-Hooded locality about four miles from Adelaide, and was from 
 birth a fragile delicate child. 8he was weaned when about six months 
 old, and was subsequently reared on cow's milk. At about that age, she 
 had a moist eruption on the scalp. The first dentition occurred normally 
 at the usual time, but there has been no succession of any of the second set. 
 At the age of about four she was still thin and delicate, and aljout this 
 period she had scarlatina and whooping cough, fi-om which she appeared 
 to recover completely. Shortly after this, howevei", a change in the 
 child was noticed, which is desciibed by the mother as a '" sort of 
 broadening of the face and hands,' and at the same time the child 
 became " podgy and heavy.' Tp to this date, her intelligence deve- 
 
 1
 
 842 INTEKCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 loped as in any ordinary child, but synchronously with the physical 
 changes she became dull and inert, and this dulness increased as the 
 bodily changes progressed. Even in her early thin and delicate days 
 she was always very sensitive to cold, which peculiarity became more 
 marked at the onset of the cretinoid symptoms. 
 
 Present Condition. — Height 3 ft. 4 in., weight 72 lbs. 14 oz. ; fronto- 
 occipital circumference of head 20^^ inches, l)ut its contigui'ation 
 presents no abnormality, and the fontanelles are closed, marked 
 heaviness of the lower part of the face, giving tlie full face a pear-shaped 
 outline. Eyes weak and watery-looking. Eyelids, especially the lower, 
 swollen and pufty; palpebral conjunctiva slightly congested; irides blue, 
 pupils slightly dilated. Hair bi'own, straight, wiry and coarse, but 
 fairly thick, and does not come out. Scalp slightly inclined to scurfiness. 
 Eyebrows and eyelashes rather thin. Bridge of nose broad. Cheeks 
 full, but firm. Lips thick, everted and pouting, pale and glazed. 
 There is a great want of mobility in the features which, with their 
 pufty condition, cause great lieaviness of the countenance. The skin of 
 the face is soft and smooth, but the natural complexion is obscured l>y 
 marked sun-burning. In spite of tliis, the general aspect, the feel, and 
 a strong suggestion of semi-ti'anslucency in the features, remind one of 
 myxoedema ; but there is no pitting, even on firm pressure. The first set 
 of teeth is persistent, witli the exception of a few that have come out ; 
 those that remain are small, discoloured and worn, the upper incisors 
 particularly being worn down to the level of the gum. The tongue is 
 clean and moist, long and narrow, and tliere is no bad breath. Under- 
 neath the lower jaw there is a soft, pufty, roll-like swelling, presenting 
 the appearance of a " double chin." Girth of neck, 13^- inches. The 
 fulness of the neck makes it impossible to say whether the thyroid is 
 present or not, but there is certainly nothing in the feel of the parts to 
 make one at all confident of its absence. In each supra-clavicular 
 region there is a soft, pufty, obscurely-circumscribed swelling, about the 
 size of half a turkey's eg^, or larger, which feels like fat, but shows 
 no dimpling under the grasp. These, the mother states, were not 
 noticed in the early stages of the disease, and she thinks they are now 
 increasing in size. There is a general diftuse soft pufRness, as of sul)- 
 cutaneous fat, below the clavicles, appai'ently continuous with the 
 supra-clavicular swellings, and extending downwards as far as the 
 areohe, and outwards as far as the anterior border of the axilhe, but 
 not observable in the axillie. Over this area, the superficial veins are 
 conspicuously enlai'ged, especially over the upper j^ai^t. The mamm;e 
 are ill-developed, and tlie nipples are small. The skin of the body is 
 veiy harsh and dry, with a tendency to scaliness, and the mother states 
 that slie never perspires, even under the influence of a steam batli. 
 There is a general puftlness over tlie whole body, but no pitting on 
 pressure in any part of the trunk or limbs. Chast measurement, 
 29 inches. Respiratory sounds nomnal, and heard clearly o\"er 
 the supra-chivicular swellings. Heart sounds distant, but normal. 
 Pulse 90, normal in cliaracter. The .ibdomen is swollen, prominent, 
 and tynipanitic, with aj'parently nuich subcutaneous fat. Girth at the 
 umbilicus 33J, inches. She is stated to be ^'ery sensitive to the pressure 
 of tightly-fitting clothes. From the percussion sounds, it is po.ssible 
 that the liver mav be enlarged, but the general swelling of the belly
 
 A CON'TlilBUTION TO THE STUDY OF SPOUADIC CRETINISM. 84y> 
 
 makes it ini]iossible to spe;ik with certainty. No hair on the pubes or 
 in the axilhe. The hands are stumpy, broad, purty, and cold, with 
 tlieir skin wrinkled and baggy, as if too large for them. Nails well 
 developed. She is very slow and clumsy in the ust; of her fingers, and 
 finds much difficulty in buttoning lier clothes. 8kin of hands and arms 
 dry and harsh, liaving on the internal surface of tlie latter light In-own 
 patches, composed of aggregations of horny- looking papilhe. The feet 
 are similarly puffy and cold, with the same dry harsh skin as the 
 liands and arms ; on the knees, there are patches of the same horny 
 }>apilla' as were noted on the ai'ms. There is no curving of the tibite, 
 or any bone distortion in any part. The calves ai'e large (11|- inches 
 in girth) and fimn. As she stands stripped, there is a considerable 
 degree of lordosis which, with the large calves, remind one of pseudo- 
 hypertrophic paralysis, but save for extreme sluggishness, there is no 
 difficulty in lising from the recumbent position. 8he walks in an 
 extremely leisurely way, with a waddling gait. In fact, exti-eme 
 fleliberation and sluggishness mark all her actions. Corresponding to 
 the lower cervical and upper dorsal vertebne, there is a diffuse soft, 
 puffy, and elastic swelling, (juite iindefined, but extending over an area 
 of about six inches in diameter, and over tliis surface there is a mai'ked 
 tendency to hairiness, which merges into the hairy scalp at the nape of 
 tlie neck. The appetite is uncertain and capricious ; the bowels regular, 
 but easily upset by irregularities of diet and changes of weather. 
 3[icturition is frequent. Urine phosphatic, witli trace of albumen. 
 
 She has never menstruated. The knee-jerk is completely absent, but 
 she is quite sensitive to tickling of the soles. Temperature in the mouth, 
 97-4°. Tlie special senses appear to be of normal acuteness, save for 
 some weakness of the eyesight at night, probalily due to the palpebral 
 congestion. Her mental faculties may be sunmied up by saying that 
 they are those of a dull child of five, and her mental operations are 
 characterised by the same sluggishness that distinguishes her bodily 
 movements. She can read children's stories, and is fond of being read 
 to. She displays a great want of application, and experiences great 
 difficulty in learning by rote. Her handwriting is neat, but very child- 
 like. In disposition she is amiable but sensitive, and she realises she 
 is not like otiier children. She does not speak much, and when she 
 does, it is in shoi't jerky sentences, ])ut without any trace of ill-temper, 
 and without ejij^ression. She is easily amused, and often laughs in a 
 short spasmodic jerky fashion. Habits perfectly cleanly, and, according 
 to her mother, she " sleejss like a top."' The extremities are always cold 
 and " frog-like," and she is extremely fond of basking in the sun, or in 
 winter before the fire, when slie will sit motionless for hours doing- 
 notliing, al)solutely jilacid, contented and torpid. 
 
 Case II. 
 E., female, tet. 17] (X(». 4 in the family .series), was a remarkaljiy 
 tine and healthy cliild up to 4 years of age, about which time tlie 
 symptoms as descriljed in the preceding case made their appearance in 
 the same way. At 7 years of age she had diphtheria, but has not had 
 scarlatina. There is a history of some scalp eruption, whicli is 
 described as commencing like a painful boil. There was always the 
 same senitiveness to cold as in tlie preceding case.
 
 844 INTERCOLONIAL MEDICAL CONGRESS OF AUSTllALASIA, 
 
 Height 3 ft. 1}, in., Aveight 43 lbs., head girth 20i- in., chest girth 
 23^ in., umbilical girth 2ih in. The general description of the bodily 
 signs of the preceding case apply with almost verbal accuracy to this 
 one also, only it is to be understood that they exist to a less marked 
 <legree. There is however more scabbiness of the scalp, which looks 
 like the remains of seborj'hwa. The face is not nearly so broad or 
 puffy, nor are tlie hands, but the skin of these members is more glazed 
 and scaly, and has a parcliment-like feel. The breath is in this case 
 offensive. In consequence, probably, of the less bulky body, she can 
 move about much more freely than her elder sister, and can even run a. 
 little, though she moves with the same kind of waddling gait, and a 
 similar sluggishness characterises all her movements. On tlie other 
 hand, there is much greater dulness all round of tlie intelligence, which 
 is associated with greater immobility of the features. She has never 
 learned to read, and speaks with more hesitancy, much indistinctness, 
 and a slight lisp. She can write a childish but careful hand. In 
 flispositiou she is amiable, but not sensitive like her elder sister. 
 Temperature 99*8°. 
 
 Case III. 
 
 C. H., male, iet. 13i (No. 6 in the family series), bom at Woodville, 
 a, suburb of Adelaide ; weaned at about 1 1 months. History of onset 
 of symptoms similar, only they have never progressed to the same 
 extent. There were no infantile diseases, and no scalp eruption. 
 Height 3 ft. 8 in., weight 52 lbs. 10 oz., head girtli 21 in., chest 24| in., 
 abdomen 27 in. Exactly the same kind of symptoms are here present, 
 but to a much less degree. The puffiness of the face is much less 
 marked, but there is still distinct woodenness and want of expression 
 in the features. The hair is much thinner than in the two preceding 
 cases, leaving much bare scalp visible. From tlie distinctness with 
 which the windpipe can be felt, it is possible the thyroid might in this 
 •case be absent. The supra-clavicular swellings are less jDrominent, but 
 still very noticeable ; and so with all the other physical signs. 
 Temperature 98°. 
 
 Mentally, this boy is much in advance of his two elder sisters. He 
 is fairly active, and attends the State School, where he plays with the 
 other boys, but he cannot run fast. At home, he is useful and busy, 
 and looks after the poultry or other domestic matters. He is very 
 good-natured and amiable, slow at learning, but fairly advanced. His 
 handwriting is remarkably good. 
 
 Case IV. 
 I. L., female, -.vt. 1 1 (No. 7 in the family series). Born at the same 
 place as tlie preceding. Weaned at 1 1 montlis. Was a particularly bright 
 and lively cliild. Onset of symptoms as before. No infantile diseases 
 nor scalp eruption. Height 3 ft. 2^ in., weight 4G lbs. 2 ozs., head 
 gii'th 19^ in., chest 25 in., abdomen 25 in. Tlie physical signs of 
 this child may be descriljed as being less advanced than Cases 
 I. and IT., but more so than Case III. The hair is softer and finer 
 than in T. and II., but the lips thicker, more pouting and everted. The 
 bowels are not so liable to be disturbed. Jn tlie supra-clavicular regions, 
 there is fulness, rather than distinct swellings. Tliere is here a slight 
 degree of knee-jerk, which was not evident in tlie preceding cases. The
 
 A CONTIUBUTION 10 I'lIK SITDY OF SFOKADIC CHE'lIXISM. 845 
 
 skin is less dry and harsh than in any of tlie other cases descriljed, 
 which the mother ascribes to lubrication with olive oil. Ts more lively 
 in her movements than her elder sisters, but can only read the smallest 
 words, though her writing is fair. Tempei-ature 9S\ 
 
 Case V. 
 
 A. A., female, set. Gi (No. 9 in the family series), was a small but 
 active healthy infant; Aveaned at 11 months. The cretinoid changes 
 in this case connnenced before she was three years old, rather earlier 
 therefore, than in the others, but thereafter pursued a similar course. 
 There were no infantile diseases, but between two and three years of 
 age she had a moist and particularly offensive eruption on the scalp. 
 Height 2 ft. 8Un., weight I'S lbs., head girth 19 in., chest 19iin., 
 alxlomen 20.^, in. 
 
 This is the only red-haired member of this family which is affected • 
 in other respects the child is a repetition, on a smaller scale, of Case II. 
 The skin of the hands especially is of the same parchment-like character • 
 tlie general surface of the body, however, being more soft and pliable, 
 \\liich is as in the preceding case attributed to oil inunction. The 
 face is much freckled, but pale and antemic. There is a very soft systolic 
 bruit. She is of the same quiet, placid and torpid disposition ; but can 
 Tu^ither read or write, and is generally at a \ery low level of intelli'^ence. 
 Temperature 97°. 
 
 An illustrating the remarkable and almost complete arrest of growth 
 in the above family series so far as height is concerned, the following 
 talile enables a comparison to be made between the measurements 
 taken (by the father) four and five years ago and those taken by 
 myself at the date of my examination : — 
 
 Height. Height. 
 
 January 18S4. January 1889. 
 
 Case 1 3 ft. Siin ,S ft. i in. 
 
 „ II 3 ft. Uiu 3 ft. 11 in. 
 
 „ m 3 ft. 8 in 3 ft. 8m. 
 
 „ IV 3 ft. 1| in 3 ft. 2| in. 
 
 „ V 2ft. 8^in 2ft. 8Un. 
 
 Case VI. 
 
 E. N., female, jet. 12|. The father is a healthy man of moderately 
 robust appearance, 50 years old. He has recently been in the Adelaide 
 Hospital, suffering from pleurisy and inflammation of the lungs, but 
 had no previous illness, save that for a long time he has suflfei-ed from 
 some affection of the sight. There is no history of any habitual or occa- 
 sional intemperance, nor of syphilis. He has one sister living, who has 
 two well-grown daughters. The mother of the present patient is 35 
 years of age, and is a healthy-looking intelligent woman. 8he was born 
 in London, but has been in the Colony for twenty years, living in 
 Adelaide during the whole of that time. There is no history of 
 syphilis or of any serious illness, and all she knows about her own 
 parents is, that her father died of a fit, which was the only one he had. 
 8he has four brothers and one sister living, all married and well, ha\ing 
 families, of whom none are dwarfed. She herself was married when a 
 little over 17, and has had ten children, born at the full time; she had
 
 •846 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 A miscarriage about six years ago, Avhen about foui- mouths pregnant. 
 No instruments have Ijeen used, nor did she receive any shock during 
 pregnancy. No relationship exists between the parents. Tlie following 
 table shows tlie order of the family : — 
 
 1. M.— Stillborn. 
 
 2. F.— Stillborn. 
 
 3. M. — Died at 12 months of measles. 
 
 4. F. — Died at 10 months of some chest complaint. 
 
 5. F. — Now 1-1 years old ; well grown. 
 (). F. — Now I'd years old ; well grown. 
 
 7. F. — The patient, aged 12 years one month. 
 
 8. F. — Now between 5 and 6 ; a well-grown girl. 
 
 9. F. — Now 4, and taller than the patient. 
 
 10. M. — Healthy infant, but died at 7 months of bronchitis. 
 
 The supposed miscarriage was between Nos. 8 and 9. The children 
 that are now living are healthy and well. 
 
 After the sixth child was boi'ii, the pai'ents went to England with 
 their family for the best part of a year, returning to Adelaide, where 
 the patient was born within six months of landing. At bii'th the child 
 was fully as large as her otlier children, and nothing wrong with it was 
 noticed. She began to walk at 12 months, and grew like other children 
 till she was three years old, when she stopped, and has not grown since. 
 She did not learn to talk till nearly 3, but could understand what was 
 said, and used to make dumb show if she wanted anything. The child 
 had some scalp eruption when 9 months old, but no other affection 
 except whooping cough. She has cut (quite recently) the four central 
 permanent incisors, but with these exceptions the milk set persists, 
 sonie being partially decayed. 
 
 Present Condition. — Height 3 ft. IyViii-) weight 37 pounds, head- 
 girth 19 J in., of normal sliape. Both anterior and posterior fontanelles 
 partially open. To describe the physical signs of this case would l)e 
 to repeat, in almost every particular, those of the preceding family 
 series. The resemljlance of the features to those of a myxoedematous 
 patient is perhaps greater in this case than in any of the others; the 
 pale anaemic pufiy face being suggestive of semi-translucency, and 
 relieved by a rosy blush patch on each cheek. There is the same expi'es- 
 sionless and immobile countenance. Diy, harsh skin, tendency to 
 double chin, supra-clavicular swellings, enlargement of veins over 
 upper part of chest, and puffiness over lower cervical and upper dorsal 
 ^'ertebr£e. Similar broad clumsy cold hands with loose baggy skin, 
 large firm calves, lordosis, and tumid belly. The appetite however 
 is good, and there is no particular liability to disturbance of the bowels; 
 nor is micturition unduly frequent, as in the previous cases. Tempera- 
 ture 97°. Mentally, she is like a dull child of four or five. She can read 
 very small words, but cannot write. That she is improving in intelli- 
 gence, her mother is quite certain. The special senses seem of normal 
 acuteness, and the ophtlialmoscope reveals nothing abnormal. The 
 knee-jerk and other reflexes are well marked, and she is sensitive to 
 tickling of the soles. In disposition she is placid but cheerful, and she 
 talks a good deal when playing with other children. She realises she 
 is not like them, but is not at all sensitive about the fact. There is a 
 similar tendency, but not nearly so strong as in the previous cases, to 
 bask in the sun, or before tlie iire.
 
 o
 
 z -. 
 
 lij ^ 
 
 a: CL 
 o
 
 A CONTHIBUTION TO TlIK STUDY OF SrOHADIC CRETINISM. 847 
 
 Photograplis of the six patients ai-e submitted herewith. But it is 
 only fail- to the photograplier, wlio obligingly took a great deal of pains 
 in the matter, to say that his work, in the first ti\e cases, was performed 
 under circumstant-es which wei'e exti-eiiiely untax ourable to a successful 
 and artistic result. 
 
 These six cases constitute a series of i-emarkable unifoi'mity of a 
 condition of arrested l)odily and mental develojjment, to which the 
 name of sporadic cretinism was provisionally given by the late Dr. 
 Hilton Fagge in 1871. In an able paper in the tifty-fourth volume 
 of the " Medico-C'hirurgical Transactions," Dr. Fagge discusses the 
 subject by the light of seven cases which were all that were then known 
 to him, and advances a theory as to the causation, which, however, the 
 post-mortem revelations in a subseijuent case obliged him partly to 
 modify. The paper is further distinguished by a remarkable forecast of 
 the condition we now know as myxicdema, with which the names of 
 Sir AVilliam (!ull and Dr. Ord are honourably associated. Since Dr. 
 Fagge's ai-ticle, I can find in the somewhat scanty medical literature to 
 which I have access, a record of only seven other cases, of which three 
 were supplied by himself. These fourteen cases are all from English 
 sources, )>ut I see no reference in any of the i^ublished accounts to any 
 occuri'ing elsewhere, so that I may believe that these reports nearly, at 
 any I'ate, exhaust the literature of the subject. The six cases reported 
 above thus form a substantial addition to the number, and, from the 
 unifoi'ndty of the series, should not be without value for future reference. 
 The fourteen cases previously reported are from the following 
 sources : — Mr. Curling, in the "Transactions of the Medico- Chirurgical 
 Society," a"o1. xxxiii, two cases ; Dr. Langdon Down, " Transactions of 
 the Pathological Society," vol. xx, one case ;. Dr. Hilton Fagge, 
 "Trans. Med. Chir. Soc," vol. liv, four cases; and three more in the 
 " Trans. Path. Soc, vol. xxv, where there is also a case reported by 
 Mr. Fletcher Beach; Dr. Ilouth, "Proceedings of the Medical Society," 
 vol. vii, one case ; Dr. Sidney Phillips, " Clinical Society's Trans- 
 actions," vol. xviii, one case ; Dr. H. H. Robinson, " Clin. Soc. Trans.," 
 vol. XX, one case. 
 
 On reference to tlie aboxe cases and those now brought forward, it 
 will be seen that, in spite of some differences, there is such a close 
 generic resemblance between them, as to make it evident that all were 
 of the same nature. 
 
 The general characters of the aliection need not be repeated here, 
 as they have been well summed up Ijy Dr. Fagge in the paper before 
 referred to, and again appeal- in the detailed account of the first case 
 of the present series. 
 
 The interest of the aU'ection lies of course in its causation, for whicli 
 we are yet without a satisfactory theory, as well as in the exact natui'e 
 of the changes in the organs and tissues, on which point the evidence 
 is extremely scanty. Indeed, so far, the only substantial and constant 
 pathological fact, is the proof of the fatty nature of the supra-clavicular 
 tumours, ANhich it will l)e seen existed at some time or other in every 
 one of the recorded cases. The interest of the whole subject is further 
 increased by the evident similai-ity of many of the symptoms to those 
 of myxoedema, a point which has been noted by previous writer.s, and 
 "which is so well-marked in the present series.
 
 848 IXTERCOLOMAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 * The question of the rehitionship of the thyroid to niyxoedematou.s 
 changes cannot be entered into here, but tlie proved absence of Una 
 organ in the two first cases of sporadic cretinism examined, and its 
 putative absence in several others of the living cases, could not fail to 
 suggest the theory enunciated by Dr. Fagge, that the absence of the 
 thyroid was the prime cause of this affection. However, the proved 
 presence of a thyroid of considerable size in a subsequent case, caused 
 Dr. Fagge himself to recognise that other causes must be looked for. 
 In the light of subsequent events, it is of course to be regretted that 
 no micioscopic examination of the thyroid in this case was made. 
 
 The theory of Dr. Langdon Down, that the mental and bodily 
 stunting results from the intoxication of one or both parents at tlie 
 time of procreation, finds no support in any of my cases, or in any others 
 except his own, that I can see. 
 
 There were no instrumental deliveries in any of my cases, a theory 
 which was at one time urged, in reference to the endemic form of 
 cretinism, and suggested as a possible cause of the sporadic form ; nor do 
 they lend any additional support to the idea, that fright during pregnancy 
 might have something to do with the origin of the affection, though, as 
 pointed out by Dr. Sidney Phillips, this has actually occurred in three 
 instances. Nothing apparently can l)e attributed to consanguinity, 
 or to any kind of local influence. 
 
 The principal features of the first five of the series which I present, 
 are undoubtedly the comparatively large number of tlie same family 
 who were affected, and in all the remarkable uniformity of the age at 
 which the cretinoid symptoms commenced, viz., at about three years of 
 age. Having in the first place learned these two facts, I was in great 
 hopes that such favourable circiunstances would permit a careful 
 investigation to throw some additional light on the question of the 
 origin ; but in this I have not been successful, as I can detect nothing 
 which in any way distinguishes the birth, early growth, or rearing of 
 the affected, fi'om the healthy members. This uniformity of the time 
 of onset does not exist in the English cases. Taking the cases in 
 which the period is definitely stated, I find that in one the symptoms 
 were congenital, in four they supervened at 1, 2^, 7 and 8 years 
 respectively ; in another, the child was noticed to become less active 
 at 9 months, and to cease growing at 2^ to 3 years. In thi-ee of 
 Dr. Fagge's cases there was evidently some bodily change, which was 
 probably the beginning of the affection in question at 6, 5 and 8 months 
 respectively. In Dr. Robinson's case, the child is reported as being 
 weakly from birth, and not walking until 12 years of age, or speaking 
 until 13. Still, in spite of these variations, the age of about three 
 years stands out as being the most favoured epoch for the onset. 
 
 There is another point to which the South Australian cases suggest a 
 reference, viz., the numerical size of the families in which sporadic 
 cretinism has occurred. The two families in which my cases were 
 found were large, being eleven and ten in number respectively. In two 
 other instances, the families consisted of seven membei-s ; and in each of 
 two more, they were five in number. Of the sex, six only of the twenty 
 cases now recorded have been males, and fourteen females, showing, as 
 far as tlie figures go, an increased liability to the affection on the pai't 
 of female childrea.
 
 RACE AND INSAXITV IX XEW SOUTH WALKS. 849 
 
 Witli regard to the possible existejice cand influence of any hereditary 
 disease, the only noteworthy features are the existence of epilepsy in 
 two of the affected families, and a severe taint of phthisis in another. 
 
 No bone deformity, nor evidence of a past or present rachitic state, 
 existed in any of my cases, though this has been observed by others ; 
 nor does there appear to be the slightest evidence to connect the 
 affection with syphilis. 
 
 The fontanelles which are reported to have been open in thi'ee 
 previous cases, were open m one only of mine (No. 6), and in no case 
 did I observe any abnormality in the shape of the skull, such as has 
 been occasionally, but rarely, noticed. The measurements which are 
 given in my own series, show a fair sized head in each case. 
 
 There is one symptom which was a conspicuous element in all my 
 cases, which I do not find specially mentioned in any of the others. I 
 allude to the marked tumefaction, with tendency to hairines.s, over the 
 region of the lower cervical and upper dorsal vertebra?. It may be, 
 however, that Mr. Curling's statement, that the " dorsal svirface of the 
 body .... was hairy," is an indication that this symptom may 
 liave existed in one of his cases. Reading this symptom by the light of 
 the general tumefaction in other parts, and the proved existence of fat 
 in the supra-clavicular regions, we may surmise that these dorsal 
 swellings are also fat. If that be the case, it brings forward the 
 abnormal development of fat as a marked feature of the affection. 
 
 From the preceding remarks, it will be seen that I am unable to 
 ><uggest any theory as to the aetiology of this singular affection, and I 
 present this I'eport as a contribution to its study, as well as with a view 
 of eliciting fui'ther information from those who may have had the 
 opportunity of observing similar cases. That sporadic cretinism and 
 myxoedema will be found to be closely related, I have little doubt, but 
 it seems clear that the symptoms of the fomier affection at least cannot be 
 attributed solely to congenital absence of the thyroid gland. Whether 
 they may still be due to retrogressive or atrophic changes in that organ, 
 and what the exact nature of tlie tissue changes are which give rise 
 to the peculiar features, are questions which have yet to be settled. 
 Viewed in the light of recent experimental evidence, it is difficult to 
 resist the belief, that some impairment of the functions of the thyroid 
 will ultimately be proved beyond all doubt to lie at the bottom of 
 sporadic cretinism, as well as of myxcedema ; but at present, for .sporadic 
 cretinism, the verdict must be — not proven. 
 
 RACE AND INSANITY IN NEW SOUTH WALES, 1878-1887. 
 
 By CiiisnoLM Ross M.D. 
 
 Medical Officer, Hospital for the Insane, Gladesville, New South Wales. 
 
 Having seen an article in a recent number (April 1888) of the 
 
 American Journal of Insanity on the subject of " Race and Insanity " — 
 
 an interesting one to us in an English-speaking country in many 
 
 respects similar to the United States of America — I have 
 
 collated the facts to follow from the Registers at Gladesville, an 
 
 institution which receives all classes and nationalities of the insane as 
 
 2i
 
 850 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 they occur in the colony of New Soutli Wales. The ten years— 1878 to 
 1887 inclusive — have been taken as fairly representative of a much 
 longer period, and allowing of a reasonable average, considering 
 that at no time in the comparatively recent history of the colony has 
 there been any special immigration of any of the races tabulated. 
 .. At the outset I am confronted with a difficulty, in that the Aus- 
 tralasians, that is those born in Australasia of whatever parentage, 
 are of no special race. For instance, a Scandinavian marries an 
 Irish woman, both having emigrated soutli; a Hcotclnnan takes to wife 
 one born in Australasia; a male Australasian mates with a native of 
 tlie British Isles or of the Continent — to what race, strictly speaking, 
 can the progeny be said to belong ? Unless then we are prepared to 
 call all those born in Australasia representatives of a race, we are 
 hampered by the fact that, for the period mentioned, less than half of 
 the whole number specified cannot be considered. But making them 
 into a race or nationality, in respect of their birth in the southern 
 hemisphere, instead of the northern, with the difference in climatic 
 conditions, habits, customs, etc., considered (and these may have 
 coloured to some extent the influence of heredity in one or both of their 
 pai-ents, as the case may be), we have something definite to go upon, 
 and comparison can be made with specific races and nationalities. 
 
 A constantly recurring source of variation in making any statement 
 in connection with the " Australasian Nationality," is found in its 
 marked hybridity. It will be admitted tliat the progeny of the native 
 born, of whatever parentage themselves, can hardly be fairly associated 
 with the progeny of parents of different race ; the only thing Austra- 
 lasian about the progeny of the latter being, that they first saw the 
 light in Australasia ; still, for the purposes of this paper, and after 
 the explanation given, this much must be allowed. 
 
 The nationalities in Table I are sufficiently well-known ; but it may 
 be as well to mention that in the Australasian group, Tasmania and 
 New Zealand have been included ; the United States of America and 
 Canada have been classed together ; the Channel Islands have been 
 thrown in with France, Austria with Germany, Russians with 
 Scandinavians, and the Ionian Isles with Greece. 
 
 As to the classification of insanity adopted, some explanation 
 is necessary. For example, under states of mental exaltation, 
 or what is generally classed simply as mania, have been placed 
 acute, sub-acute, senile, puei'peral and recurrent mania. Under the 
 next great type — states of mental depression or melancholia — simple 
 melancholia, acute, and puerperal. Under states of mental enfeeble- 
 ment (not want of development) all forms of dementia, including 
 primary, secondary, organic, itc, but excepting that caused by 
 intemperance, which comes under a separate heading. Under general 
 insanity, with which is included chronic mania, are classed all those 
 who are simply insane hopelessly, and who are incoherent always, have 
 no idea of their surroundings, &.c. Under the heading of paranoia, 
 or states of delusional insanity, come both delusional mania and 
 delusional melancholia, which is to some extent unfortunate as regards 
 the object of this paper. It would have been better had the cases 
 of exaltation and depression been placed under the separate headings 
 prepared for them, especially as the cases of delusional melancholia are
 
 RACK AXD IXSAXITY IN NKW SOUTH WALKS. 851 
 
 luuijli in excess ot' those of delusional mania, but I was obliged to take 
 tlie figures as they appeared in the registers. The i-est of the headings, 
 with one exception, are self-explanatory. The cases of intemperances in 
 drink have been placed together, whatever their mental condition, 
 and this has led to some interesting facts, to be mentioned later. The 
 figures include, of course, both males and females, without special 
 mention as to their social condition. 
 
 The numbers in the races or nationalities iiumbered from 11 to 
 21 inclusive in Table T, are, apart from other considerations, 
 so few, that little need be said about them. In passing, it may 
 however be remarked, that the "West Indians were all of negro 
 extraction, if not jDure-blooded Africans ; their tendency being towards 
 delusional insanity. The natives of the Indian Peninsula were of the 
 Coolie class, and insanity with them seems to be compi-ehensive in 
 its subdivisions. But those numbered 1 to 10 inclusive {vide Table I), 
 may connnand a good deal of notice. 
 
 By comparing the actual number admitted to Gladesville Hospital in 
 the ten years (the grand total of all nationalities being 2858, out of an 
 a^■erage population resident in New South Wales of 847,725, vldn 
 Table II), it will be noticed that, although this hospital is the oldest in 
 the English-speaking southern hemisphere, and that it is situated in the 
 oldest settled part of Australasia, there were admitted but 99 more 
 Australasians than English, and 141 more than Irish in the decade. 
 
 It has just been stated, that very few more Australasians than 
 English or Irish were admitted during the decade, and this anomaly 
 may \o some extent be explained, when we remember that the majority 
 of those (omitting idiots and imbeciles) sent to this hospital Avere 
 adults, and that presumably almost all the English and Irish were so, 
 whereas the general population of the colony consisted of Australasian 
 children in addition to the adults. Again, it is well known that many 
 " ne'er-do-weels," either from vice or mental infirmity, and some who 
 have been insane in the old country, but who have recovered to a certain 
 extent, are sent here to be out of sight of their friends. But apart 
 from this, we still have the startling fact, that the number of English 
 and Irish insane in this colony (especially the Irish) are vastly in 
 excess of their pi'oper proportion. The subjoined figures (Table III) 
 will show the proportion of the insane in Gladesville to the population 
 of New .South Wales in respect of nationality : — 
 
 1. 1 Frenchman in every 76 was insane. 
 
 2. 
 
 1 German 
 
 
 So 
 
 3! 
 
 1 Scandinavian 
 
 
 89 
 
 4. 
 
 1 Irishman 
 
 
 . 93 
 
 5. 
 
 1 American 
 
 
 96 
 
 0. 
 
 1 Welshman 
 
 
 127 
 
 7. 
 
 1 Englishman 
 
 
 135 
 
 8. 
 
 1 Scotsman 
 
 
 155 
 
 9. 
 
 1 Chinese 
 
 
 188 
 
 10. 
 
 1 Australasian 
 
 
 579 
 
 It will be seen that the French head the list. This may be due to 
 the proximity of New Caledonia, many of the patients being escapees 
 from there: and it is interesting in this connection to speculate, whether 
 
 2i 2
 
 852 INTERCOLONIAL MEDICAL COXGKESS OF AUSTRALASIA. 
 
 ill the tirst instance they were not titter subjects for asylum treatment, 
 than for penal discipline. A glance at Table I will show that the majority 
 of the cases of the French nationality were of delusional insanity — a 
 common form in foreigners, and caused no douVjt by their want of appre- 
 ciation of the English language, the customs and habits of the new covmtry, 
 t^vrc, these tending to make them suspicious, and inclining them to false 
 beliefs. Following the French, are tiieir near neighbours the Gei'mans, 
 showing a large number of insane for their popvdation, the tendency 
 with them also being towards delusional insanity, and probably for the 
 same reasons. Indeed, this seems to be true of all foreign nationalities, 
 but less so of the Chinese than any other. To return to the numbei's of 
 the insane compared to the population, it is found that tliird on the list 
 are the Scandinavians, fourth the Irish, fifth the Americans of the 
 United States, sixth the Welsh, seventh the English, eighth the Scotch, 
 ninth the Chinese, and last the Australasians. The above figures point 
 strongly to the fact, that the peoples of the Continent of Europe, what- 
 ever may be their tendency to become insane when at home, seem to 
 have a marked tendency to mental alienation here. Running them 
 close however are the Irish people, whose number of insane is altogether 
 disproportionate to any other of the English-speaking people, excepting 
 the Americans, and they are so few as to hardly bear comparison. 
 The reasons for the excess of insanity in the Irish nationality have 
 been very variously stated, and need not occupy much time now. I am 
 of opinion that a powerful factor in their becoming subjects for asylum 
 treatment when insane is, that tliey seem to have moi"e loss or abeyance 
 of will-power and to be moi^e demonstrative then than any other 
 nation, and that for these reasons they find their way earlier to asylums, 
 whereas persons of other nationalities recover at home. But if race or 
 nationality was all-important in the causation of, or tendency to, 
 insanity, the Welsh who, like the Irish, are of Celtic extraction, should 
 hold as high a place numerically ; but it is found that the Irish number 
 1 in 93, the AVelsh only 1 in 127. The percentage of the English is 
 slightly larger than the Welsh, that of the Scotch considei'ably less than 
 the English. The Chinese insane, according to statistics, are fe^\', 
 l)ut this must be accepted with reserve, as many of the Chinese 
 insane are harboured by their countrymen, and instead of being sent to 
 asylums, are shipped off to their own country. On the other hand, it 
 would seem that their being foreigners has not the same weight in the 
 causation of mental alienation as obtains in European foreigners. 
 
 Having taken the various nationalities seriatini, the Australasian is 
 reached, and a glance at the figures in Table III will show how very 
 few became insane compared with any other nationality ; the nearest 
 approach to them, but still very distant, being the Chinese. It has 
 been stated previously, that as regards the British Isles, the discrepancy 
 is explained away to a very slight extent by the fact, that adults fill 
 asylums, and that the number of Australasians in the Colony is to a 
 considerable extent made up of children. But this is not neai'ly 
 sufficient to account for the great disparity. What then are the 
 reasons for the extraordinary immunity the Australasian nationality 
 seems to have? Is it because of their marked hybridity? Has the 
 climate anything to do with it ? " Are the habits and conditions of life of 
 the native white people conduci\'e to mental stability? Is the standard
 
 RACE AND INSANITY IN NEW SOUTH WALES. 853 
 
 of civilisation a reason for it, or are the morals of the Australasians in 
 tlieir favour ? Is their self-reliance and self-confidence a reason ? 
 
 That the hybridity is a large factor against insanity I have little 
 doubt, in that the chances of perpetuation by heredity are lessened 
 wliere people of distinct nationalities inter-marry, the breed as it were 
 being changed. For example, it is more probable according to the 
 facts elicited, that the cliildren of French, German or Ii-ish parents 
 may become insane, than that the children of — say a Scotch father and 
 Irish mother should ; the cross-ljreeding here causing a dilution, if I 
 may use the word, of any tendency to iirsanity which may have existed. 
 
 That climate may be in their favoui- seems to me to be demonsti-able, 
 seeing that generally speaking everything which conduces to physical, 
 conduces also to mental health ; and the Australasian climate certainly 
 lends itself to the acquiring and keeping up of health, by the amount of 
 open air life which it permits. 
 
 It may be worth a passing thought, that (statistically) warm 
 countries or climates do not furnish a large percentage of insane from 
 among their inliabitants. At any rate, the number of Chinese and 
 Australasians compared to those further distant from the equator 
 would seem to point to this. Can it be that the almost perpetual 
 sunshine ovei' the greater part of Australasia militates against insanity 'I 
 
 That the conditions of life, or rather of li\ing, are easier here than 
 in most other countries, is undeniable. Tliis can, T think, be admitted 
 as a reasonable factor in tlie maintaining of mental health. Food, and 
 even luxuries, are abundant ; the cares and worries of life are not 
 so constant or harassing ; not so much thought is taken for the 
 morrow, because it seems to be unnecessary. The habits of the 
 Australasians are mostly begotten by the climate ; life is taken as it 
 comes, what matter if troubles loom I The worst is in the anticipation, 
 the realisation proves itself to be nothing vei-y dreadful after all, 
 and this they seem to appreciate. 
 
 That they have reached a standard of civilisation which may be 
 in their favour, is open to doubt. It is just possible, however, that 
 their habits and conditions of life permit of no othei-, and in this way 
 it may be in their favoiu'. As to their morals, comparison indicates 
 nothing either way. 
 
 The last, but perhaps most important, reason for the preservation 
 of their mental equilibrium, is the possession of much self-reliance 
 and self-coniidence. Precocity may be a questionable virtue, es- 
 pecially as it is often allied to genius, which again is so often 
 associated with mental disease ; but what j^eople assert theitiselves 
 so freely? (often, no doubt, on mistaken or insufficient premises); 
 and as regards the individual, who at the age of fifteen is so 
 much a man in thought, word, and deed ? who cuts the ajDron-strings 
 which remain intact so much longer in older countries ? and what 
 nationality lias made such material progress, according to the I'esources 
 available, as the Australasian ? I do not urge that these (jualities are 
 eminently in their favoui- in the eyes of other nationalities, but I 
 submit that their self-reliance and self-con tidence remain potent factors 
 in the prevention of mental alienation. It may be said tliat the same 
 reasoning would apply with equal force to the Americans of the United 
 States and to the Canadians, in whose case* the proportion of insanity
 
 854 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 is large ; but I imagine that the very high pressure which obtains with 
 them is a sufficient reason to annul, or at any rate modify largely, the 
 advantage gained by their self-contidence. Besides, they are notably a 
 nervous people — this, in itself, being a predisposition or ally, no matter 
 how slight, to mental disturbance. 
 
 It remains to me, for the completion of my subject, to indicate more 
 particularly the kinds of insanity from which the various nationalities 
 in this Colony at any rate are prone to sutler, and finally, to draw 
 conclusions if possible therefrom. 
 
 The nationalities in Table I, numbered 11 to 21 inclusive, have as 
 far as their importance goes been already dealt with, and Avill not be 
 again referred to. Tliose numbered 1 to 10 inclusive, I shall take in 
 the order given in the table. It may be as well to mention here, that 
 the mental states known as idiocy and imbecility, and that of epileptic 
 insanity will not be considered separately, ina.smuch as the number of those 
 so afflicted appertain almost solely to Australasia for obvious reason.s, 
 and cannot therefore inAite any comparison with other countries. But 
 statistically, they have been included among the Avistralasian insane — 
 another proof of the small tendency of that nationality to insanity. 
 
 A reference to Table I will sliow that, with tlie exception of the 
 AVelsh, the Australasians seem to have the greatest tendency to states 
 of mental exaltation or excitement, the Americans of the United States 
 (always remembering that the number compared is few) least. I have 
 no explanation to offer for these facts, but would like to say that of all 
 forms of insanity, the cases of mania are sent earliest to asylums, 
 mainly on account of the demonstrativeness common in such cases, and 
 this may account for the large number of maniacal cases found under 
 most of the nationalities in Table I. 
 
 Of melancholiacs, it is found that the Americans head the list a\ ith 
 a percentage of 20, the Welsh haA'ing the least tendency to states of 
 mental depression. It has just been seen, iiowever, that the "Welsh are 
 eminently giAen to exaltation of mind — a confirmation, if any were 
 needed, that it is unlikely they would also be subject to melancholia. 
 Following the Americans are the Chinese, with a percentage of 16. 
 Tlie English, Irish, kScotch, German and Australasian nationalities seem 
 to have about an equal tendency to mental depression. In tliis country 
 many of the cases of melancholia are found in shepherds, and in people 
 who live a more or less solitary life in the bush. A considerable number 
 of the Chinese admitted were shepherds, and in their case, no doubt, the 
 depi-ession was often set up or aggravated by the use of opium. 
 
 The next great type of insanity — the one accoi'ding to Dr. Clou st on 
 to whicli most others tend, the bane of asylums, the unwished-for 
 goal — is dementia, or enfeeblement of mind. The Welsh show the 
 large percentage of 50, but the numbers are too small to allow of any 
 accurate inference. The Chinese show 33 per cent., and next come the 
 English with a pei'centage of 21, tlien the French and Scotch. That the 
 M elsh should be oO per cent, points to the incural)ility of their insanity, 
 in that, if it is not originally dementia, it finally reaches tliis goal. 
 
 General paralysis of the insane next conies uji for consideration, and' 
 it is at once seen, that from this most fatal form of insanity the 
 Australasians seem to have marked iunnunit}', more so than any other 
 nation, the Americans having tlie higliest proportion. The Inspector-
 
 RACE AND IXSANITV I\ XRW SOUTH WALES. 8J)0 
 
 C!-euerul of the Insane for New South Wales assures me that twenty years 
 ago ■••eneral paralysis was almost unknown, or at any rate a great rarity, 
 in the asylums of the United States of America, but that now it is rife. 
 1 find tliiit the percentage of general paralysis in Australasians is 1 per 
 cent., English 5 per cent., and Americans 12 per cent. The Durham 
 minei- who, when earning good wages, drinks hard, works hard, lives on 
 nmch Hesh meat and is given to excess generally, is .said to fulfil all 
 the conditions necessary to the setting up of general ])aralysis. It is said 
 also to he commonest in races of high civilisation. This latter points 
 liardly at the Australasians, but is doubtfully complimentary to tiie other 
 nationalities concerned. We have yet to learn tlie I'eason of its selection. 
 
 In paranoia, or delusional insanity, Great Britain, Ireland, and 
 foreign countries stand pre-eminent compared to the Australasians, the 
 Scandinavians showing the liighest proportion. In foreigners, whose 
 knowledge of the English language is limited, this is to some extent 
 explainal)le; but the Irish do not lag far behind. 
 
 The remaining forms of insanity are unimportant to our subject, 
 e.xcepting those tabulated as lia\ing been caused by drink. As before 
 stated, the mental condition, no matter in what form, if caused 
 by intemperance, was placed under this lieading. A glance at 
 Table I will show that from intemperance there were no Chinese 
 admitted ; surely a plea in their favour as colonists. The Americans 
 seem "to^ have been most guilty, the Scotch next, the Australasians 
 (excepting of course the Chinese) least; and betw-een these come the 
 English, Ii'ish, Germans, and Scandinavians, of about equal demerit. 
 It appears, then, that by comparison with old-world European nation- 
 alities, the Australasian is a temperate one. This is, I think, held true, 
 apart from proof derived from statistics of insanity. I would, however, 
 Ijefore closing the subject of insanity, as supposed to be caused by 
 intemperance in drink, like to add, that it is an uncertain cause in 
 statistics, inasnmch as many cases are put down as being caused by drink, 
 whereas the converse was true — the insanity caused the drinking 
 liabit. This of course applies to all nationalities equally. 
 
 What then can l)e deduced from what has been said 1 
 
 (1) It seems undoubted that .so far, or as at present constituted, the 
 Australasian nationality is peculiarly free from mental di.sease. ( Vide 
 Table III.) 
 
 (2) That in tlie decade (1878-1887) less thiui half of tliose admitted 
 were Australasians. 
 
 (3) That the English and Ii'ish insane (especially the latter) are, by 
 comparison with the Australasians, vastly out of propoi'tion. 
 
 (4) That tlie Continent of Europe supplies an undue number of 
 insane to the colony. 
 
 (5) That Chinese liave a much smallei- number of insane tlian 
 any other nationality, excepting the Australasian. 
 
 (6) That foreigners (not including the Chinese) have a tendency 
 towards delusional insanity. 
 
 (7) That Australasians seem most inclined to states of mental 
 exaltation, and least to general paralysis of the insane, wliich is indeed 
 conspicuous by its infrequency. 
 
 In Table I, under each nationality, will be found the absolute number 
 and the number per cent., suffeiing from each form of insanity.
 
 856 
 
 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 
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 including — 
 
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 (^/) Acute 
 
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 ment, including— 
 
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 (6) Secondary ,, . . T 
 
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 (<0 Paralytic ,, ..] 
 Epileptic Insanity 
 
 General Paralysis 
 
 jParanoia, or Delusional \ 
 
 \ Insanity .. ) 
 
 General Insanity, including) 
 
 Chronic Jlania .. > 
 
 Mania I i 
 
 Melancholia e potu \ 
 
 Dementia ) ( 
 
 Hysterical Insai ity .. 
 
 Imbecility .. 
 
 Idiocy 
 
 j Total of each Nationality
 
 INSANITY IN AUSTRALIAN ABORIGINES. 
 
 857 
 
 Table IL 
 
 Shoioing average members of respective nationalities resident in ^^.S.W. 
 during 1878-1887. 
 
 1 
 2 
 3 
 
 4 
 5 
 (5 
 7 
 8 
 !) 
 10 
 11 
 
 Nationalities. 
 
 Australasian 
 
 English . . 
 
 Irish 
 
 Scotcli 
 
 Chinese . . 
 
 Germans, etc. 
 
 Welsli 
 
 Scandinavians, &c. 
 
 U.S. America, &c. 
 
 French, &c. 
 
 All other Nations 
 
 Population. 
 
 509,788 
 
 10('),20O 
 
 (;<.), 044 
 
 24,828 
 
 10,179 
 
 7,809 
 
 3,067 
 
 2,958 
 
 2,407 
 
 1,369 
 
 110,076 
 
 Total 847,725 
 
 Table III. 
 
 Showing 2^''oportion of iiisane of each nationalitg in Gladesville to 
 persons of that nationality resident in X.S.W. during 1878-1887. 
 
 
 Nationalities. 
 
 Insanity According to 
 Population. 
 
 1 
 
 French 
 
 1 in 
 
 every 76 
 
 2 
 
 Germans, &c. 
 
 
 85 
 
 3 
 
 Scandinavians, &c. 
 
 
 89 
 
 4 
 
 Irish 
 
 
 93 
 
 5 
 
 U.S. America, &c. 
 
 
 96 
 
 6 
 
 Welsh 
 
 
 „ 127 
 
 7 
 
 English . . 
 
 
 „ 135 
 
 8 
 
 Scotch 
 
 
 „ 1.55 
 
 9 
 
 Chinese . , 
 
 
 „ 188 
 
 10 
 
 Australasian 
 
 
 „ 579 
 
 INSANITY IN AUSTRALIAN ABOllIGINES, WITH A 
 
 BRIEF ANALYSIS OF THIRTY-TWO CASES. 
 
 By F. Norton Manning, M.D. 
 
 Inspector-General of the Insane in New South Wales, and Lecturer on 
 Psychological Medicine in tlie University of Sydney. 
 
 So far a.s can be gathered from tlie accounts published by explorers 
 and early colonists, insanity was a very rare aliection among the 
 Australian aborigines whilst in their primitive and uncivilised 
 condition.* From such accounts as are accessible, it appears that 
 when insanity did occur, if the subject of it was violent and aggressive, 
 
 • "The Australian Kace," by Edward M. Curr, p. 2'J3.
 
 858 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 he was promptly slauglitered ;* if melancliolic, he was allowed — if so 
 disposed — to commit suicide ; if demented and helpless, he was left to 
 die ; and only when quiet and peaceable, and when his erroneous ideas 
 did not result in offensive acts, was he allowed to continue in the trilje, 
 and in some cases was held in reverence as a superior and inspired 
 being. The Australian aborigines, in fact, acted towards their insane 
 in much the same manner as almost all savage races apjDear to have 
 done, and carried out to its fullest extent, in this respect, the great 
 principle of the survival of the fittest — practically working in the 
 direction of stamping out tlie malady. In addition to this, their simple 
 and uneventful existence, without worry or strain, and their marriage 
 laws (which forbade all consanguineous, or even intertribal or interseptal 
 marriages) served to prevent the occurrence of what may be called 
 occasional, and of hereditary insanity. 
 
 As time rolled on, and the aborigines were brought more in contact 
 with Europeans, and became acquainted with the vices and the cai*e» 
 of civilisation, we find more frequent notices of mental disease. The 
 Rev. George Taphill writing on " The Natives of New South Wales," 
 says : — " I have frequently seen cases of epilepsy " (p. 259). " I have 
 seen several cases of lunacy among them, and it is not uncommon for 
 the intellect of old men to give way, and for them to be insane " (p. 260). 
 Mr. Phillip Clancy, in an appendix to Mr. Brough Smyth's learned 
 work on " The Australian Aborigines," says : — " I have never observed 
 insanity or hereditary or chronic complaints among the natives, except 
 in those vitiated by white people " (p. 254) ; and Mr. James Dawson 
 writes : — " Suicide is uncommon and cases of insanity rarely met with, 
 but the aborigines believe there is more of it since the use of intoxicating 
 liquors, and especially since they began to disregard their laws of 
 consanguinity in marriage" (pp. 61 and 62). The growing amount of 
 insanity, and the greater tendency to it in so-called civilised aboi'igines, 
 are illustrated by the statistics of Queensland and New South Wales. 
 In Queensland a large part of the aboriginal population had not, until 
 quite recent years, been brouglit into contact with more than the 
 confines of civilisation. This population is estimated, as I gather from 
 information obtained from the Registrar-General's Office in Brisbane, 
 at something like 20,000, whilst the number of aljorigines admitted to 
 Queensland asylums, since the year 1868, has been fourteen only. The 
 aboriginal poj^ulation of New South Wales has been for years past a 
 miserable remnant, supported for the most part by the Government, 
 afflicted with the vices and diseases of civilisation, and devoid of the 
 nobler and better chai-acteristics of the race. Since the year 1868, 18 
 aborigines have been admitted to the asylums of New South Wales 
 from a population which has never during that time exceeded 2500, 
 and is now less than half that number. It is noteworthy too, that 
 during tlie decennial period 1868-1877, eight aborigines were admitted ; 
 wliilst during the next decade 1878-1887, ten wei'e received, showing 
 an increasing number of insane, whilst the aboriginal population was 
 steadily decreasing. In the census year 1881, the proportion of 
 aboriginal insane to the aboriginal population in New South Wales 
 was 2"8;3 per thousand, a proportion in excess of that for the general 
 
 * " Aus-traliau Aborigines," by James Dawson, yt. 01.
 
 INSANITV IX AUSTHALIAX AUOHIGINES. 859' 
 
 jiopuliition : and at tlic clo.so of I.'^N?, it was upwards of 5 per 
 thousand. The rate at this period would liave been even higher, if the 
 duration of life in aborigines in conHncnient were not extremely sliort, 
 and much below the average of tliat of Europeans under similar 
 conditions. We have then, in New South Wales, passed from a period 
 in which insanity was ahnost unknown among the native race, to one 
 in which it is almost twice as conunon as among the European race 
 inhabiting the same territory. I liave received from my friend and 
 colleague Dr. Scholes, brief notes of all the cases (foui'teen in number) 
 admitted to Queensland asylums since 1868 ; and all admitted to 
 asylums in Xew South Wales, fi'om August 1, 1868, to December 31, 
 1887, (eighteen in numl)ei-), came more or less fully under my own 
 observation. 
 
 Of the thirty-two cases, twenty-foui' were males and eight females, 
 and the following short return gi\es the general results : — 
 
 
 JIale.-.. 
 
 Females. 
 
 Total. 
 
 Admitted ... 
 
 ... 24 
 
 8 
 
 3-2 
 
 Died 
 
 17 
 
 :] 
 
 20 
 
 Dischai;ged recovered 
 
 3 
 
 3 
 
 6 
 
 Remaining ... 
 
 4 
 
 2 
 
 6 
 
 In addition to the above, two half-castes were admitted. 
 
 In considering the causation of the malady in these thirty-two cases,, 
 it was beyond a doubt that the chief share was due to civilisation and. 
 its accompanying vices, and to the changes of life and habits incident 
 to this. A considerable propoi'tion of the cases were due directly 
 to drink ; four or five were due to impi'isonment, awarded either for 
 offences springing from drink, or for violence which, though witliin the 
 ethical code of the nati\e, was by civilisation accounted a crime. 
 
 It was a remarkable fact that, with one or two exceptions, the whole 
 of the patients spoke English — some witli great facility and correctness, 
 and with a rich knowledge of expletive and objurgatoiy expression. 
 Three of the patients had served in the [)olice as troopers or trackers. 
 
 As might have been expected in a dai-k -skinned race, the prevailing 
 type of the malady was mania, usually acute, and as a rule accom- 
 jmnied by turbulence and violence, and this passed very rapidly 
 — much more rapidly than in Europeans — into dementia, with filthy 
 and degraded habits. In some of the cases, the hallucinations of sight 
 and hearing were extremely vivid ; and in one of the less civilised cases, 
 the patient, not I'ecognising his own reflection, persistently smashed 
 looking-glasses, or tore them down when in fixed positions, .so as to get 
 at the source of the voices which annoyed him. 
 
 The melancholic ca.ses all originated in gaol, and were due apparently 
 to more or less prolonged imprisonment for ort'ences sucli as rape, wife 
 murder, or manslaughter, wliich the native code regarded as venial. 
 The melancholic as well as the maniacal cases tended at an early stage 
 to dementia, and this was in most cases extreme, and accomiianied by 
 failing health and indescribably dirty liabits. 
 
 Epilepsy occurred in three cases, and the fits were well marked and 
 severe. 
 
 No ca.se of general paralysis, or anything which could be mistaken for 
 it was seen, and there were no cases of monomania or delusional 
 insanity.
 
 860 INTEKCOLONIAL MEDICAL CONGRKSS OF AUSTHALASIA. 
 
 One of Dr. Sclioles' cases was an imbecile, but as the girl was blind 
 from a very early age, it was difficulty to say whether the imbecility was 
 congenital, or was mainly due to deprivation. Another of Dr. Scholes' 
 cases was an excellent example of puerperal mania. It followed imme- 
 diately on the birth of the patient's second child, and she was admitted 
 ■a foi'tnight after parturition, the breasts being full of milk, and all the 
 ordinary symptoms of puerperal mania present. She made a good, but 
 not rapid, recovery. 
 
 The cases of recovery — six only in number — were in hospital for 
 comparatively sliort jieriods, the longest being eight months. In several 
 cases discharge was postponed, owing to the difficulty of fixing a 
 standard of saneness, and also by reason of the necessity of finding a 
 home for the patient. 
 
 In only one case was there relapse and re-admission, and in this, 
 the cause of the original attack and of the relapse was drink. 
 
 The deaths numbered twenty, and in several cases the only cause 
 Avhich could be assigned was " marasmus " — a gradual wasting, without 
 tubercular or other manifest ailment. Eight deaths were due to 
 phthisis, either comparatively slow in approach, or in the form of rapid 
 tuberculosis. Two died from epilepsy, three from serous apoplexy, 
 ^nd one from maniacal exhaustion. 
 
 Tlie average duration of life in hospital was much shorter than in 
 Europeans. The confinement, though tempered by many unaccus- 
 tomed comforts, being apparently the great factor in shortening life. 
 
 Two of the men were described as the last of their tribes. Several 
 of the women were much cut about the head, in accordance with 
 Aboriginal custom. In one case, the cuts penetrated the outer table of 
 the skull, which now forms an admirable museum specimen, in several 
 places. All the cases now in hospital display considerable dementia, 
 but two are usefully employed. 
 
 INEBRIETY— ITS ETIOLOGY AND TREATMENT. 
 
 By Patrick Smith, M.D. 
 
 What is inebriety ? Inebriety may be defined to be an overwhelming 
 morbid desire for the state of intoxication, or narcotism. I say 
 advisedly intoxication, in contra-distinction to intoxicating liquors. 
 This definition at once excludes the great majority of so-called drinkers 
 or drunkards, for some drink out of good-fellowship, others for the 
 exhilarating effects to be obtained, and a few for the pleasurable 
 sensations to the palate. But it is the aim and object of most to stop 
 short of intoxication. If drinking were likely to affect their position, 
 socially or pecuni.irily, oi- to interfere with their health, comfort, or 
 convenience, the liabit could be given up with greater or less effort by 
 all. In sliort, they are not yet under the power- of the habit. Now in 
 so far as such do injury to themselves, or are entrapped by intoxication, 
 they must be classified as vicious. This is the vice of inebriety. It is
 
 INEUIUKTV ITS KTIOLOfJY AND TliEATMKXT. 861 
 
 fi'om the niuks of the vicious driukei's tliat the inebriates, strictly so 
 called, are drawn. A careless habit or social custom has been followed 
 till it has become a vice, which in time may develope into a disease. T 
 shall confine my attention in this paper, not to the vicious inebriate, 
 but to the diseased. 
 
 The inei)riate propei' is a remarkable contrast to the di'unkard. He 
 cannot drink in moderation. For him, no apprenticeship of years, or 
 lon<^ familiarity with alcohol is necessai'y. On slight acquaiiitance, a 
 tierce ungovernaljle desire is set up. Two men begin to drink together, 
 say from the same l)ottle, and after one or two glasses, one is totally 
 unattected, bilt^in the other a craving has been excited, wdiich only a 
 complete debauch will satisfy. Loss of position, of character, of fortune, 
 and of health may be the I'esult of the gratification of this impulse, but 
 tliese are utterly disregarded. Dr. Wright, in his work on " Inebrietism," 
 page 43, thus describes and explains tiiis craving : — " The whole mind 
 is lilled, at certain times, with the contemplation of an imperative 
 morbid desire. All the resources possible ax-e brouglit to bear in pro- 
 curing the gratification of a per\ading and domineei'ing appetite. Such 
 a condition of perverted inclination will i-est content with nothing short 
 of the con^plete satisfaction of its demands. Any such satisfaction 
 must reflect properties e([ually powerful and unixersal with the element 
 demanding it, and also equally morbid." 
 
 The question arises — Why was the one drinker uninfluenced by the 
 same quantity of the same liquor, and why in the other Avas there such 
 a tempest of desire aroused 1 Was the one totally depraved, or less 
 under the resti-aining power of religious, moral, or social influences than 
 the other? The probability is that such was not the case. The coii- 
 clusion is ine\'itable, that the difference in effects arose from a 
 fundamental difference in constitution. In the one case, there was no 
 response to the stimulant from without, wdiile in the other the response 
 was totally disproportionate. The one had not what is technically 
 called the neurotic tempei'ament or diathesis, while the other had. 
 
 What is the neurotic temjierament ? In this temperament, when it 
 is a damnosa liereditas, tliere is some fundamental deficiency, lesion, or 
 flaw of the brain, whereby that organ is placed in a state of unstable 
 eciuilibrium. To borrow a term from meclianics — the governor of the 
 engine is faulty. There is an extreme susceptibility in the nervous 
 sy.stem to take no spasmodic action. A stimulus applied from without, 
 which in the healthy would be without effect, creates in the neurotic 
 subject an outburst, or quasi-storm of function, which has been described 
 as beyond his control, and without his consent. The power of inhibition 
 and of will are for the time lost. Handicapped with such a tempera- 
 ment, the neurotic is indeed an object for pity. How is such an one to 
 meet the trials and temptations of life without succumbing to them 1 
 Only by the most judicious management and intimate knowledge of his 
 condition. 
 
 Maudsley says that this neurotic or spismodic temperament is 
 fundamental— its outcomes, various. It will be a mere accident, 
 depending on external influences, whether this diathesis will lead its 
 po.s.sessor to ci'ime, inebriety, or insanity. However, it is just possible 
 it may remain latent through life. If search be made into the family 
 history of the neui^otic, very decided confirmation of the law of heredity
 
 562 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 may be discovered. Tt is found, except in the rarest instances, either 
 that one or both of his paroits, or grandparents — not to go further 
 back — had a strain of insanity, or inebriety, or crime in their con- 
 stitution ; or that they suti'ered from epilepsy, or some wasting disease ; 
 or that they were deljilitated, from overstrain of mental work, oi- 
 excesses of some kind ; or were themselves neurotic. The neurotic 
 diathesis, though usually inherited, may also be acquired. The high 
 state of nervous tension, which has been induced by our modern 
 civilisation, tlie hurry, bustle, and excitement in which we live, the 
 temptation to engage in speculation, which involves risk and anxiety ; 
 the injury done to the young in the tierce competition of school life, the 
 prevalence of luxurious and drinking habits, and the debilitating 
 influences brought to bear in coneeiitrated form on our own 
 generation, as on no foi'mer one, tend to make neurotic parents, in 
 wliose ottspring the diathesis must appear in a still more marked form. 
 The increase of neurotics at the present time is in the light of these 
 conditions easily comprehended. 
 
 Now, all that applies to the general neui'otic condition, applies equally 
 to the special neurosis of inebriety — the alcoholic. Some are born with 
 a special susceptibility to the stimulus of alcohol, and an insignificant 
 quantity drunk produce in such the most disproportionate results — the 
 morbid craving before described. It is in this brain deficiency, 
 inherited or acquired by long indulgence in alcoholic liquors, that we 
 have the fons et origo of the craving for narcotism. The act of 
 drunkenness is merely the expression of the inward craving, just as the 
 ■excessive drinking of Avater is the expression of the existence of a 
 feverisli or other diseased condition. The symptoms haAe attracted the 
 ■chief attention, while the real disease has been unnoticed. 
 
 It is surely then a legitimate deduction, that a craving so fierce, so 
 disjDropoi'tionate to the exciting cause, is not due to the gratification of 
 the palate, but to a diseased condition. That craving must surely be 
 due to disease, which suddenly seizes on some of the most cultured, 
 refined, and generous men, which in a few hours completely changes 
 their characters, and causes them to associate with men they despise, 
 and makes them resort to cruelty, and selfishness, and meanness, utterly 
 foreign to their nature. 
 
 The close analogy existing between insanity and ineljriety proves tlie 
 existence of an alcoholic, as well as of an insane, neurosis. The funda- 
 mental principle on which insanity is treated, is that it is a physical 
 disease. As we are warranted in inferring a morbid diathesis in the 
 one case, so are we in the other. 80 alike in almost eveiy respect are 
 tlie symptoms of periodic insanity and of dipsomania, that apart fron 
 the history of the case, it would be hard to distinguish between them. 
 In both the attack may come without any known exciting cause ; for it 
 is not always necessary to take alcohol to set w.]) an attack. On the 
 contrary, the impulse is from within — central. The attack once begun 
 rapidly advances to an explosive point. If alcohol be obtainable, the 
 impulse cannot be stayed till conqjlete exhaustion of mind and body is 
 reached. When the point of narcotism is readied the craving ceases, 
 and an interval of comparative qviiet succeeds, during wliich the dipso- 
 maniac has no inclination foi* alcohol, and may even loathe it. Another 
 attack, exactly like tlie foi'mer, at irregular intervals of weeks, or
 
 INEBRIETY ITS ETIOLOGY AND TREATMENT. 863 
 
 perliJips inontlis, follows, and it is this periodicity that stamps the 
 attack as a neurosis. The prodroniic symptoms in both cases are exactly 
 alike. In both, there may be observed a day or two prior to an attack, 
 some alteration in manner, gait, oi* speech, a twitching of the muscles 
 of the face or fingers, or a general restlessness and malaise. But a 
 craving, similar in degree and nature, may also be acquired by the 
 habitual drinker. The periodicity of the attack in his case is absent, 
 but craving may be said to be perpetual. In the former it would surely 
 be monstrous to impute vice, whereas in the latter no condemnation can 
 be strong enough. 
 
 Injuries to the liead, and the conseipu'ut disease of some portion of 
 the brain, are a frequent cause of sudden development of inebriety, 
 just as of insanity. After an injury to the head, a considerable interval 
 may elapse before inebriety shows itself, because time is required for 
 the morbid changes set up to extend far enough to produce a condition 
 of unstable equilibrium. Disease origin is doubly proved in such cases, 
 for when the injury is capable of repair by surgical means, the inebriety 
 <;ea.ses. Out of 600 inebriates treated at Fort Hamilton (the Inebriate 
 Ketreat for the State of Xew York), Dr. Norman Kerr tells us 
 (" Inebriety," page 165) that 123, oi- nearly one-hfth, had received blows 
 on the head ; one-third of these were fractures of the skvill. Out of 
 the 123, seventy-oiie had become habitual, and tifty-two periodic, 
 ineln-iates. In the Dalrymple Home at Bickmanswarth, England, out 
 of 103 admissions, six owed their inebriety to injuries of some kind, 
 three being in the region of the head. 
 
 When we hnd outbreaks of inebriety, just as of insanity, following 
 more or less closely, even in previously sober people, on heat apoplexy, 
 on severe nervous shocks from excessive grief, or from railway or other 
 accidents, in the course of wasting diseases, in nervous exhaustion, it 
 seems impossible not to admit a physical disease origin. 
 
 With regai'd to the crucial test of jjost-mortem appearances, inebi'iety 
 like insanity being to a large extent functional, and due to congenital 
 or prenatal brain deficiency, morbid clianges cannot in the present 
 state of our chemical and mechanical knowledge be demonstrated. 
 When the disease is of long standing, especially if acquired by long- 
 continued hard drinking, alterations in the encephalon structures are 
 found, but these are the results, not the causes, of disease. Dr. N". Kerr 
 (" Inebriety," p. 212) says : — "That in his examination of the bodies of 
 those who died during, or immediately after an attack of inebriety, he 
 found appearances of hypera-mia, injection of the mucous membrane of 
 the stomach — in cases so inflamed as to suggest metallic poisoning ; 
 in all cases, congestion of the meninges ; in several, general congestion 
 of the brain ; and extravasations of blood existed both on the interior 
 and exterior of the cerebrum." More extended observation will no 
 doubt add to our knowledge of these morbid appearances, which are 
 after all only what might be expected fi-om the symptoms. 
 
 Assuming then, that inebriety is a physical disease, I proceed to 
 inquire what we can reasonably expect to accomplish by treatment. 
 Up to within a very recent pei-iod, inebriety has been regarded by the 
 profession and the public as arising from utter moral depravity, and 
 as such to be dealt with by clergymen, social reformers, and temperance 
 lecturei-s. But thanks to our professional brethren in America, who
 
 864 INTERCOLOXIAL MEDICAL COXGRESS OF AUSTRALASIA. 
 
 ]la^'e nobly pioneered this field of study, it is widely recognised as a 
 physical disease and amenable to treatment. As a profession, we 
 regarded the inebriate with despair, but now we ai^e more hopeful. 
 Moral and religious influences and persuasion have induced multitudes 
 to reform, and have saved them from becoming dipsomaniacs ; but the 
 diseased inebriate and the dipsomaniac has been proof against all 
 attempts to reform. But, what is possible to be done by treatment ? 
 We cannot eradicate the diathesis, and give the inebriate a new 
 constitution ; but we can recognise the symptoms of a coming attack, 
 and prepare for it. The pi'odromata, the restlessness, depi'ession, 
 timidity, the muscular twitching and other storm signals alx'eady 
 mentioned, can be corrected and rendered practically harmless. 
 Especially can we attend to organs which may be in a morbid condition 
 by medicinal and hygienic appliances. We can promote the repair of 
 diseased tissue, and with healthy oi'gans may expect to remove morljid 
 craving. Two conditions, and only two, are essential to the attainment 
 of cure as far as that may be possible, viz., the withdrawal of alcohol 
 from the inebriate, and securing suflicient time for the repair of damage 
 done to organs and tissues. 
 
 Easy as these two conditions seem, they are even now most difficult 
 of attainment. Home treatment of the inebriate on many accounts 
 so desirable, is rendered all but hopeless, on account of the difficulty 
 of preventing the patient from obtaining liquor ; let those testify, who 
 have ever made the attempt. Is it any wonder that failure has 
 been the result? Even Inebriate Asylums in America and elsewhere, 
 have largely failed on account of not being able to overcome this 
 difficulty. Prior to the establishment of retreats, it was only in gaols 
 and lunatic asylums that alcohol could be efi'ectively prohibited ; but 
 they failed, and still fail to cure, because sufficient time for the repair 
 of diseased tissue cannot be obtained ; not even the most worthless 
 police-court " repeater," let alone a wage-earning citizen, Avould be sent 
 to gaol for a year for drunkenness ; nor even the worst dipsomaniac 
 is it now possible to keep for a like period in a lunatic asylum. For 
 as soon as the attack is over, the detained can plead so well his possession 
 of all his faculties, his loss of time, his surroundings, that .speedy 
 release generally follows ; thus sufficient time is not allowed. The 
 shortest time of treatment which would give even the hope of permanent 
 cure, is allowed to be a year. Dx\ W. B. Richardson gives it as his 
 estimate, that two years are required for many, and that three, four, or 
 even five years for numbers. What can moral and religious influences 
 do against a disease so formidable ? The great obstacle to efficient cure 
 in insanity, with all our enlightenment on the subject, is the element 
 of time. If it has taken so long to impress the public mind with the 
 essential nature of the time element in a disease so plainly marked as 
 insanity, what can be expected in inebriety, which even now, many 
 refuse to recognise as a disease. 
 
 While on the subject of treatment of inebriates in lunatic asylums, I 
 state, on the authority of Dr. Norman Kerr ("Inebriety"), that 
 an attempt is being made to treat inebriates in lunatic asylums in New 
 Zealand. They are kept in separate wards, and do not mingle with 
 the insane. Tlie combination has very much to recommend it. There 
 is no need to agitate and wait for the erection of retreats, as the
 
 INEBRIETY—ITS ETIOLOGY AND TREATMENT. 865 
 
 asylums arc accessible to e\evy part of tlic country. There is only one 
 ol)jection that I can see to this combination — but that is likely to 
 militate very strongly against voluntary seclusion — and that is, that 
 the attainder of insanity is likely to attach to inebriates who have been 
 treated in lunatic asylums. The experiment will be watched with 
 great interest. 
 
 But to return, the only chance of securing eftectually the two 
 conditions referred to, seems to be to place the inebriate in a home or 
 retreat. Here he would be relie\ed from the upbraidings and 
 i-eproaches of relatives who, belio\ing that it is only want of will 
 that stands between him and cure, cannot keep from aggravating and 
 annoying. In a retreat, too, it ought to be possible to bring to bear 
 on the inebriate all the resources of medicine and hygiene, and so 
 greatly expedite the process of repair and the restoration of healthy 
 function. It would be presumptuous in me to enter into details of 
 treatment, even did time allow. 
 
 It is of the last importance, if restoration is to be accomplished, that 
 the co-operation of the patient himself should be obtained. " \Mio 
 would be free, himself must strike the blow," is very pertinent to the 
 case of the inebriate. If there be no strong desire for cure on the part 
 of the patient, then indeed is the case a desperate one. But fortunately, 
 this desire is seldom absent. It is necessary by little — and little it 
 may be — but it is necessary that the patient be fully informed of the 
 grave disease of which he is the subject. He should know his family 
 history — the failing, or vices, or diseases of his immediate ancestry ; the 
 necessity, if ever he is again successfully to face the temptations 
 and troubles of life, of obtaining a radical cure. Above all, he should 
 be taught to recognise the physical and mental conditions that hei'ald 
 an attack of the craving. Nor are the aids of religion and morality, 
 though in themselves impotent to suddenly bring about a cure of a 
 diseased condition, to be despised. Those who believe in the possibility 
 of Divine aid being extended to the distressed, may by prayer be 
 greatly strengthened in their attempts at refoiination. If the physical 
 state of the inebriate is such as I have described, the utter uselessness 
 of antidotes for the drink-craving, and of the belauded specifics, must 
 be at once apparent. The Turkish bath, cinchona rubra, raw-meat 
 diet, all valuable as adjuncts to treatment, are in tliemselves valueless, 
 as experience has well pro^"ed. 
 
 In Victoria, South Australia and New Zealand, tlie laws give ample 
 opportunity to deal with inel:)riates, either by Aoluntary or compulsory 
 seclusion in asylums or I'etreats. In New South Wales and Queensland 
 similar legislation is promised. It is only a few months since a similar 
 law was placed in the English Statute-book. Legislation then is fairly 
 abreast, if not ahead, of public opinion. Bnt there is much necessity 
 for the education of public opinion on this subject. There are many 
 inebriates in the colonies where reti'eats have been by law established, 
 but how few seem anxious to avail themsehes of tliem. We must 
 recognise that most inheritors of the alcoholic diathesis are ignorant of 
 the fact. Many have a dim idea that their indulgence in drink is moie 
 than a craving — that it is a disease ; but e\en so, it is a disease for 
 which there is no cure. 
 
 2k
 
 866 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 As a profession, it is only within a few years back that we have 
 given in our adhesion to the disease oiigin of the drink craving, if some 
 are not even now avowed sceptics ; and if so, what can we expect in 
 the general public? If inebriates are to he effectually helped, it can 
 only be liy pulilic opinion being enlightened on the subject. The press 
 is doubtless the best educator of public opinion. In England and 
 America, there are established societies for the study of inebriety. 
 Similar societies might well be tried here. Just as our Health Societies 
 popularise the laws of health, so might such societies popularise the 
 laws of inebriety. Whatever means we employ, efforts ought to be 
 made to extend to the inebriate — than whom none more deserves our 
 pity — a helping hand. We should do our duty by the inebriate, as 
 we have already done by those afflicted with a similar malady — the 
 insane. Provision should be made for rich and poor alike in asylums 
 or retreats. I am not referring — in naming asylums or retreats as the 
 only satisfactory mode of treatment — to the ordinary drunkard or 
 tippler, for if so, then no number of institutions that we could erect 
 would be sufficient to contain them. 
 
 The provision for the true inebriate, whether rich or pooi", would no 
 doubt entail considerable outlay ; and yet, not so. much as might at 
 first sight appear. For a large number of the police-court drunkards — 
 a proportion of whom are, no doubt, diseased — are already a public 
 burden, for Avhen not in gaol, they live on private charity. They cost 
 the country more than if they were systematically maintained by it. 
 A sufficiently long period of detention, during which they might be 
 compelled to work, might effect a cure. Coming to the skilled mechanic 
 or ordinary wage-earning inebriate, the labour that could be done by 
 such while in seclusion might amount to little short of maintaining him. 
 A certain proportion of inebriates, socially higher than those mentioned, 
 might he paid for by friends to the full, so that the expense of main- 
 tenance would be small in comparison to the good effected directly, and 
 tlie indirect gain would be even greater. But into details of such a 
 scheme, it is impossible here to enter. 
 
 But it may be asked — What are the actual results from the establish- 
 ment of retreats ? The movement for the rescue of the inebriate is 
 only of yesterday, and statistics cannot be other than meagre as yet. 
 Dr. T. D. Crothers of America, at the Colonial and International 
 Congress on Inebriety held in London last year, stated that out of 
 3000 cases of inebriety ti'eated in American institutions, nearly forty 
 per cent, were restored and temperate after a period of from six to 
 eight years from the time of their discharge. The results of treatment 
 at the Dalrymple Home in England are given as 42 per cent, of 
 recoveries, out of a total of eighty-two under treatment. A percentage 
 of 35 of permanent cures is considered a fair general average in 
 the case of those who remain under treatment for one year. There is 
 a very close approximation to the general average of cures among the 
 insane. These results are, considering the difficulties attending the 
 inception of a new system, eminently satisfactory. 
 
 Our great hope in coping with this formidable ailment, which 
 threatens to sap tlie physique of our own generation specially, is in the 
 diffusion of a more accurate knowledge of the effects of alcohol on the 
 system. The ignorance that prevails on this point in the popular
 
 A CO\THIHUTIO\ TO THK STUDY OK IXlCBinETV. 867 
 
 mind is simply inci-edible. Were the disease-producing qualities of 
 alcohol better understood, many now on the high road to inebriety 
 would recognise their own symptoms, at a stage when they were 
 curable. ^Many who are advanced in disease would submit themsehes 
 to curative means. We miglit almost despair of ever sufficiently 
 educating pul)lic opinion on inebriety, liad we not before us the history 
 of the long battle that had to be fought ere due provision was made foi- 
 the sciei:(,titic treatment of insanity. 
 
 The propositions which T have very briefly and vny imperfectly tried 
 to establish are these : — That the inordinate craving for intoxication, 
 which is irresistible, has its /otts et orlyo in the alcoliolic diathesis or 
 temperament, a subdivision of the neurotic group of diatheses; that 
 intoxication is merely a symptom or outward expression of an internal 
 morbid state, and is not itself the disease ; that the originating causes 
 of inebriety are so analogous to those of insanity, as to warrant the 
 inference that, if the one is a physical disease, so is the other ; that the 
 essential conditions of successful treatment are two — viz., the absolute 
 prohibition to the patient of alcohol, and the granting of sufficient 
 time for tlie reparation of diseased tissue and restoration of lost func- 
 tion ; and that asylums or reti-eats afford the best means of securin" 
 the fulfilment of these conditions. 
 
 The paper was well received, and all were agreed that treatment, to 
 be successful, must carry with it the co-operation of the patient, and 
 that treatment away from home was absolutely necessary. The associa- 
 tion of inebriates and the insane was strongly decried, a separate 
 institution being clearly I'equisite. It was approved that the law should 
 allow some authority, such as a judge or justice, on proof being shown 
 to commit the patient for treatment ; and that treatment, to be effective, 
 .shoidd be for at least one year. 
 
 Dr: Patrick Smith briefly replied. 
 
 A CO^^TRIBUTIOX TO THE STUDY OF INEBRIETY. 
 
 By CiiAKLEs McCarthy, ^[.D., Inebriate Ketreat, Northcote, 
 ^Eelbourne. 
 
 Hon. Member, American Association for Cure of Inebriates. Hon. Member, Council 
 of the Society for the Study and Care of Inebriety in England. 
 
 As to statistics of cure, they are valueless unless based on large 
 numbei-s in inebriety, where the puVjlic demand a new definition of 
 cure, namely, its permanency. The inelniate has such a craving for 
 stimulants or narcotics, lirc, that if not under restraint, he cannot 
 refrain from over indulgence; the drunkard can, if he choose. 
 
 The inebriate is suffering from disease of the nervous system — he is 
 labouring under moral insanity. There is no inebriety in a medical 
 sense witliout disease of the brain, either functional or structural. The 
 
 2k 2
 
 868 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 man may appear to reason well, l:>ut though his language may be sane,, 
 his conduct is insane. Generally speaking, no exhortation, no con- 
 sideration (temporal or spiritual), no ruin staring him in the face, nO' 
 affection for family will weigh with him; indulge he must, and Avill, 
 until he becomes helpless. Consequences are nothing to Tiim before 
 indulgence, and everything after; then his i-emorse imposes on his 
 friends, who determine to give him another trial. But, alas ! the 
 f)aroxysms and the scenes are repeated until he dies, or becomes insane. 
 
 To say that this state dejaends on vice, betrays extreme ignorance. 
 It may have been so at first, l)ut it is disease now. 
 
 What are the causes of inebriety ? They are numerous. The most 
 frequent cause is indulgence in alcohol acting on a constitution predis- 
 fjosed to nervous disease; were it not for this predisposition, tlie person's 
 excessive indulgence may terminate in lunacy or death, without his 
 becoming an inebriate. Next to this, and nearly allied to it, but much 
 more difficult to cure, are hereditary cases, which are very frequently 
 periodical. This heredity may be from parents or grandparents, or from 
 more remote sources. There is nothing strange in this. I have often 
 called the attention of parents to the fact that the new-born babe did 
 not resemble either of them, when I was informed that it resembled an 
 uncle or an aunt, or more distant relative. It is quite certain that all 
 children inherit some taint or peculiarity of their parents or relatives — 
 some children one thing, some another. When the father and mother 
 are both drunkards before the child's conception, there is great proba- 
 bility that the child's nature will be degraded, so that it may be born 
 an idiot ; or, when grown up, become imbecile, consumptive, an 
 inebriate, a drunkard, or a criminal, the source of whose misfortune is 
 never dreamed of. Many of this class inhabit the jails, the lunatic 
 asylums, or end their lives on the gallows. 
 
 It is not outside this consideration to state that the neglect of early 
 religious and moi'al training and education will very materially tend to 
 insure and accelerate the degi-adation necessarily resulting from heredity 
 and over-indulgence, and at the saiiie time certainly impede, if not 
 hinder, the cure of inebriates. I think it very improbable that an 
 inebriate who does not believe in a future judgement, can be cured, as 
 he has n® motive strong enough to induce him to have recourse to any 
 self-denial, which is certainly necessary as an adjuvant in effecting 
 permanent cure. This is no contradiction of the A-iew, that inebriety is 
 a disease, as our lunacy doctors Avell know and utilise in practice. 
 
 This question of heredity as to drink, profligacy, lunacy, ignorance, 
 indulgence, and all inherited unhealthy states and diseases, is a question 
 of the utmost importance, and should engage the serious consideration 
 of legislators, and of all those who wish well to posterity. This is of 
 more importance than the interest of the liquor trade. As inebriety is 
 a frequent cause of insanity, so may it also be a symptom of insanity. 
 Sunsti'oke, shock, grief, melancholy, remorse, debilitating diseases, 
 injury to the brain, in fact any cause that may produce insanity, may 
 l)e the cause of inebriety. A sound mind requires a sound brain and 
 healthy body ; yes, and healthy ancestors, those who have marriageable 
 sons or daughters, should not forget this. I need say no more, nor 
 perhaps so mucli, to a medical audience, but others may profit by these 
 warning remarks, which are free of all technicalities.
 
 A COXTHIIJUTION TO I III:; STUDY OF IXEHUIKTY. 869 
 
 What is to be done about inebriety? Let the medical profession 
 insist upon the establishment of inebriate retreats, suitable for 
 all classes ; the Chief 8ecretai'y said last month that if Pai'liament 
 desired it, he would establish tliem. Let the medical profession, the 
 only persons capable of Aiewing this matter in all its bearings, speak 
 out on the subject. It has latterly been the custom here to exclude 
 medical men from Commissions on subjects Avhich they only know any- 
 thing of, and the consequence is that froin want of knowledge, I'ecom- 
 mendations are made to Parliament by Commissions of laymen, and 
 members of Pai'liament think they ought to carry out these recom- 
 inendations as if they wei'e made by experts (see the absurd blunders 
 and mistakes of the New Inebriates' Act passed a few days ago ; it 
 must be amended next session). I need scarcely say anything as to the 
 medical treatment, my main dependence being on time. T give no hope 
 ■of cure in less than three months in the mildest case, six months being 
 reipiired in the majority of cases, and txselve months, or longer, in bad 
 •cases ; yet the new Act says three months must be tlie maximum time ! 
 but says thoughtlessly, the time may be prolonged if a wife and two 
 )nedical men each make a solemn declaration, that the man that lias 
 lived in the retreat for three months is not cured I ! 
 
 Again it says, that if the patient be out for a time with the Super- 
 intendent's consent, he shall >)e punished by being kept in longer. 
 Again it says, the patient may be detained until as hereinafter provided ; 
 that hereinafter refers to Sect. 10 of the old Act, which is omitted in the 
 new. The same ignorance appears in the Lunacy Amendment Act ; 
 moi-e faith is placed in ignorant jurymen than in medical men. The 
 fact is, that many members of the community who have access to the 
 public press feel it their duty to make a greater sensation when they 
 liear of a case of doubtful insanity being sent to the asylum, tlian if 
 that same lunatic committed half a dozen murdei's before his arrest ; but 
 presumption is always accompanied by ignorance. T may here be per- 
 mitted to state, that for many years T have been of opinion that where 
 lunacy is pleaded in a capital case, the jury ought to be composed 
 exclusively of medical experts. There has been a popular opinion, that 
 women are more difficult to cure of inebriety than men. That has not 
 been my experience ; women are certainly more easily managed in a 
 retreat than men, and I think as easily cured, if not more so, than men. 
 For sixteen years that the retreat is open, I never had a death among 
 my female patients, and very few among the males ; only two males 1 
 think directly from drink. 
 
 There is no mystery about the treatment, and T therefore shall not 
 detain you with it. Australian youths are decidedly more opposed to 
 discipline than Europeans, and therefore more difficult of cure. Any 
 opinion formed froin practice outside a retreat as to the curability of 
 men or women of any age, is of no ^ alue, from the fact that alcohol 
 ■cannot be kept from tliem ; confinement in a jail does not meet 
 the question. ^ly own opinion is, that men and women of any age can 
 be cured if sufficient time be atibrded. I believe tliat twelve moiiths in 
 a retreat will cure 80 per cent., six months 60 per cent., three months 
 30 per cent., Init in a shorter time than three months, I only expect 
 recovery, not cure. Too frecjuent visits, and too much correspondence, 
 will hinder cure. Vicious patients are mostly drunkards, and lequii-e
 
 870 INTEKCOLOXIAL MEDICAL CONGHKSS OF AUSTRALASIA 
 
 years for cure ; .1 penitentiary is their pro})er place, not an inebriate 
 retreat. 
 
 I shall now, with your permission, venture to make a few remarks 
 that may be useful to the younger members of the pi'ofession, in relation 
 to drink. The tirst is, that if they are called to a suckling baby in 
 convulsions, they make special enquiiy as to whether the mother takes 
 gin, especially if there be a succession of convulsions. Another is, never 
 to recommend spirits of any kind to a nurse for the sake of the child, 
 under the impression that it would impi-ove her milk in quantity or 
 quality ; any nurse that cannot do without alcohol, ought not to suckle 
 at all. Be extremely careful in prescribing spirits to patients, whatever 
 quantity you order will be exceeded and continued longer than you 
 intended. Women will absolutely deny to the medical man, even to 
 their husbands, that they take alcohol to excess, or at all, but attribute 
 their state to nervous debility. When you find a man, especially a 
 publican, who cannot take his breakfast without alcohol, tell him he is 
 on the straight road to inebriety. Warn the police not to put a man 
 helplessly drunk into a cold cell ; discourage the use and abuse of 
 tobacco, as well as of alcohol, by example and advice ; do these things 
 as a conscientious and n;oral duty, and when so acting, fear not 
 pecuniary consequences. The trust and confidence bestowed by patients 
 on conscientious medical men is exti'aordinary, and where olienee is 
 taken against moral ad^ ice, the medical man feels that he performed a 
 sacred duty. 
 
 AUSTKALIAN I.UNATIC ASYLUMS— REMARKS ON THEIR 
 ECOXOMIC MANAGEMENT IN THE FUTURE. 
 
 By W. L. Clelaxd, M.B., Cli. M. Edin. 
 Eesident Medical Officer, I'aikside Lunatic Asylum, South Australia. 
 
 In selecting a subject for the consideration of this Section of 
 Psychological Medicine, I have endeavoured to choose such a one as 
 would have a distinct l)eai'ing on the fact, that this Association is an 
 Intercolonial Australian JVIedical Congress. As Australian alienists, 
 we haAe to deal with two important factors pertaining : — 
 
 (d) To the social and political constitution of the people, which is 
 essentially democratic. 
 
 (b) To climatic influences, which admit of a continuous out-of-door 
 life. 
 
 It will be the object of the following remarks, to point out how one 
 or both of these factors cannot l)ut fail to produce its impre.ssion on 
 the management of the asylums of the future. Tiiose who are wise, 
 will not wait to have these impressions rudely thrust upon them b}' an 
 imperious necessity, but by a timely provision will so arrange their 
 ordering as to be found standing "at attention" when the .searching 
 light of public criticism sweeps over them. It will therefore not be
 
 AUSTKALIAX LUN'ATIC ASYLUMS. 871 
 
 unbecoming to enquire on wli.it lines should the management of 
 lunatic asylums be most justiried in striking out a course, that shall \)e 
 essentially Australian in its eiiai-aeter, and practical in its aims. 
 
 It must be admitted, that in the Australian colonies the tone of 
 society is more essentially democratic than in the mother country. 
 This, consequently, cannot fail to produce a cei'tain influence on the 
 positicm of the Medical Supei'intendent of any large institution for the 
 insane, as regards the public at large. One of the peculiarities of a 
 pronounced democratic form of society, is to discount or even to question 
 any prescripti\'e right that may l)e advanced by any particulai' individual 
 or class of individuals. Hence, is noted a certain intolerance of any 
 professional assumption. The democrat cries out, away with your titles 
 and professions and parchment certificates, and let us see what you can 
 do, and to that extent we will believe in you. 
 
 How does this atlect the relation of the medical man to the care of 
 the insane? To a medical audience, to assert that lunacy is a disease 
 of the brain, and that lunatic asylums are really hospitals for the 
 insane, is to give utterance to bald [)latitudes. 8uch assertions do not 
 eariy the same indisputable weight to the ordinary lay mind. It may 
 l)e possible that there is a glinnnering perception on the part of the 
 public of the truth of insanity being a disease of the brain in acute 
 t-ases, and that such are best under medical supervision. With respect 
 to the chronic insane, who may be more or less manageable and quiet, 
 the fact to the uneducated mind is less obvious. Thus we find the 
 democratic economist asking. Why engage expensive medical super- 
 vision for those who only i-ec|uire the shelter of a workhouse 1 There 
 is here sucli a radical misconception or ignorance of the nature of 
 insanity, that argument or counter-assertion would be equally thrown 
 away. Before anything could be done to eradicate such a false 
 conception, it would be necessary tirst to carefully educate the would-be 
 economist in some of the first principles of psyehology. If our 
 democrat were some Hodge l)etween the stilts of a plough, he miglit be 
 passed by without further comment ; but when, as not infrequently 
 haf)pens, he stands in the position of a political master, the situation 
 becomes nmch more serious. And this is not an idle fear, for we have 
 (mly to turn to the United States of America to see that in many 
 instances this has been the logical outcome of this ignorance of tirst 
 principles as regards the insane. The medical element has been reduced 
 to periodical visits to the ostensibly sick, and not to .siqierintend 
 the management of those suffering tVom chronically diseased brains. 
 Even though it be admitted that, exceptionally, a layman might be found 
 who would enter upon his duties of superintendence with the I'equisite 
 intelligence and largene.ss of views, yet what in him would be almost 
 plienomenal, would in a well educated medical man be simply a natural out- 
 come of his previous training, and be to him, as it were, a .second nature. 
 
 To guard against this danger of lay-superintendence, it must ])e made 
 patently obvious to the most ignorant, that no one, excepting a medical 
 man, is fit or cajjable of managing a lunatic a.sylum. It might be argued 
 that there is already provision made for this in the various Australian 
 Lunacy Acts. But this would be but a poor .safeguard, for in un.settled 
 social conditions, an Act of Parliament can be as easily expunged from 
 the Statute Book, as it can be ])itcliforked into it. Nothing will stand
 
 872 INTERCOLOXIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 the ordeal of public criticism, but what is manifestly on the face of it 
 indispensable. The safety would therefore lie in making the asylum 
 arrangements suitable both for acute and chronic cases. It will always 
 be admitted that the former should be under medical superintendence, 
 and for the sake of economy of supervision, the laity will not object to 
 the chronic insane being also included under the same management. This 
 implies, that the asylums of the future must not be below a certain size, 
 say a minimum of 800 patients. Much has been said respecting the 
 advantages of small institutions, especially for acute cases. All the.se 
 advantages can be easily secui'ed by appropriate arrangement, and 
 isolation of the respective wards and airing courts. A distance of 300 
 or 400 yards is as effective a barrier to intercourse as a corresponding 
 number of miles, and yet the former allows of one supervision. The 
 model arrangement would consequently partake of the village character, 
 with a small strong portion for acute cases. To allow of the requisite 
 dispersion of buildings, a large area of ground would be a sine qud non. 
 The advantages of such an arrangement did not fail to strike so in- 
 telligent and receptive an observer as Dr. Hack Tuke in his visit to the 
 Kankaka Asylum, Illinois, U.S. He says "it is a pleasant thing to 
 see this breaking up of buildings on so extensive a scale. It must do 
 good. The air blows more freely and freshly through this group of 
 houses, which will soon form a little village, than it would, or could, 
 through monster structures filled from top to bottom with the insane." 
 To this asylum there are attached about 480 acres of land. It contains 
 600 patients at present, and is designed to accommodate 1500. If this 
 " very interesting experiment " should fail to accomplish all that is 
 expected of it in the future, it will, I am sure, be wholly attributable to 
 the relatively small amount of land attached to it. Some fifteen years 
 before the Kankaka Asylum was thought of, the Soiith Australian 
 Government, acting under the enlightened advice of the then Colonial 
 surgeon, the late Dr. R. W. Moore, caused the Parkside Lunatic 
 Asylum to be built on the "segregation" principle. The asylum is not 
 yet completed, but is estimated to accounnodate about 800 patients. It 
 already partakes of the a]»pearance of a village, as the buildings are 
 evenly distributed over the area of 135 acres of land. All that Dr. 
 Tuke says of Kankaka, applies with equal force and truth to Parkside. 
 The defects of the place are, a too ex})ensive and elaborate main build- 
 ing, and a too small endowment of land. 
 
 This brings us to the consideration of what should be the effect on 
 management of our special climatic conditions. For in the lunatic, we 
 have to deal with a sick per.son, who differs from all other sick ])ersons 
 in being benefited by work or employment of some kind. In such an 
 asylum for acute and chronic cases as has been held uj> as a model, there 
 would be at least from 70 to 80 per cent, of the inmates avail- 
 able for some industry. The nature of the climate, which allows of 
 continuous out-of-door life, points to such industries as gardening and 
 ordinary farming work. No more healthy and desiral)Ie occupations for 
 a diseased mind could possibly be imagined. We have here then two 
 important points — {a) labour of a certain kind and amount; {b) climatic 
 surroundings exactly suited to the employment of that labour to the best 
 advantage. This, however, is not enough. A third important point is 
 requisite, namely — (c) turning the labour to a profitable account.
 
 AUSTRALIAN LUNATIC ASYLUMS. 873 
 
 The tendency of jjublic opinion is to rebel at all unj)roductive 
 expenditure ; hence, every now and then some euthanistic theory is 
 advanced for the weeding out of unproductive humanity. But whilst 
 such theories are never likely to become ])opular, yet on the other hand, 
 any schemes that would have for their aim the causing of the individual 
 to produce his own foo<l and raiment would ever be received with 
 enthusiastic ap)»roval. In fact, this is the avowed oV>ject of the most 
 advanced socialistic and communistic theories of the present day. This 
 has evidently been the underlying principle in the management of many 
 of the lunatic asylums and prisons of the United States of America ; 
 and in some cases, the apjjlication has been attended with marked 
 success in reducing expenditure. It aj)pears to me that unfortunately a 
 radical error crejit into these efforts, or rather was in the methods used 
 by which the object was to be attained. The conception of the idea of 
 making these institutions self-supporting was a thoroughly sound one ; 
 the channels into which the efforts were directed were, in my opinion, 
 undesirable. These latter, in many instances, partook of the nature of 
 handicrafts, or ordinary artisan work. As long as this was simply to 
 sujiply the needs of the place, no objection could be taken ; but natur- 
 ally, the requirements of these institutions for such products were quickly 
 satisfied, and a suri)lus became available. This excess of production 
 over consumption could not be convei-ted into something eatable or 
 wearable without being first sold. This at once implied coming into 
 collision or competition with other ])roducers of similar produce. These, 
 in democratic communities, are frequently a large and demonstrative 
 section of society. It was, therefore, not long before an outcry was 
 made that the State was unduly competing with their industry, and 
 taking the bread from the mouths of their children. Such a thing 
 could nob be tolerated, and the sale of these articles was prohibited in 
 the country in which they were manufactured. If, instead of making 
 such articles as wooden buckets, ikc, the above institutions had devoted 
 their energies to producing bread and meat and material for clothing, 
 no adverse comment would ever have been made. As long as produc- 
 tion is confined to su])plying the daily wants of the inmates, no section 
 of society will ever object. 
 
 Australian society will urge the desirability of making Government 
 lunatic asylums self-supporting; the Australian climate, with a beaming 
 countenance, already says —Why not? the Australian sun daily pouring 
 upon the land inexhanstilile sup})lies of radiant energy sutiicient to warm 
 into life the most slothful and apathetic, encourages us to try. Water 
 may be always had for the sinking ; and our soils are unsurpassed for 
 productiveness in any portion of the woild. Will society be far wrong 
 then in making this demand, when sucli requisites exist as laljour, 
 climate, sun, water, and soil. The indications then point unmistakeably 
 to the production of the necessaries of life. 
 
 To what extent can this be done"? The answer to this question will 
 depend largely on how it is done. If the attempt is to be made a success, 
 the ordinaiy Australian methods of tillage must be carefully avoided ; 
 and we must look elsewhere for a model. Such examjjles worthy of 
 being imitated may be found occasionally in England, but to a greater 
 extent on the Continent of Europe. These aie compi-ised under the 
 method known as the " culture mai-aichere," the essence of the .system
 
 874 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 being to create for the plant a ))oroiis and nutritive soil, containing the 
 necessary decaying organic and inorganic compounds, under conditions 
 of temperature and moisture, sui)erior to those existing in unaided 
 natural surroundings. Social economists assure us that " with cultural 
 methods already used on a large scale, a thousand human beings living on 
 a square mile (640 acres), could easily, without any kind of overwork, 
 obtain from that area a luxurious vegetable and animal food, as well as 
 the flax, wool, hides, &c., necessary for their clothing." An important 
 requisite is, therefore, an approved method of tillage. 
 
 Before we can till, a suitable area of ground must be secured. What 
 should be apiiroximately its extent? As a working example, we may 
 limit our attention to the size of a lunatic asylum that might be con- 
 veniently worked by two medical men. This would be one caj)able of 
 accommodating about 800 j)atients. The area of ground required for 
 such an asylum should not be less than one square mile (640 acres) ; 
 and the whole of the grounds not required for buildings and airing 
 courts, should be inider tlie above high system of culture. It is not to 
 be su[)posed for a moment that any institution would attempt to under- 
 take to do this at a bound. Here, as in other things, a gradual growth 
 and develo[)raent towards an ideal should be the aim. Existing 
 institutions should try, to tlie extent of their area of available ground, 
 to produce a corresponding amount of food value; and thus help to 
 demonstrate the feasibility of procuring the whole of the necessarie.s of 
 life, from an area of ground suited to their number of patients. Again, 
 all future asylums should from the first be provided with an area of 
 ground suitable for their contem])lated size. 
 
 The first attempts would natural!}' be to produce some of the more 
 easily obtained articles, such as milk, eggs, and butter, a trio that, in an 
 institution for 800 patients, would represent the respectal)le sum of 
 something like £2000 per annum. This should be ])i'acticable with any 
 asylum of like number of patients, that lias, exclusive of ground taken 
 up by buildings and pleasure grounds, an area of arable land of fifty 
 acres in extent. At the same time, the production of the necessary 
 fruit and vegetaljles, jams made with honey instead of sugar, osiers for 
 baskets, tobacco, oil and fat for soap, and fibre plants for mats, <kc., 
 would come as a matter of course. These things would monopolise 
 something like 100 acres of our contemplated square mile (640 acres) 
 
 The next article to be attacked, in the natural order of things, would 
 be the meat bills, representing, as it would, some £4000 ])er annum. 
 By the system of culture advocated, ever}^ acre of land shoukl return at 
 least from lOOU to 1500 lbs. of meat per annum. To obtain the total 
 quantity, some 200 acres would have to be devoted to this. As supi)le- 
 mentary, would be the keeping of pigs on the a.sylum and garden refuse. 
 Grazing cattle would be out of the question, but stall feeding would have 
 to take its [)lace. The hides from the animals woitld contribute largely 
 to defray the lioot and shoe account of £1000. 
 
 The next im[)ortant item on the diet scale would be the bread account 
 of £1800 per annum. An area of ground equal to that recjuired for the 
 production of meat would, in all probability, be wanted for the produc- 
 tion of wheat, if something like ten bushels were allowed as the yearly 
 consumption per head. This, in addition to flour, would give a large
 
 AUSTRALIAN LUNATIC ASYLUMS. 875 
 
 quantity of liniu aiul pullai'd, so that a portion of this area might he 
 put down to the creelit of tlie milk, butter, and meat accounts. 
 
 This leaves a balance of 140 acres still unutilised. The produce froui 
 this, forming surplus quantities, could be sold or exchanged, without 
 interfering with private enterprise, because tlie respective amounts 
 would be comparatively small and diversified ; and belonging to the 
 class of the necessaries of life, would never produce any noticeable- 
 effect on the market, nor bring the asylum into hostile competition with 
 small producers. 
 
 In addition to these natural products, would be the nmnberless 
 mechanical em])loyments — such as making clothing and ))Oots, mats,, 
 baskets, i^-c. — which together constitute a considerable item in asylum 
 expenditure. 
 
 If the idea is to be carried out successfully, the superintendance of 
 these industries mvist not be left to the direction of an ordinary bailiff 
 or steward. 8uch an official, however zealous he might be, would not 
 have those (jualitications that would fit him for utilising the work of 
 insane labourers. From his natural up-bringing, he would look at the 
 matter from the wrong end. The ])roduce anil not the producer would 
 absorb his attention. His views and those of the Medical Superintendent 
 would be as wide as the Poles. All will admit, that in a lunatic asylum 
 there must be no tlual ctmtrol. but the management must be essentially 
 an autocratic one. As C'onolly, of Hanwell, remarked, " the regulation 
 of the employment of patients, is the regulation of a highly important 
 remed}-, and should never be attem['ted witliout the physician's 
 
 assistance Constant and regular- work cannot properly be 
 
 exacted from insane ])ersons ; and they should not Vie kept at work as 
 many hours as sane people." The kind of asylum advocated in these 
 remarks, would exactly supply the want felt by Dr. (JonoUy to exist in 
 his day, as is shown by the following (juotation from his " Keports" : — 
 " Many of the incurable patients work so steadily and tranquilly, and 
 many of the convalescent are capalile of regular employment, so long 
 before they are altogether fit to take care of themselves, that it is 
 impossible not to wish to see some establishments founded, intermediate 
 between asylums and ordinary life, in which [)rofitable labour could be 
 supplied to some for a short time, and to others for a longer period." 
 The princijjle of "segregation," accompanied with a suitable endowment 
 of land, meets these requirements in every res))ect. 
 
 It is thus evident, that the Medical Superintendent should not only 
 understand the physical necessities of . his patients, so that their labours 
 should be collectively and respectively beneficial to them ; but he should 
 also have an intelligent comprehension of the rndonfile of the various 
 cultural processes. Unless the work of an asylum were tlius supervised, 
 it would in a short time degenerate into a form of white slavery, and 
 be brought into disrepute. If it is difficult now to get a thoroughly 
 capal)le all-round superintendent, the fear is that in the future it may 
 Vx'come still harder. T\venty-tive years ago, Griesinger of Berlin, gave 
 a sufficiently long list of the nece.ssary qualifications for a Medical 
 Superintendent of a lunatic asylum. ^' At the head oi the personnel " 
 he says, " stands the superintending physician, by whose character as a 
 man and as a scholar, the pervading infiuence in the institution in a^ 
 great measure de2)ends. Side by side with the grand essential of a
 
 876 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA, 
 
 thorough acquaintance with medicine, there is required in the head 
 physician, and justly expected of him, a rare combination of moral 
 excellencies — benevolence, great patience, self-command, freedom from 
 prejudice, a knowledge of men gained by actual experience of the world, 
 conversational ))owers, and a decided liking for his own special vocation." 
 To this long list must now be added a thorough grounding in the chemical 
 4ind ])hysical sciences, and their application to general physiology. We 
 may indeed be excused for having a certain feeling of hopelessness, as 
 we look around to see if we can discern anywhere signs of such an 
 *' Admirable Crichton." Fortunately, able and scientific men are more 
 frequently made than found ready born, so that there is a prospect that 
 •when the demand becomes urgent, the man will be forthcoming. 
 
 A concluding consideration yet remains, and this is to ask why 
 the fees received in aid of maintenance from patients' friends bear so 
 small a ratio to the total cost. It surely ought to be one of our Aus- 
 tralian features, that the relatives or friends of nearly every patient 
 should be able to contribute something. It can hardly be conceived, 
 that there are many families who could not pay a penny a day, or seven- 
 pence per week. And yet this insignificant sum is not to be despised, 
 for on 800 patients it represents <£1200 per annum. Now what do we 
 find to be the existing state of matters as regards the maintenance fees 
 received at our public asylums. Take those of South Australia as an 
 illustration. We find that out of some 750 patients less than forty pay 
 anything at all. The receipts from this small number give an average 
 of twopence per head per day. For every penny per diem per capitem 
 that the remaining 700 could be made to pay, the cost of maintenance 
 to the State would be lessened by J 1000. It would seem that not 
 enough value has been placed on these small heli)s towards maintenance 
 in the past; and there can be no doubt but that a stricter attention to 
 them in the future would mean a considerable annual saving in the cost 
 of lunatic asylums generally. Instead of South Australia being remiss 
 in this respect, I l^elieve I am correct in saying that it compares very 
 favourably with other Australian colonies. Considering the well-to-do 
 character of the Australian laboui-ing classes, it should be one of our 
 Australian characteristics tliat patients' friends contributed largely 
 towards their maintenance. No asylum management should rest satis- 
 fied until these fees were sufllicient to meet the expenditure incurred 
 in salaries and wages. This would then leave all produce to be devoted 
 to the use of the patients themselves. 
 
 As a corollary on the leniarks about our climate admitting of an 
 open-door life, the accommodation for those patients who are unable to 
 be employed productively, should be of such a character as to allow of 
 an abundance of life in the open air. To this end, the airing-courts 
 should Vje large and roomy, and, where practicable, be laid out in the 
 form of extensive gardens. The dining or day rooms should foi-m an 
 integral portion of these courts, and be totally disconnected from the 
 <lorinitori('s. This arrangement allows of the sleeping rooms being 
 thoroughly purified during the day time by means of o])en windows, and 
 ])revents them ever becoming contaminated by the smell of food or 
 tobacco. 
 
 The foregoing remarks have been an attemi)t on my part to i)ut in a 
 concrete form views that I have held for some years with resj)ect to
 
 LUNACY LEGISLATION IX THE AUSTRALIAN COLONIES. 877 
 
 management. They do not pretend to be new or original, but as far as 
 I know, the experiment of putting them fully to the test has not yet 
 been made by any superintendent in Australia. If they meet with 
 your sympathetic a])preei:ition, I feel that already much will have been 
 gained, and that it will only remain a question of time to make them 
 accomplished facts. 
 
 The general views of the writer were commended, but some doul)t was 
 expressed as to the practicability of carrying out Dr. Cleland's scjjeme^ 
 which was looked u^ton as idyllic. 
 
 LUNACY LEGISLATION IN THE AUSTRALIAN 
 COLONIES. 
 
 By William Aumstroxg, M.D., Ch. B. 
 Late Snperintendeut, Hospital for Insane, Ai'arat. 
 
 The paper which I have the honour to read before the Psychological 
 Section of this Congi'ess, is most comprehensive in its title, and so 
 demands an early definition of its scope. I may state that when I first 
 undertook to write it, my intention was to show what would be 
 necessary to render the lunacy statutes of the diflferent Australian 
 colonies capable of codification, so that one universal law for dealing 
 with the insane could be adopted, but I found the task much more 
 difiicult and extensive than I had anticipated, and have had to content 
 myself with a history of the existing statutes, with short comments upon 
 their resemblances, and the apparent origin of their main features. 
 Descending more into particulars, I have also compared the most 
 essential points in the difierent processes of the methods of committal, 
 detention, and discharge in vogue. We can then readily see how far 
 our statutes are alike in these matters, and in what they ditfer, and 
 form opinions as to their respective advantages, when thus placed in 
 juxtaposition. 
 
 I think the present a fitting oi)i)ortunity to initiate the making of such 
 comparisons, as it is well to take time by the forelock, in view of the 
 greater uniformity of legislation that will be advisable, in the event of 
 the much talked-of federation of the colonies becoming un fait accompli. 
 It can then only be a disadvantage to be in the condition of the United 
 States of America, which are very far from possessing uniform lunacy 
 laws, e.fj., before a patient can be admitted, one State requires two 
 physicians' certificates, another only one, a third none at all, but a 
 judge's certificate ; while a fourth adopts a method than which none can 
 be conceived more objectionable, viz., trial by jury. In our colonies, as 
 will subsequently appear, there is already sufficient diversity in the 
 lunacy laws without luckily such absurd incongruity. Until quite 
 recently I had not studied the legislation of the other colonies, and must 
 confess I was rather taken aback by the mass of statutes that had been
 
 878 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 framed, and had to be read before comparisons could be instituted. I 
 never before so clearly recognised the latent tendency within me as a 
 Victorian native, " to blow," until I felt with what hardness of belief 
 it gradually dawned ujjon me that for some years past almost all the 
 •Other colonies had been much in advance of Victoria in the completeness 
 of their lunacy laws. But for the pas.sage of the Amending Statute at 
 the end of last year, Victoria would have occupied a very humiliating 
 position, for the want of attention bestowed n])on this important subject. 
 That it should have been so is not in the least surprising, when one 
 recalls the systematic neglect until recent years with which the insane 
 had been treated in Victoria. In other matters, anything was thought 
 good enough for them, and the repeated requests of asylum officers for 
 better accommodation and means of treatment were constantly turned a 
 deaf ear to. Moreover, one of our most ])rominent legislators, and who 
 of late years has longest held the reins of office, viewed the position of 
 medical men as alienist physicians, with unconcealed contempt. When 
 in ])0wer, he reduced the medical staff, which is at present even consider- 
 ably undermanned, to a point at which scientific work was impracticaljle. 
 He also made no secret of his desire to adopt the retrograde step of lay 
 superintendence, and was only prevented by the fortuitous circuuistauce 
 of i)olitical exigency from proposing to Parliament, and probably effecting 
 the alteration of the law required for this purpose. So long indeed as 
 his party remained in power, the asylum at Sunbury was visited only by 
 an extra physician, the law being evaded by dubbing an attendant officer- 
 in-charge, instead of appointing a superintendent, who would of necessity 
 have been a medical man. I am glad to hnd that in the colonies gene- 
 rally the law distinctly requires that the medical officer of a public 
 asylum shall be superintendent. In New Zealand and Tasmania alone 
 is there a possibility of it being otherwise ; but in these colonies, although 
 the law is less stringent, the superintendent may be also the medical 
 officer, and 1 believe I am correct in saying that he is so in every instance. 
 
 The ministerial attitude has been a very considerable factor in check- 
 ing the development of a scientitic spirit in the medical officers of 
 Victorian asylums. The staff has been kept at such a low limit, tliat 
 sn])erintendents have not time for anything but the necessary routine 
 duty. It has been the almost invariable rule also, that medical officers have 
 entered the service with the fixed determination not to remain, as their 
 salaries are fixed at an unremunerative point. There are, consequently, 
 very frequent changes in the medical staff; and a su})erintendent lias 
 no sooner got his assistant to take an interest in his work than he loses 
 him by transfer, if not resignation. What scientific research, I might 
 ask, has been ])racticable to our al)le secretary during the last three 
 months, when in sole charge of an asylum with over 500 inmates, and a 
 new admi.ssion late of from 80 to 100 per annum 1 When the medical 
 staff is at this low rate, is it any wonder that so far we have only had 
 tliree members of it present at meetings of this section of the Congress 1 
 
 I will now proceed with the subject matter of my paper, simply pre- 
 facing it with the remark that my comparisons are obtained from a 
 consideration of the statute laws of the different colonies, and not from 
 their asylum reports. 
 
 Many of the methods of legally dealing with the insane are common 
 to all the colonies ; others are common to a group of colonies ; while a
 
 LUNACY LEGISLATIOX 1\ TllK AUSTRALIAX COLONIES. 879 
 
 few are peculiar to one colony. If the existing Acts be reatl in chrono- 
 logical order, it will be readily traced that each coloiiy has largely 
 Ijorrowed from the one that legislated immediately before it. Each 
 successive Act has usually marked a distinct advance, and has, in turn, 
 served its successors as a starting-point. 
 
 The earliest statute that still remains in force is that of Tasmania, 
 ]»assed in 18.58. It was amended in 1885, but only with respect to the 
 machinery of administration. The old Commissioners were then replaced 
 by a board of otlieial visitors, who are dii-ectly responsible to the 
 Government for tlie administration of the princijial Act. 
 
 In 18G4, South Australia passed her statute, which is a model of 
 coiii])leteness as far as it goes, and should, I think, be capable of easy 
 a<lininistration. Here a very good example was set by the draughts- 
 man in having the sections clearly subdivided, making the Act easily 
 read. The main features are to be found embodied in the next piece of 
 colonial legislation — the Victorian Act of 1867 — but were more faith- 
 fully copied by Western Australia in 1871. In neither case was the 
 same clear subdivision adopted, so that the proper interpretation pf the 
 sections is no easy matter, and the hurried clerks of petty sessions 
 make frequent mistakes in drawing out the warrants — in Victoria, at 
 least. 
 
 The first distinct colonial departure was made in 1878 when, owing 
 to the energy and ability of our worthy President (Dr. Manning) New 
 South AVales passed an Act which has been in great measure the basis 
 of all subse(pient legislation. Its newest feature, the establishment of 
 reception houses for the temporai'y treatment of the insane, has met 
 with world-wide a|)proval, and been incorporated in the laws of New 
 Zealand, Queensland, and Victoria. The Act also provided for the 
 establishment of the first separate hospitals for criminal insane, the laws 
 relating to whom were first brought together in a separate section. The 
 distinct advance then made did not long satisfy l3r. Manning, as in 
 1881 he inspired the passage of a short amending Bill, with the humane 
 clauses — (I) that first offenders, including attempted suicides, should not 
 be sent to a criminal asylum ; and (2) a still more beneficent one, 
 providing that attempted suicides should not be prosecuted after mental 
 recoveiy. 
 
 New Zealand passed a very complete statute in 1882, but it has 
 debateable clauses quite distinct from those of any other colony. Its 
 special feature is the prominence given to legal authority both in 
 committal and discharge. The resident inagistrate, or in his absence 
 two justices, must authorise even the committal of a patient sent volun- 
 tarily by his friends ; and also has to authorise the discharge. It is 
 the first Act providing for the boarding out of patients ; but its clauses 
 apply only to recently-committed i)atients before being sent to an 
 asylum, and must l)e rather a dead letter, I should imagine. Recent 
 cases of insanity would certainly not thus be placed under the most 
 favourable conditions for recovery. Few chronic cases could be safely 
 recommended as suitable for boarding out, before they had undergone a 
 period of trial in an asylum. 
 
 It is the only lunacy act that retains clauses under which habitual 
 drunkards as such may be treated in lunatic asylums. This is admittedly 
 a mistake on two grounds. The undeserved stigma of in.sanity readily
 
 880 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 attaches itself to the children ; as for the patient himself, there is a great 
 tendency to too early release, and consequent relapse, as the asylum-made 
 lunatic argument is powerfully urged by friends. The Inebriate Asylum 
 Act 1888, just pas.sed by Victoria, allows a lunatic asylum, or an}'- part 
 of it, to be set ajjart for the reception of inebriates, but it is expected 
 that this clause will only be brought into operation in the country 
 districts. Queensland passed her Act in 1884, and made a clean sweep 
 of all previous laws, repealing no less than six others, and portion of a 
 seventh. She wisely was content to follow the excellent lead of New 
 South Wales, and faithfully adopted the main features of her Act. 
 
 Victoria has the latest and most radical piece of lunacy legislation in 
 the Amending Bill, which came into operation on the 1st inst. The 
 Bill is without doubt a substantial advance upon the principal Act of 
 1867, although superintendents hoped for a larger instalment after the 
 exhaustive labours and sti'ong recommendations of the late Lunacy 
 Commi.ssiou. Given more power, they could without doubt effect great 
 reforms, ameliorate the condition of their unfortunate chai-ges, and have 
 infinitely more time to devote to the advancement of science. The 
 repression of questions that would have led to fierce debate has had its 
 advantages, as the Bill has practically been passed as drafted. Its 
 jtrinciples, therefore, will have a fair trial ; but the effect of many of its 
 provisions remains to be seen, and certainly they have not been adopted 
 with the full concurrence of the profession. Receiving houses and an 
 asylum for the criminal insane are adopted as elsewhere ; regulations for 
 boarding-out are provided as a means of i-elief to the over-crowding. 
 Its most striking feature, however, is a more elaborate attempt than has 
 hitherto been made to eliminate, as far as possible, the pernicious 
 principle of profit in regard to the treatment and maintenance of lunatics. 
 This is by provision for the gradual abolition of licensed houses, for all 
 but the reception of a single lunatic. The feeling that individual 
 liberty was menaced by the pre-existing law, must have been at the 
 bottom of many of the clauses of the Act. It certainly does not require 
 any great stretch of the imagination to view lunacy law as excessively 
 dangerous to the liberty of the subject. All will agree that personal 
 liberty should be hedged about by every safeguard, with which the law 
 and public opinion can environ it. But I think we will all agree, the 
 facts are wanting in this country to justify the wholesale sweeping 
 away of private asylums, which have done much good in their time, and 
 the want of which has in this Colony been severely felt. Personally, 
 as a matter of sentiment, I approve of the change, and would do so more 
 heartily could I hope that the Government Pay Cottages would be as 
 well equipped as a private asylum. It remains to be seen to what 
 extent the entirely new privilege of establishing philanthropic hospitals 
 will be availed of by those charitably disposed towards the insane. 
 
 Legal machinery, for the committal of insane persons, is separately 
 provided for by three great streams of admissions, according to the 
 agency which brings them, and these are further subdivided, as illustrated 
 ill this table. Brought by — 
 
 I. — Police. («) Dangerous, chiefly so through an intention expressed, 
 or otherwise, of committing suicide ; or criminal, those who have actually 
 committed, or appeared likely to commit, an indictable offence, (h)-
 
 LUXACV LP:GISLATI0\ IX THE AUSTRALIAX COLOMES. 881 
 
 Not dangerous or non-criiainal, separately legislated for as — (1) Pauper ; 
 (2) Found wandering at large ; (3) Not j)ropei-ly taken care of, or 
 ci-uelly treated, or neglected. 
 
 II. — Relatives or Frieiuh. 
 
 III. — Gaol Warder, (a) Prisoners of Crown who have become insane 
 while undergoing sentence ; (b) Accused persons unable to plead on 
 account of insanity ; (c) Accused persons acquitted on the ground of 
 insanity. 
 
 South Australia, Tasmania, Western Australia provide asylums and 
 hosj)itals only. 
 
 New South Wales, New Zealand, Queensland, Victoria provide in 
 addition, lios[>itals for temporary reception. 
 
 New South Wales, Queensland, Victoria have also separate asylums 
 and hospitals for criminal insane. 
 
 New South Wales, New Zealand, Queensland have licensed houses. 
 
 New Zealand, Victoria, boarding out. 
 
 Victoria, paying asylum and philanthropic asylum; licensed hou.ses ta 
 be gradually abolished. 
 
 Medical and judicial powers to go hand in hand, the judicial order 
 lieing given upon the medical testimony. This association is complete 
 in New Zealand, where the Resident Magistrate has to order what are 
 called ])rivate admissions in other colonies. The checks and safeguards 
 to wrongful admission and detention are both numerous and efficient. 
 In the vast majority of instances, all alleged lunatics are committed by 
 two Justices on the certificate of two medical men. Exceptions 
 occur, as in the case of paupers, where South Australia and Western 
 Australia allow one Justice, and Tasmania two Justices, to commit on 
 one medical certificate. The other exception is in the case of a 
 dangerous or criminal lunatic who, in South Australia or Western 
 Australia, can be committed with or without a medical certificate at all, 
 if one is not readily obtainable, as may often happen in these si)arsely 
 populated colonies. The Justices can examine at private houses if they 
 wish in most colonies ; but New South Wales jealously guards against 
 any al>use of this power by enacting a ])enalty up to .£100 sterling if the 
 Justices fail to report the fact of private examination. 
 
 Private admissions ai'e in all cases obtained by an order or request 
 from a relative or friend, supported by two medical certificates. New 
 South Wales and Queensland require the signature to this request to be 
 authenticated by a Justice or Minister of Religion, while New Zealand 
 requires the person signing the order to make oath before the Resident 
 Magistrate. 
 
 In all the colonies, persons may be found lunatic by inquisition or 
 order of the Supreme Court, and committed to asylum. The methods 
 of dealing witli insane criminals ari; practically the same in all the 
 colonies; but in Tasmania the Sherifi', as well as the two medical prac- 
 titioners, must be satisfied as to the insanity before removal to an 
 asylum can take place. 
 
 The question whether a jjerson is sane or insane, has been rightly held 
 here, as elsewhere, to be a medical one. It is a duty that has for genera- 
 tions past been thrust upon the profession, and like many another that 
 falls to its lot, a most disagreeable one at best. Its discharge has caused 
 
 2l
 
 882 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 most respectable members to be more than suspected of lieartless con- 
 spiracy and downright dishonesty. Laymen have not hesitated to set 
 themselves up as superior judges to si)ecia]ly qualified medical men on 
 the question, regardless of the fact that the possession of a medical 
 qualiticatiou presupposes a more liberal education, and a still greater 
 experience of human nature than falls to the lot of the average man. 
 Much interesting food for i-eflection could be obtained by an observation 
 of the different degrees of faith reposed in medical men in these matters 
 by the different colonies, and to what extent they accept lay opinions as 
 of weight in cases of insanity. 
 
 All require each alleged lunatic to be certified by two medical men, 
 with the exception of South Australia and Western Australia, where, as 
 I have already shown, one is sufiicient in the case of paupers ; even one 
 may be done without if a lunatic is dangerous and a certificate not readily 
 obtainable. Only in the case of a prisoner under sentence of death can 
 I find any legal provision for more than two medical men inquiring int(5 
 the insanity before committal to an asylum. 
 
 With the exception of New Zealand, which allows the examination to 
 be made jointly in certain cases, the medical man must always examine 
 separately from not only the one who has already given a certificate in 
 the case, but any other. 
 
 The medical certificate must state facts, distinguishing between those 
 indicated by the examinee, and those communicated by others. The 
 only exception to this rule occurs in Victoria in cases that are brought 
 before justices, when the certificate only contains an expression of 
 opinion, without showing any grounds for it. This is a matter calling 
 for remed}', as too great facility is thus given for })erfunctory examina- 
 tion, which is further intensified by magistrates in busy courts only 
 examining one medical man, and even then not requiring depositions to 
 be taken. Hence the patient arrives at the asylum with little or no 
 information to guide the medical officers, and a certain amount of colour- 
 ing is given to the stories that are not wanting of a certificate of insanity 
 having been given, when the wrong man has been examined. The 
 medical man is paid also, not for his examination of the patient, but for 
 his certificate of insanity. This can only be regarded as a menace to the 
 liberty of the subject, and has been the reverse of satisfactory to con- 
 scientious men, who have found themselves unable to give the required 
 certificate. 
 
 The examination must be made not more than seven clear days before 
 admission in New Zealand, South Australia, Victoria, and Western 
 Australia, while in Tasmania and Queensland this time is extended to 
 ten and fourteen days respectively. In New South Wales, in private 
 admissions, the time is ten days, but in police cases, twenty-eight days 
 are allowed from the date of the last medical certificate. The restriction 
 upon medical men, preventing them from signing for a particular patient 
 for whom one certificate has ah'eady been obtained, extends from the 
 simple prohibition of a " partner or assistant," as in South Australia, 
 Tasmania, and "Western Australia, to most elaborate I'estrictions in New 
 South Wales. " Father, brother, and son," ought certainly to be added 
 to " partner and assistant," as the mutual influence must be regarded as 
 greater. Under the Victorian law, I have had to refuse certificates 
 signed unwittijigly by such relations.
 
 LUNACY LKGISLATIOX IN IIIK AUSTliALlAN COLONIES. 883 
 
 When, owing to .special iiic|uii'y, a patient liass been admitted on one 
 certiticate only, tlie procedure to make lengtliy detention legal, varies 
 considerably. All New South Wales and Queensland recjuire is one 
 other certiticate within fourteen days; Tasmania within tifteen days. 
 The remaining colonies demand two more certificates within three clear 
 days. If the urgency be distinctly proved, I think one additional 
 certiticate quite sutKcioit, as two would have suthced in the tirst 
 instance. In the great majoi-ity of cases the patients are in poor circum- 
 stances, often reduced thereto by the pre-existing lunacy that has not, 
 or would not, be recognised as sucli. 
 
 The legal means provided, to justify the detention of the })atient after 
 his admission, aie both numerous and ethcient. They are exactly the 
 same for lunatics admitted through the law courts as for those sent 
 privately by their i^elatives or friends, although ditierent methods exist 
 in different colonies. 
 
 In Xew .South Wales, New Zealand, (^)ueensland, and Victoria, within 
 seven days of admission the Medical Superintendent must forward to 
 tlie State ofhcial head of his dejiartnient a personal examination certi- 
 ficate as to the mental and bodily state of his jiatient. 
 
 1 n South Australia and Western Australia, if within forty -eight hours 
 of the admission the Resident Medical OfMcer and the officer next in 
 authority (probably a layman) are not both satisfied as to the insanity 
 of the patient, a meeting of the Permanent Board of Inquiry mtist be 
 held within three days to decide the qttestion, and of this Board, the 
 Ooxernment Medical Officer (the Colonial Surgeon) is Chairman. 
 
 Tasmania appears to consider that con)mittal to her asylums is not to 
 be lightly obtained. Having full confidence in her officers, she is not 
 afraid of unnecessary detention, as the powers of discharge given to the 
 official visitors, and the responsibility thrown upon the Medical Super- 
 intendent are, I think rightly, considered more than sttfficient to prevent 
 such. In marked contrast with this simple faith is the elaborate 
 machinery of medical examination at the asylum, by outside men, 
 provided by the latest Victorian Statute. Under this Act, the Super- 
 intendent is allowed to fortify his opinion of the sanity of a reception- 
 house patient, before discharging him, by calling in another practitioner. 
 If this man does not concur, another is called in as arbiter, and upon his 
 decision rests the discharge of the patient, or his committal to asylum. 
 Fortunately, the Superintendent has the choice of asylum to which the 
 patient shall be sent, as the law might have placed him in a still more 
 ancmialous position, by calling upon him to ti'eat as insane a ])atient 
 whom he did not believe to be so. If the Superintendent considers the 
 patient insane, he is compelled to call in two medical practitioners. If 
 they agree with him, the patient is to be sent to asylum. If they agree 
 with one another that the patient is sane, he is to be discharged; while 
 if they difier in o])inion, the services of a police magistrate and another 
 medico are to be called into requisition to decide the question. 
 
 These provisions will, I venture to jiredict, occasion a great amount 
 of unnecessary trouble, especially in recurrent maniacal and obscure 
 delusional cases. This might have been saved by placing more reliance 
 U])on the Superintendent's opinion, which should carry more weight, if 
 only from his opportunities of examination extended over from at least 
 three to twentv-eight days. Whereas, the oi)inions that over-ride his 
 
 2l 2
 
 884 IKTEllCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 are formed Ti])on one examination only, wliich may easily cliance to 
 take place during a lucid interval, ft would have Ijeen too much to 
 expect that that reluctance on the part of e\-en intelligent laymen to 
 consider insanity as the result of disease, and a special branch of medical 
 science — a reluctance that is exhibited by even the learned judges of 
 (rreat Britain — would have been so far eradicated by the transplanting 
 of the majority of our legislators to Australia, as to induce them to 
 frame laws, giving anything like full weight to the opinions of 
 expeiienced alienists on questions of insanity. I think we must 
 liowever congratulate ourselves in Victoria, that such prominence has 
 been given to medical opinion in the new legal departure which, with 
 the establishment of this section of the Congress, will I hope be the 
 beginning of V)etter things. The laws have pierced the asylums with 
 means of inspection, that would more than suffice to demolish the abuses 
 of fifty years ago. In many instances no distinction is made between 
 licensed houses and asylums in this respect, oblivious of the fact that, in 
 the one case patients are being kept for profit, wdiile in the other, the 
 officers can have no personal motive in detaining patients. 
 
 In New South Wales, New Zealand, Queensland, and Victoria, we 
 have inspectors whose whole time is occupied with asylum matters, 
 and who have able assistants in the Official Visitors, who are usually 
 chosen from the medical or legal profession, or are members of the 
 Legislature, or magistrates. In South Australia and Western Australia 
 the same officers exist, but the inspectors have other duties to i)erforni 
 in addition. In Tasmania, the inspector's duties are jterformed by a 
 Board of three official visitors. It is one of the duties of all these 
 to see every patient in the asylum at each visit, to listen patiently 
 to and inquire into all complaints, and to pay special attention to 
 the newly admitted. They have the right of entry at all times ; 
 and in South Australia, it is specially enacted that any Justice has the 
 same. 
 
 In South Australia and Western Australia, anj- two householders 
 can obtain a meeting of the Board of Inquiry into the case, if they 
 allege the sanity of ])atient has not been inquired into for three months. 
 In the other colonies, any complaint addressed to the Inspector or 
 Official Visitor, would cause full inquiry to be made into the special 
 case. 
 
 Victoria has, in addition, just provided for the annual examination of 
 all patients by specially appointed medical practitioners. This is I 
 consider, a move in the right direction, as it altogether prevents the 
 possibility of any patient being over looked, and is a duty that, with its 
 attendant clerical work, could not have been discharged by the asylum 
 medical staff in its undermanned condition. 
 
 The laws have fully provided for the discharge of patients on recovery, 
 and the means of obtaining it are numerous. Admission to an asylum 
 does not necessarily mean perpetual confinement therein. There is more 
 uniformity in the method of dischai^ge than of admission, and without 
 much disarrangement of the sections of the various statutes, it would be 
 easy to draft a law of discharge common to all the colonies. Discharge 
 will be considered under three heads : — (1) Discharge by order of 
 relative or friends. (2) Discharge by action of asylum authorities. 
 (3) Discharge by order of Supreme Court.
 
 lunacy legislation ix iiie ausihalian coloniks. 885 
 
 (1) Discharge by Order of Eelative or Friexds. 
 
 In all but New Zealand and Queensland, the person who signed the 
 request for admission, or his legal representative, may order the 
 discharge of the patient, unless the medical officer certifies that he is 
 dangerous or untit to be removed, liut the insjiector or other superior 
 authority has the power of over-riding this certificate. It is well that 
 this method is little availed of, as its adoption would be constantly 
 against the Superintendent's advice, and would lead to frequent relapses 
 and other damage. 
 
 In New Zealand these dangers are guarded against by the proviso, 
 that the ))erson who signed the request must first obtain the consent of 
 the Colonial Secretary, Insjjector, or Medical Officer to the discharge, and 
 then apply to the Resident Magistrate for a discharge warrant. 
 
 Kenioval by £50 bond, entei-ed into with the Inspector, is a method 
 in operation in New Zealand and Victoria, and perhaps in other 
 colonies. It operates as a discharge from the asylum, but is altogether 
 unsatisfactory in the event of subsequent recovery. 
 
 In New South Wales, the Inspector-General, as an official visitor, and 
 in Queensland, the Minister, can allow friends to undertake the care of 
 a patient, with the approval of the Superintendent or Medical Officer. 
 Endeavours are made to lessen overcrowding, by making monetary 
 allowances to indigent persons for so taking cai-e of their relatives in 
 these colonies. 
 
 (2) DiSCHARCE BY ASYLUM AUTHORITIES. 
 
 The simplest method — almost the only one in use in Victoria, and 
 adopted also in New South Wales, New Zealand, and Queensland — is 
 for the Inspector, Official Visitor, or Superintendent simply to certify 
 that the patient is detained " without sufficient cause." The issue of 
 this elastically-phrased certificate to a superior authority, is followed by 
 the discharge, except when a criminal is returned to gaol, or a Queen's 
 pleasure man is detained until the pleasui'e is notified. 
 
 In South Australia, Tasmania, and Western Australia, any two 
 visitors, with the advice of Resident Medical Officer, may order 
 discharge, and this apj)ears to be the regulation method. 
 
 South Australia and Western Australia have their laws further alike 
 in that — 
 
 (1) Any three visitors may order the discharge, and in the case of a 
 paupei-, any two may do so. 
 
 (2) The Resident ]Medical Officer, or any two visitors, one being the 
 Colonial Surgeon, may order the discharge of a patient committed as 
 " dangerous or criminal," on receipt of certificates of sanity from two 
 medical men. This provision can Ije set in motion apparently either by 
 the asylum authorities, or relatives or friends. 
 
 In New South Wales and Queensland, the Inspector-General, or 
 Official Visitor, has full discretionary ])0\ver of di.scharge, whether 
 recovered or not, after he has taken the advice of the Superintendent or 
 Medical Officer. 
 
 In Queensland, the Minister can order the discharge upon the receijjt 
 of a statutory certificate from the Superintendent (or two medicos, if he 
 be a layman), that the patient is "recovered and fit to be discharged."
 
 886 INTEKCOLOXIAL MEDICAL CONGHKSS OF AUSTRALASIA. 
 
 In New Zealand, the certificates are worded (a) of unsound mind, 
 or (6) in such a condition that can be liberated without danger to self 
 or public, and no necessity exists for further confinement or detention. 
 It will be seen, that the general principle underlying these proceedings 
 is, that a medical certificate of suitability is followed l)y the discharge, 
 as a natural consequence of the same authority having led to the 
 admission. The opinions of intelligent laymen have expression in the 
 voices of the ofticial visitors. 
 
 In New South Wales, New Zealand, Queensland and Victoria, the 
 Medical Attendant, Superintendent, or Kee})er, can ol)tain a veto to a 
 discharge proposed against his judgment, by tendering himself for 
 examination by the Inspector or Official Visitor, and giving written 
 reasons of objection to the political head of the department. 
 
 (3) Discharge by Order of the Supreme Court. 
 
 If the foregoing numerous methods fail to secure freedom, there is 
 still the right of legal redress, by an appeal to the Supreme Court. 
 This exjiensive method has verv rarely been had recourse to ; asylum 
 phj^sicians know full well, that so far from patients being unnecessarily 
 detained, grave risks are constantly being incurred in granting what 
 afterwards prove to be undoubted cases of premature discharge. Any- 
 one specially interested in a patient can have the matter brought before 
 the Su})reme Court, which can sit in private, and any judge of which 
 has absolute authority to oi-der the dischai-gp. The patient himself can 
 set the machinery in motii)ii in the.se democratic colonies, by a simple 
 letter addressed to the Minister, which must be forwarded unopened. 
 The Supreme Court also has the sole authority to order the discharge 
 of any person whom it has found lunatic by inquisition. 
 
 After a survey of the different methods of discharge, it will be 
 recognised that complete provision is made, and that a patient's exit 
 from an asylum, when the public safely i)erniits, is quite as easily 
 obtained as even his voluntary admission into it. 
 
 I will conclude, Mr. President and Gentlemen, by saying tliat, although 
 many debateable subjects are raised, the ground travelled over is too 
 extensive to ]iermit of the Avhole paper being the subject of profitable 
 discussion. The issues are too numerous for aiay practical good to 
 result at present ; but I will hope, that the result of my labours in 
 collating this information from the various statutes, will be found useful 
 in the ])reparation of papers upon some of its points for future meetings 
 of the Congress. The comi)arisons instituted will also, I trust, serve to 
 make us better acquainted with the laws under which our neighbours 
 have to act in their dealings with the insane. What we already know, 
 but what the general public is remarkably slow to believe, is also I 
 think clearly demonstrated, that admission to an asylum is hedged 
 about with such precautions, the i)robal)iIity of wrongful detention is 
 so carefully guarded against, and discharge on mental recovery is 
 rendered so easy, that it is practically out of the question that sane 
 persons can be immured in our lunatic asylums. 
 
 The Members tiianked Dr. Armstrong for his paper, and a sti'ong 
 expression of opinion was given l)y all members against that portion of 
 the further Amended Lunacy Act of Victoria, which provides for the
 
 TRAINING OF NURSES AND ATTENDANTS IN INSANE HOSPITALS. 887 
 
 inspection of asylums once a year liy an outside medical man. It %vas 
 thought that the asylum officials -were the best judges as to the sanitv 
 of the patients, and that the Act throughout threw discredit on them 
 in a manner that was highly undesirable. Private asylums were 
 considered unnecessary, except for verv wealthy })eoi)le. 
 
 Dr. Armstrong in replying, stated that though he considered it was 
 practically out of the question that sane persons could be immured in 
 our asylums, he nevertheless defended the a]ipointment of an outside 
 examiner, as an additional safeguard. 
 
 THE TRAINING OF NURSES AND ATTENDANTS IN 
 HOSPITALS FOR THE INSANE. 
 
 By W. C. Williamson, M.D. 
 
 Medical Oflficer, Hosijilal for Iiisauc, Parramatta, N.S.W. 
 
 The question of establisliing some system of training for nurses and 
 attendants engaged in the care of the insane in our asylums, has been, 
 in recent years, one of very great interest. The subject is an old one 
 revived. Many years ago, close on half a century, the need of reform 
 in the class, character, and education of persons entrusted with this 
 responsibility was recognised. Curiously enough, though our co-workers 
 in general hospitals have made trained nurses what they are, the honour 
 of leadership in the ideas of nursing reform belongs especially to Drs. 
 Jacobi and Pinel, two alienists whose names will be for ever held sacred 
 as early pioneers in the humane tieatmenc of the insane. 
 
 Tliere has always been a difficulty in obtaining nurses of the right 
 kind for service in our hospitals for the insane. Samuel Tuke, in 1841, 
 describing the trying and arduous character of the work of caring for 
 the insane, writes:— -" Can it be surprising if it be so difficult to meet 
 with per.sons to till properly the post of attendant on the insane, that 
 instances of neglect or abuse so frequently occur 1" 
 
 Dr. Kirkbride, about the same time, in the United States, was 
 commenting on the same trouble, and thus defines his conception of an 
 ideal nurse : — '' A person of high moral character, of good education, 
 strictly temj^erate, kind and res])ectful in manners, cheerful and for- 
 bearing in temper, with calmness under every irritation, industrious, 
 zealous and watchful in the discharge of duty, and above all sympathetic 
 with those under care. No wonder," he added, " The services of such 
 an individual, after proper instruction in the performance of duty, 
 would be invaluable." Nurses of this stamp, however, were not to be 
 had, and I do not think there could have been much at this ])eriod to 
 choose between the hospital and the asylum pattern. 
 
 No change in either service took place till Florence Nightingale began 
 her noble work in the Crimea. Her efforts to ameliorate the sulferin^s 
 of our soldiers wounded in that campaign, and her organisation and 
 management of the nursing in the camp hospitals laid the foundation
 
 888 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 for her future labours on her return to England. To her, the entire 
 Avorkl owes a permanent debt of gratitude for the reforms of modern 
 nursing. 
 
 Coincident with Miss Nightingale's labours in the Crimea, we find 
 Dr. W. A. F. Browne delivering at the Crichton Institution in 1854, 
 tliirty lectiires to his asylum staff, with the express object of elevating 
 the standard of nursing efficiency. Dr. Mackintosh at (xartnavel, made 
 somewhat later an effort in the same direction, and gave instructions to 
 his attendants, taught them to take notes, and observe physical 
 alteration in patients, &c. 
 
 These efforts were unattended with the success they deserved, and the 
 movement lapsed. Then, as years went by, and the marked success of 
 the I'eform in general nursing was noted, and while superintendents 
 were bewailing the scarcity of suitable asylum nurses, there became 
 a])parent the possibility of educating the mental nurse on the same 
 lines as her sister trained for bodily nursing. 
 
 Dr. Clouston, of Morningside, in a paper read l)y him in 1876 before 
 the Medico-Psychological Association, on the question of " Getting, 
 Training, and Retaining the Services of Good Asylum Attendants," 
 pointed out that there were at the end of 1875 in Great Britain about 
 72,000 insane persons, for whose care and treatment some 6000 nurses 
 and attendants wei'e necessary. He stated the raw niaterial of the 
 right kind out of which they endeavoured to make good attendants 
 was, and had been, most difficult to obtain, and he showed how unsatis- 
 factory this condition of things -svas. It made matters hard for the 
 proper management of asylums, was detrimental to the insane, inter- 
 fering with the comfort and happiness of some of them, prolonging the 
 malady of others, preventing the recovery of a number, and causing 
 risk to the lives of not a few. He described, in fact, this attendants 
 question as the one causing most anxiety to many at the head of asylums. 
 
 To obviate to some extent the difficulty of developing his raw material 
 into satisfactoi-y shape, he had found the early placing of his probationers 
 in small classes in the sick wards under a careful and competent senior, 
 to be a step in the right direction. In this way probationers came into 
 contact with the sick in mind and body, learned tlie individual wants of 
 tlie insane, became impressed with the fact that they were really 
 p-itients, got into good habits and right ways of thinking generally, and 
 proved to be far better qualified for the more regular work of ward 
 routine. 
 
 The basis of action here was evidently to impart at the outset some 
 knowledge of bodily nursing, at the same time bringing those cases of 
 insanity in which more than ordinary care and attention were required, 
 more prominently under the observation of the young attendant. Dr. 
 Clouston foresaw the marked influence which tlie fii'st few months of 
 asylum life have upon the future of the j)robationer, and he rightly 
 determined to make tlie best use of his opportunities. No systematic 
 teaching had up to this time been attempted, but tlie lapidly advancing 
 importance and benefit of trained nurses in general hospitals and ehe- 
 where, gave fui'ther imjietus to the proposals and practice of tlif 
 distinguished Superintendent of Morningside. 
 
 Dr. Campbell Clark, of the Glasgow District Asylum, Bothwell, began 
 in 1881 (not witliout distrust of the lesults), a course of eighteen
 
 TH 
 
 AINING OF NURSES AND ATTENDANTS IN INSANE HOSPITALS. 889 
 
 lectures to liis start", the subject inattev tliereof Ijeing ajipavently })ractical 
 mental nursing, put into as siui])lf' form as possible. The success of this 
 departure was so marked that he ventured on a second course of lectures, 
 and again tlie result was most gratifying. The latter series embraced a 
 wider field of teaching, and prizes and certificates were eagerly competed 
 for at the examinations on the conclusion of the course. 
 
 In Dr. Uaui])I)ell Clark's i)aper, read before the Medico-Psycliological 
 Association in 1883, lie stated as the result of his somewhat varied 
 experience :— " (1) That too great a barrier existed between officers and 
 attendants ; (2) That the mental and moral qualities of attendants 
 w(3re not utilised as fully as they might be, and (3) That attendants 
 require to be individualised as well as patients." In working out his 
 scheme, Dr. Clark ])ut on i-ecord his opinion that, " We are becoming 
 more and more fully impi-essed with the idea, that the asylum of the 
 future will partake largely of the hospital type." 
 
 In America, the necessity of reform in the nursing of their insane, 
 had also been recognised, and for some years liad occupied the minds of 
 asylum superintendents. In 1879, the plan of the McLean Asylum 
 Training School was definitely determined upon. "The object was to 
 create a school, not simjily for the instruction of attendants on the 
 insane, but to fit young women, as in the general lios})itals, to undertake 
 nursing in all its branches, wish special qualifications for the cai"e of 
 cases of nervous and mental disease." I have no hesitation in expressing 
 my belief that the work done there by Dr. Cowles, as fully set forth in 
 the paper on " Nursing Reform for the Insane,' read by him in 
 September 1887, before the Psychological Section of the International 
 Congress at Washington, embodies the most important advance in our 
 modern methods of caring for the insane. Dr. Cowles had not, up to 
 the time of v/riting his paper, extended his system of training to his 
 male attendants, but the success of tlie movement amoug his nurses was 
 such as to leave no doubt in the reader's mind he intended shortly to 
 include his men in the scheme of nursing reform. 
 
 In February 1884, a sub-committee of the British Medico- 
 Psychological Association prejtared an ofiicial handbook for the special 
 instruction of attendants, and since then a considerable amount of 
 literature has been published on the same subject. 
 
 I am glad to say that reform in this direction has not been confined 
 to the few asylums already mentioned. In our own colony, Dr. Sinclair 
 has, at Gladesville, for the jmst two winters carried out complete courses 
 of lectures and ward training, both for nurses and attendants, and I shall 
 have much ])leasure later on in giving an outline of tlie system practised 
 there with very great success. 
 
 The practicability of establishing with success a legular system of 
 training being now assured, the development and extension of the 
 Scheme can only be a matter of time. In reviewing the i)resent position 
 of trained nursing in general hospitals, we are at once struck with the 
 enormous advance it has made within the generation of its existence, and 
 tliat, not alone in the marked efficiency of its service, but — another 
 ■excellent test — in the appreciation with which it is held by the public. 
 Tlie employment of trained nurses may now be said to be universal. 
 We have nursing departments for the army and navy existing in our 
 large military and naval hospitals in England, and we find that in time
 
 890 IXTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA, 
 
 of war these nurses are seat ovit for service in the hospitals wliich receive 
 the wounded from the field of battle. In all civilised countries, there 
 are to be found training schools attached to the larger and more 
 important hospitals, where nurses are carefully prepared for their future 
 mission. In public and in private, none but trained nurses are employed, 
 and we shall probal)ly tind ere long Tuany of these qualifying themselves 
 specially — on the same princi})le as do our professional brethren — for 
 attendance on special varieties of bodily illness. 
 
 In New South Wales, Sir Henry Parkes long since recognised the 
 wisdom of having a similar system to that established at St. Thomas', in 
 London, under the supervision of Miss Nightingale, and some twenty 
 years ago, acting on the recommendation of Sir Alfred Roberts, then 
 one of tlie Surgeons to the Sydney Infirmary, obtained the services of 
 several trained nurses from England, as a nucleus from which nursing 
 i-eform might lie extended in the mother colony. AVe now tind appoint- 
 ments on the nursing staff of our hospitals the object of keen competition, 
 and the list of a))plicants for training always much larger than can be 
 accommodated. Trained nursing, in short, has now been elevated into 
 a profession. It enlists the best sympathies of mankind, atibrds a large 
 field of noble usefulness, and |)rovides a valuable and self-supporting 
 occupation. 
 
 When we turn froui this view of nursing, as it exists for bodily 
 illness, to the present condition of nursing for the insane, we naturally 
 say to ourselves, "If the nurse of one sick of a physical disease is sa 
 mucli improved by training, how infinitely more important is it that 
 those who are to minister to a mind diseased should have a special 
 teaching 1" I am inclined to think that in the past the medical officers 
 have put too much faith in the means which they personally brought to 
 bear upon the recovery of their patients, and have overlooked, or not 
 made sufficient out of the association of the nurse or attendant with 
 the patient. We recognise how great is the influence of surroundings 
 upon the insane. We improve their accommodation, brighten their 
 rooms, give them amusements and occupation in variety, but we have 
 not yet made for them ideal nurses. If we omit to train the nurse to 
 understand the patient, there exists a barrier between the two, caused 
 by indifference, ignorance, and lack of syuipathy on the one hand, and 
 distrust, perhaps fear, on the other. 
 
 If, as there is little reason to doubt, success in the treatment of our 
 insane depends largely on the men and women to whom we confide the 
 trust of our patients, and the fulfilment of our instructions, the neces- 
 sity of providing the best possible type of nurse and attendant, and of 
 training them thoroughly for their important duties, is evident. 
 
 In too many instances the system hitherto has been to allow the I'aw 
 material to develop of itself, without assistance or instruction worthy of 
 the name from the medical officers. A copy of rules, a few hints from 
 matron or chief attendant, and the new comer enters upon his work. 
 Nurses and attendants some time in the service of the in.stitution are 
 not found to bother themselves about new hands, and if there be any 
 training or exan^jle sliown them, it cannot, I fear, always be said to be 
 what is desirable. Almost invariably a lazy, indifferent senior will sjjoil 
 the juniors in the same ward by force of example, and the first six or 
 twelve montiis mav well be said to make or mar the future of the
 
 THAIXIXG OF \UHSK8 A\D ATTENDANTS IX INSANE HOSPITALS. 891 
 
 probatioiaer. The difference between a truined nnrsing staff and one 
 allowed to develop of itself, is just the difference between skilled and 
 unskilled labour. 
 
 Acce{)table applicants for the posts of nurse or attendant must have 
 had a fair general education. They are usually under the age of 25 
 years. They have had, in the large majority of instances, no previous 
 knowledge of nur.sing or experience of the insane. The appointments 
 sought for are permanent (de)>endent on good Itehaviour). This is, in 
 itself, a considerable attraction. The rates of pay are good, and i)ro- 
 inotion to senior grades follows on efficiency and length of service. 
 With us in New South Wales — for all who elect to ])articii)ate in the 
 advantages of the Civil Service Act — pensions are attainable when unfit 
 for further work tlirough age or ill health. Yet, despite these inducements 
 to enter the asylum service, we have, from time to time, actual difficulty 
 in filling vacancies on the nursing staff with material of the right kind. 
 The reasons seem obvious. There must be — as compared with ordinary 
 nui-sing — a want of interest in their patients, inasmuch as in hospitals 
 there is a rapid change of cases, with visible and speedy imjn-ovement 
 in many instances to which nurses can personally contribute. Whereas, 
 in asylums, interest and zeal are apt to flag under the prolonged character 
 of the disease; when there is but little, if any, change from day to day;, 
 when convalesence is slow, and when patience and nursing are not 
 quickly rewarded by results, the work is frequently unpleasant, and 
 there has been no attempt made, till very I'ecently, to develop the senti- 
 ments which should animate nurses. They have been left too much to 
 their own devices, have had but little interest taken in them by their 
 superior officers, and, so long as they fille<l their position without 
 unfavourable notice, all went well. 
 
 The occupation, however, is a healthy on(\ and entails an out-door 
 life. Its monotony is relieved by frequent holidays, by varied amuse- 
 ments in which both patients and nurses participate, and by having the 
 evenings off duty. Still, there is no doubt, while the asylum nurse is 
 much better paid, the general hos[}ital attracts to its service a])plicants 
 of better social standing and education, and is becoming increasingly 
 ])opular ; while the asylums seem, in this respect, at a standstill, and 
 our nurses continue to be nurses by name, rather than by virtue of their 
 special knowledge. To remedy this condition of things, to improve our 
 nursing system, to render our service more popular, and to attract 
 thereto better material, 1 would earnestly advocate a systematic course 
 of training. 
 
 If our nui-sos and attendants are not taught liow to do their work, 
 what can we hoi)e from them ? Surely, even as we expect good work 
 from them, may they fairly and rightly look for help and instruction in 
 their duties from us. Wherever tiiis plan of nursing reform has been 
 carried out, the result has far exceeded the expectations. A new 
 interest has been awakened for nurses in their work ; a spirit of 
 healthy enndation excited ; medical officers have readily testified to the 
 remarkable iuqjrovement in the general efficiency of their staff; patients 
 liave been better — infinitely better — looked after, and the tone of the 
 hospital has been sensibly improved. Officers by this means are 
 brought into more immediate contact with nurses and attendants, and 
 thus get abundant oppoitunities of ascertaining tiieirindividual characters.
 
 892 INTEKCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 dispositions, and temperaments. A feeling of community of interest, of 
 unity of purpose, of mutual regard, springs up. Incapacity, indifference 
 or neglect meet the fate they deserve ; and the elimination of those 
 i;ntitted for their trust, tends to strengthen the staff as a body. Special 
 aptitude and intelligence are soon discovered ; defects of primary 
 education are removed by the ordinary exeix-ises ; encouragement is 
 given to all, and none are over-looked. Discijtline is also promoted, 
 esprit (h corps becomes a reality, evil habits are held in check, and self- 
 respect is more mai'ked. Such knowledge of real nursing once obtained, 
 is of immense advantage in after life, when perhaps connection with 
 the hospital may be severed, and some other occupation entered upon. 
 For the nurse, her certificate of training assures a future independency, 
 as it qualifies her to obtain her livelihood, either in undertaking the 
 charge of a mental case, or of some patient suffering from bodily illness. 
 Wlierever her future life may be spent, her knowledge of nursing will 
 proA'e a ])riceless boon to herself as well as those around her. 
 
 The value of men as nurses for members of their own sex, ha.s lately 
 been commented on by Surgeon-General Longniore, C.B., and with them, 
 as with women, such knowledge of nursing must be always an advantage 
 to themselves personally, as well as to those who, from any cause, need 
 their services. In support of this, I would point out the present state of 
 organisation and efficiency of the Army hospital coi'ps in England ; their 
 constant presence in all military centres at home and abroad, and the 
 very valuable character of the services they render to the sick or wounded. 
 
 Again, at the Royal Naval Hospital, Haslar, near Portsmouth, theie 
 is a very perfect system of training and teacliing for duty, both afloat 
 and ashore. Boys are selected immediately on entering the service, and 
 before they have been to sea they are sent to the hospital at Haslar, 
 where they receive three years' tuition in the wards, and a thoroughly 
 practical training under strict discipline. They thus become qualified 
 for their duties as sick berth attendants in Her Majesty's ships ; and 
 after they return from sea, are again remitted to Haslar for further 
 tuition, so as to keep them up to the mark. 
 
 Trained male nurses are also largely employed for attendance on 
 patients in private practice, as well as in public institutions in the old 
 country, and with satisfactory results. It would thus appear that men 
 are quite as capable of becoming good nurses, as the gentler sex. 
 
 To come to the actual teaching. I c;tnnot do better than quote 
 Dr. (Jole's final advice to those who would follow in his footsteps : — " Get 
 ready before beginning, begin rightly, go slowly, do the work thoroughly, 
 and there will surely be good results." The best plan seems to begin 
 with the nurses, and as soon as they are on an established basis, extend 
 the system to the men. Women have more of the nursing instinct in 
 them ; they are on the whole more sympathetic and gentle, and seem 
 to take almost naturally to tending the sick. Florence Nightingale 
 sti-uck the right cliord in basing her nursing reform upon that most 
 potent quality of human nature, its motherliness. 
 
 Instruction should be by lectures, ward teacliing, and demonstrations. 
 The course sliould extend over two, or perhaps preferably three Sessions, 
 the winter being naturally the best time for work. Tlie tir.st Session 
 being devoted to bodily nursing, the second and more advanced to the 
 special nursing of tlie insane, and where more insti'uction is thought
 
 TRAIXIN{; OF XUKSKS AXD ATTP;XI).\XTS [X IXSAXK HOSPITALS. 893 
 
 cKsirable. it might take the form of re.sidence and tuition in some 
 geneial hosj)ita], where a more intimate practical acquaintance might 
 lie had with bodily diseases, accidents, operation cases, aiad such like. 
 Tt must not be forgotten that the amount of ordinary physical illness in 
 our asylums is not sufficient of itself to afford an ample experience to a 
 large staff of nurses and attendants, and it is for this reason I would — 
 where the arrangement could be effected — recommend the adoj)tion of a 
 scheme, whereby our asylum nui-ses might, after being well grounded in 
 ail the jiractical work the asylum is capable of, be sent, a few at a time, 
 to assist in ordinary ward duty in a hospital devoted to general diseases. 
 In New South Wales, where there is a Government institution of this 
 kind (the Coast Hospital, Little Bay), some such arrangement might be 
 made with, I believe, very great advantage. 
 
 There will doubtless be some diversity of opinion among medical 
 officers, as to the detailed working of any scheme of nur.sing reform ; 
 what might answer well in one place, might not suit in another. 
 
 The system adopted with success at Gladesville, began in the winter 
 of 1887 with the nurses, and was a year later extended to the 
 attendants. The object has been to teach the staff how to nurse the 
 patients, without taking on themselves any authorit} in the matter of 
 treatment. Up to the present, the nurses and attendants have been in 
 separate classes, but later on, when the majority have l)een taught, it is 
 proposed to have combined classes for facility of teaching. The subject 
 of these earlier (or first year) lectures, are medical and surgical nursing, 
 with very elementary anatomy and physiology. The work commenced 
 by one of the medical officei-s delivering lectures bi-weekly. A suitable 
 day and hour (usually Thursday afternoon of each week) were set apart, 
 and the nurses divided into two classes, so as not to interfere with 
 ward routine. The subject matter of the lectures was couched in the 
 simplest language, was illustrated by diagrams and plates, by the 
 skeleton, or other means which suggested themselves ; the blackboard 
 was also an assistance. The lecture occupied about one hour. The 
 second class of nurses received the same instruction on the following 
 day. Then on each Saturday, while the course of lectures lasted, the 
 medical officers spent part of the afternoon in the wards, holding a kind 
 of tutorial class, ex[)laining any points of doubt or difficulty, and 
 ascertaining how each nurse individually grasped the subject of tlie 
 previous lecture. At such times, he demonstrated the use of the 
 thermometer, taught them how to apply bandages, and for himself 
 gained many hints as to the best means of conveying knowledge. Being 
 thus brought into actual contact with the nurses, he made sure one 
 lecture was understood, before another AA'as delivered. 
 
 Then, on the completion of the course of lectures, a few tutorial 
 classes were held on the subject of the lectures throughout. Exami- 
 nations (oral and written) were subsequently held by outside 
 practitioners, and the result communicated to the nurses. Those who 
 fail to reach a fair standard of efficiency are referred back for more 
 study, but .so far these have been quite exceptional. 
 
 In addition to the subjects already mentioned as belonging to the 
 first year's course, I tliink some elementary knowledge of hygiene, so 
 far as it relates to air, water, disposal of nightsoil, might be added with 
 advantage. It would also be well, now that the use of the gas-stove is 
 
 I
 
 894 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 SO much more general, to have some practical lessons on cookery, as 
 required in sick nursing. The second year's lectures at Gladesville have 
 been in connection with mental nursing proper. They have dealt with 
 the elementary anatomy and physiology of the l»rain, with the operations 
 of the mind, will, &c., and with the subject generally of insanity. 
 Practical illustrations were made of jmtients in the wards in connection 
 with each lecture, and an examination followed as before, with the 
 -ditference that, on this occasion, one of the examiners at least must be a 
 medical officer attached to the hospital itself. 
 
 Subsequent to this second examination there is a third, which 
 embraces the whole course of lectures — of the first as well as the second 
 year — and on the passing of this, together with a satisfactoiy record of 
 ward work and general treatment of patients, nurses obtain their 
 •certificate. 
 
 80 much for the practice of (jrladesville. That it is fruitful of results, 
 I can well testify. In 1882, 1 was the acting medical superintendent of 
 that institution. We had no teaching then, and the quality of the 
 nursing did not always recommend itself. In 1887, I examined the 
 mu'ses on the conclusion of the first course of lectures. Without 
 hesitation I affirm, that they would have well compared with any body 
 of nurses who had received a similar course of training in a general 
 hos[)ital. Their accuracy of knowledge, zeal, and evident wish to learn 
 was as creditable to themselves as to the medical officers who had 
 taught them. I have gone somewhat fully into this training of nurses 
 and attendants at Gladesville, as I believe the system there adoj)ted to 
 be both thorough and judicious. 
 
 The whole subject, Gentlemen, is one of absorlnng interest, and is, 1 
 believe, but in its infancy. There can be little doubt of its growth and 
 extension. I believe the old order of things will .soon give way, and 
 that a few years hence will witness in each asylum for the treatment of 
 the insane in Australia, the establishment of a i-egular .s^'stem of 
 training both for nurses and attendants. I know of no one subject in 
 our special branch of medicine fi'aught with more important issues to 
 the welfare of our patients, or which bears more closely on our own 
 actual success in ward work. 1 do not, for one moment, think we can 
 at jiresent estimate the far-reacliing influences arising therefrom, and I 
 believe that new possibilities of all kinds will open out under the 
 influence of such a staff", as we may reasonably hope to obtain when 
 nui'sing is taught in our asylums as fully and completely as in other 
 hospitals. 
 
 I trust. Gentlemen, at our next Congress we may have recorded the 
 experiences of the medical officers of other colonies, and that their 
 success will be quite ecpial to that reported elsewhere. 
 
 The members thanked Dr. Williamson for his valuable paper, and all 
 were agreed that instruction of the attendant and nurse was the thing, 
 at the present time, in the further advancement of the curative agencies 
 brought to bear on the insane, and ought to be carried out zealously, as 
 part of the medical officers' duties. 
 
 Dr. Manning spoke most hopefully of the results of the lectui'es given 
 during the last two years at Gladesville, New South Wales.
 
 EXTENSION OF HOSPITAL METHODS TO ASYLUM PRACTICE. 895 
 
 Dr. FisiiHOUKNE remarked tliat Victoria was the only colony where 
 medical superintendents had not the engaging and dismissing of their 
 attendants and nurses — a state of things which militated against pi-oper 
 discipline and attention to duties, and would certainly come in the way 
 of a system of instiuction being fully carried out. 
 
 THE EXTENSION OF HOSPITAL METHODS TO 
 ASYLUM PRACTICE. 
 
 By Eric Sinclaik, M. D. 
 
 Medical Supeiintciulent, Hospital for Insano, Gladesvillc, New South Wales. 
 
 The following ])aper would ])erha|)s have been Ijetter named " The 
 Further Extension of Hospital Methods to Asylum Practice." It is not 
 intended to presume that hospitals for the insane are far behind general 
 hospitals in their methods of practice, if indeed they are behind at all ; 
 what IS ])roposed is, to advocate that some of the modes of nursing in 
 vogue in general hospitals, might with advantage be adopted in hospitals 
 for the insane. 
 
 Each year, those who have to do with the insane become more 
 convinced, that the asylum of the future should be a hospital, with 
 powers of detention ; that the insane patient should be treated altogether 
 as a sick person ; and that the main idea of the hospital for insane 
 sliould be medical treatment of disease, not mere detention and separation 
 from society. 
 
 It is mainly such hospital methods as will assist in improving nursing, 
 and the nursing staff", that the present remarks are intended to advocate. 
 Not that 1 do not believe that many other hospital methods, not 
 mentioned here, may be introduced with advantage. 
 
 All who have to do with asylums have experienced that nurses and 
 attendants have improved much in past 5"ears, and that they are still 
 improving yearly, Ijoth in education and social position. A better class 
 are now applying for ai)pointment, and i)i larger numbei-s, allowing us 
 greater scope for selection. Imitroved asylum methods give them a better 
 position and a clearer idea of what their work is ; they consequently, 
 devote more time to the care of individual jjatients, and less to mere 
 guarding. The modern system of trusting patients, in work and exercise, 
 is a direct outcome of this improved staff. jMost of the advances in 
 the past have been obtained by making liospitals for the in.sane 
 less of the asylum or refuge, and more of the hos})ital for cure. The 
 hospital for the insane is not primarily intended for retaining chronic 
 and incurable patients, so much as to j)revent acute cases from 
 becoming chronic. 
 
 And now, the need for improved nui-sing arrangements Ijeing 
 recognised, it is evident that the nursing staff" must first have some 
 more or less systematic training, to allow of their being able to carry 
 out intelligently, ideas as to improved nursing. A course of lectuies,
 
 896 INTERCOLOXIAL MEDICAL OOXGKESS OF AUSTRALASIA. 
 
 demonstrations, and examinations, will do much to ,i,ave this ; but, 
 unless supplemented by special training in a ward, moulded more after 
 the style of a general hospital than most hospitals for the insane at present 
 possess, it will not make the staft' sufficiently good to effect a radical 
 change in tlie nursing of the [latients. I do not for a moment intend to 
 have it understood, that training of nurses cannot be carried out without 
 such a ward, or that the training when completed, will not be of value 
 in its absence ; but I do think, that the possession of such a ward 
 will allow of the training being carried to a pitch of perfection, impossible 
 without it. 
 
 What form the ward should take, will depend so much on the circum- 
 stances of the asylum it is to be attached to, that much time need not 
 be taken up in describing an ideal one. The following may, however, 
 be taken as a general outline of one that would fullil all necessary 
 conditions : — It should be large enough to contain forty or fifty patients, 
 and be separate from the main hospital ; not necessarily on a separate 
 site, but distinct enough to avoid having j^atients from other wards 
 coming in, or being sent in at night to utilise vacant beds. The 
 proportion of single rooms to a.ssociated dormitories a large one, not less 
 than one to five, preferably one to four. Some at least, of the single 
 rooms must o):ien from the day-room, or be so near as to allow of the 
 attendants hearing what is going on in them, and also to make it easy 
 for them to be visited every few minutes. The associated dormitories 
 may either be a series of small ones, containing three or four, to ten or 
 twelve beds each, or be one large one of sixteen or twenty beds, with 
 partitions four feet high between the beds. In this way, privacy and 
 comfort may be secured with efficient supervision. The day-rooms to 
 be light and cheerful, to have large windows with bays and as extensive 
 and beautiful an outlook as circumstances permit. There should be, if 
 ])ossible, two day rooms — one to be used by excited [)atients, the other \jy 
 depressed and sick. Theseday -rooms should be contiguous, communicating 
 with each other by a door or passage, so that as a rule both classes 
 of patients mix. Separation is only necessary when ver}- noisy or 
 destructive patients are in hospital. 
 
 in this sick hospital and hospital ward, the patients should be looked 
 on as sick in body, kept in bed when required, and otherwise treated as 
 they would be in a general hospital. When they had improved or 
 recovered so as to benefit by the change, they would be sent to another 
 ward, and into the working parties. All new admissions should be sent 
 here, as well as all cases of sickness occurring among the ordinary 
 patients. Thus attendants or nurses would have an opitortunity of 
 seeing all kinds of illness, Ijodily as \vell as mental. 
 
 The main use of this ward would be. as already indicated, the training 
 of the staff. There should always be a large number of nurses or 
 attendants here, partly to allow of special modes of treatment requiring 
 extra assistance being carried out, and partly to let as large a proportion 
 of attendants as possible benefit by the training. 
 
 On first joining the hospital, all probationers without exception, 
 would be sent here, and each would remain till he or she had become a 
 nurse, and had had hospital methods thoroughly drilled into him. It 
 would be advantageous to have the new comer remain in this ward 
 during the whole two years of training ; but this is not absolutely
 
 EXTEXSIOX OF HOSPITAL ^FETIIODS TO ASYLUM PItACTICK. 897 
 
 necessary. From tliree to six moutlis at least must bo spent here, 
 before lie is allowed to enter the ordinary wards ; and if the service can 
 allow of it, he should have attended the first year's course of instruc- 
 tion — that on ordinary nursing— and have passed an examination on it 
 satisfactorily. It sliould also be arranged, that attendants x-eturn to 
 this waril during the lectures on mental nursing in their second year's 
 coui'se. If the staff is so small as to require it, the series of lectures 
 and demonstrations could be given at different periods of the year, so 
 that new attendants could receive their elementary instruction, and be 
 sent into the different wards, and their place be taken V)y second year 
 students. 
 
 A further extension of hos[)ital methods, that might with advantage 
 be made, is the training of nurses and attendants for private work. In 
 America, it has been found i)Ossible to institute a training school for 
 attendants on the insane, apart from the asylum staff, "and we should l)e 
 able to do the same in such a wurd. There need not Ije much difficulty 
 in procuring both nurses and attendants at a lower rate of pav than is 
 at present given, if it is understood that, on their passing examinations, 
 and showing proficiency in the wards at tlie end of two years, a 
 certificate will be given. In this way a larger junior staft" might be 
 employed, without materially increasing expenditure. These certificates 
 would be of value in procuring employment as private nurses for insane 
 patients. There is not yet any large demand for these nurses in 
 piivate practice ; but undoubtedly, if thoroughly efticient nurses and 
 attendants were to be had, they would find employment. This has been 
 the experience in America and England. 
 
 Of course, the best of the trained nurses might be taken on to fill 
 vacancies in the hospital staff, and by thus giving a larger numlier to 
 select from, the standard of etticieiicy would be materially raised. 
 
 All that has just been said may be called practical, in that it is 
 jtossible to have it carried out — without any great or expensive 
 alteration of staff or buildings — in hospitals for the insane as at present 
 constituted in Australia. If a special ward cannot be built, it may be 
 possible to alter one of the ordinary wards to suit the purpose. If even 
 this cannot be done, the school might be begun i,. the present wards, 
 making such minor alterations as would adapt them to the purpose. 
 
 But there is still a higher point to be aimed at, and this may, perhaps, 
 be called ideal. To me, it seems not to be so. I mean the adoption 
 of another hospital method — in the separation of the nursing from the 
 cleaning, housemaid, and labouring work. In general hospitals this 
 step was found to be necessary, to induce well-educated and gentls- 
 nurtured women to become nurses, and to retain them. And, in our as 
 yet small experience in training, the want of this is found to be a great 
 hindrance. 
 
 The objections to this separation are great, but not insuperable. It 
 is already partially carried out in most hospitals for the insane. The 
 laundresses, cooks, and needlewomen are not usually nurses. On the 
 male side, the artisans, engineers, gardeners, (fee, though they have 
 complete charge and care of patients during working hours, have usually 
 had no nursing experience or ward training. Why should it not be 
 possible to have a part of the female staff — paid at a lower rate — to do 
 the mere cleaning work, with the assistance of patients, and of course 
 
 2m
 
 898 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 under the su])eiinteiulence of the trained nurse in charge of the ward t 
 They would be available to help in watching the patients, and thus 
 an increase in the ninnber of the staff need not be necessary. And 
 on the male side, why should not the arrangement at present in 
 force with the artisans be extended to all the out-door staff"? The more 
 perfect the classitication, the more feasible it would be to adopt such 
 a system. In a hospital with large wards of 80 to 100 patients in each, 
 it would not be easy to individualise the patients well enough to allow 
 of the smaller ]jurely nursing staff looking after them efficiently. But 
 in one with smaller and more numerous wards, classification may easily 
 be )Derfect enough for one trained attendant to know each of his patients 
 thoroughly, and not neglect any of them. 
 
 Until some such system is adopted, it is difficult to see how we are to 
 induce people from a higher station in life than that from which the 
 majority of our stall" is at present drawn, to join the ranks of nurses 
 and attendants. 
 
 THE HOUSING OF THE INSANE IN VICTORIA, WITH 
 SPECIAL RELATION TO THE BOARDING-OUT 
 SYSTEM OF TREATMENT. 
 
 By W. Beattie Smith, F.R.C.S. Ed., L.R.C.P. 
 
 Medical Supeiiutenclent, Hospital for the Insane, Ararat, Victoria. Member of the 
 Medico-Psychological Association of Great Britain and Ireland. 
 
 The housing of the insane is a subject of so constant importance to 
 asylum physicians, and the authorities who charge themselves with the 
 providing of such, that I feel sure nothing in the way of introduction 
 is necessary on my part, before launching into what is a troubled sea. 
 
 I would court discussion to the fullest extent, with the hope of arriv- 
 ing at some general understanding amongst us as to the best means to 
 be adojited for the housing of the various classes of patients with whom, 
 as mental physicians, we have to deal, and in whose interests, as 
 managers of insane hospitals, our voices should be heard. That we shall 
 establish some sound basis is all we can hope for, seeing that the 
 question is as vast as the ever-increasing numbers for whom 
 accommodation has to be provided. 
 
 First then, let us study the existing methods adopted in England, 
 Wales, and Scotland, before coming to Victoria, where extension of 
 accommodation is particularly rampant just now. I am not going to 
 enter into statistical figures, as it would only be wearisome. I shall 
 content myself with asking you to allow me to generalise only, the more 
 esi)ecially as in England, Wales, and Scotland, the various names given 
 to the insane hospitals, according to their method of government, 
 precludes exactness in figures, when compared with colonial institutions.
 
 nOUSINr; OF Till: IXS.WK I\ VICTOKIA, 899 
 
 Til England and Wales, tlu; gi-oss ludk of the patients, according to 
 Dr. Hack Tuke, to the extent of about 70 per cent., are in the jjuhlio 
 asylums; the i)rivate asylums take up 5 ))er cent., while about 8 per 
 cent, are in private dwellings, and the balance in workhouses, which in 
 .some instances have lunacy wards. Taking the private jjatients 
 separately, rather more than half reside in public asylums, a small per- 
 centage are single patients in private dwellings, and the balance, about 
 30 per cent., are in licensed houses. 
 
 In Scotland, nearly GO ])er cent, are in public asylums, only about 
 2 per cent, in licensed houses, "20 per cent, in workhouses, and about 
 the same number cared for in private dwellings under official insj^ection ; 
 thus it will be seen that the Scotch have adopted to a large extent the 
 .system of supervision of insane persons in private dwellings, and that 
 they make scant use of licensed houses. If we again take private 
 patients by themselves, we find that moi'e than three-fourths are in 
 j)ublic institutions, and a vei-y small percentage in licensed houses and 
 l)rivate dwellings. 
 
 [n America, Dr. Hack Tuke tells us " the tendency is in favour of 
 proprietary asylums," while " in Britain the current feeling Hows in the 
 direction of the larger appropriation of the i)ublic asylums to the 
 wealthier classes." 
 
 In Victoria, indeed in Australia, the insane at present are broadly 
 looked upon as wards of the State, and housed by the various govern- 
 ments almost regardless of social distinction, the friends of each patient 
 [laying as much as they can be got to. 
 
 What tlien ought we to decide are the necessary requirements to be 
 striven for in the interest of our insane population ? ]My own views 
 are, that as no licensed houses exist, none should b(; authorised ; that 
 public institutions should alone be recognised, and that they should 
 have proper reception wards in the shape of an acute hospital, with all 
 the necessary api)liances for observation and treatment, where new 
 patients may be a])art from chionic, or at all events, advanced cases; 
 that these public hosititals should each be so arx'anged as to admit of 
 providing for the treatment of patients of different classes, whether 
 socially or mentally, and that segregation be the point to be arrived at. 
 Those patients serving sentence, and connnitted from gaols, as well as 
 Queen's pleasure cases, shoidd be treated in an establishment by them- 
 selves, and it is a question whether the i)enal departments ought not to 
 -look after those serving sentences themselves, as from their very nature 
 they are uncertain and disturbing elements in hospitals for the insane. 
 
 As my main object in this paper is the dealing with the treatment of 
 the insane in private dwellings, it will be necessary to at once say that 
 the princi|)le of segregation, though j^ood on the whole, has run riot in 
 the amateur psychological mind, and it shall be my l)usiness to set foilh 
 the special circumstances under which the housing of the insane is most 
 calculated to be of advantage in this colony, which really means how 
 best to deal with the chronic harndess insane in such a manner as to 
 hamper as little as possible the active treatment of cases in their earlier 
 stages. First of all then, let us dispose of those cases of neces.sity 
 requiring hospital care and treatment, by .stating that each district 
 institution — for I would divide the colony into districts — sliould have its 
 reception wards for observation and treatment, its convalescent wards 
 
 2 m 2
 
 900 INTKRCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 or cottages, its wards for chronic cases and epileptics requiring skilled 
 supervision, and some accommodation for the chronic harmless patients, 
 ])ending further arrangement. 
 
 In Scotland, the treatment of the insane in private dwellings has 
 been legislated for very fully, and the macliinery is ready made in the 
 shape of existing parocliial authorities, both medical and lay ; the main 
 object of the system being the relieving of the county asylums of the 
 over-crowding caused by the accumulation of the chi'onic harmless 
 insane of the pauper classes, by the dispersion of such as do not requii-e 
 "institutional control "amongst cottagers willing to accejit the careof tliem. 
 
 This subject was dealt with some twenty-five years ago by 8ir Arthur 
 Mitchell, one of the Scotch commissioners, and has been receiving 
 attention ever since, with the result that some twenty-two j)er cent. 
 of the registered pauper insane are now in private dwellings, where 
 special attention is given to the fact that the General Board of Lunacy 
 discountenances all efforts to form aggregations of lunatics or so-called 
 colonies, like Glieel ; and that while recognising the benefits to be 
 derived by patients in asylums, strongly urges that family treatment 
 outside of institutions is proper in a considerable number of cases, 
 which must be under the control and careful supervision of some ])ublic 
 central authority. 
 
 As all insanities have a tendency towards dementia, or that mental 
 enfeeblement which comes to all of us with advancing years, it would 
 api)ear that we have a large field for selection of those cases supposed 
 suitable for boarding out ; perhaps half of all " those I'emaining at the 
 end of the year " coming under this statistical heading, and not only 
 remaining so at the end of the year, but actually being so on admission 
 to our asylums, and yet how difficult to make a selection of the patients 
 and the domestic care which may be suitable. It must always be 
 remembered, that in a colony like ours there are many difficulties in the 
 way of adopting a plan like this, where cost, suitable guardianship, and 
 a system of constant supervision are the three elements in its formation. 
 
 First, then, let us look at the cost. Are we in Victoria likely to get 
 anyone to undertake the care of a lunatic, and maintain him as a 
 member of his own famil}^, under the strict supervision of some central 
 authority, for the small sum of say twelve shillings a week, which is the 
 asylum rate of maintenance 1 Next, have we the class of cottcigers, in 
 easily accessible districts, who would be suitable guardians? And 
 lastly, have we that means of supervision which is so necessary? To 
 all of these we would be apt to answer No, and neither are we likely 
 to have, except at a most exorbitant cost, at a risk that guardianship 
 might take to farming a patient as merchandise, without further regard, 
 and at the expense of supervision which must be newly created. The 
 recjuirements are such that it would be difficult to find guardians 
 pre[)ared to give efficient and kindly control ; yet we ought not to 
 magnify these difficulties, as, if once we started in earnest, they might 
 bi; more apparent than real, as was found to l»e the case in Scotland. 
 
 It would be well here to consider the classes of patients apparently 
 suitable for treatment in private dwellings ; and they are fairly numerous 
 in our institutions, and comj)rise such as may have come from foreign 
 countries, those who have outlived their relations, or been long since 
 lost sight of — even deliberately deserted and shunned, from apprehen-
 
 nousixr; ok the insani<; in victokia. 901 
 
 sions lest res{)onsil)ility of niainten:ince be incurred, or tVom roluctanee 
 that their acquaintanceship with an inmate of a lunatic asylum should 
 become known. 
 
 Uranting then that we have a large percentage of the so-called 
 chronic harmless insane, the points to be sought for in the guardians are 
 that — (a) Relatives are to be guardians where possible and suitable ; 
 (h) the religion of the guardian to be the same as that of the jiatient ; 
 (c) strangers, when guardians, to be of the same social level as, certainly 
 not a lower level than, the patient, wdio is to be treated as a member of 
 the family, and emjjloyed as such ; and ((/) that all guardians must 
 submit to constant supervision of their houses by a central authority, 
 whose business it will be to see that these houses are moderately 
 attractive, and not in sparsely ])opulated districts ; also to carefully 
 supervise the arrangements for the boarding of young females ; to note 
 the possibility of an insuthcient food-sup})ly : to see that all are bedded 
 properly, and not undidy worked for profit, or looked upon merely as 
 paying objects. As regards the cost where relatives are guardians, we 
 need only defray the actual amount of maintenance ; but when aliens are 
 employed, something in addition, as an inducement, must be ofFei-ed, 
 subject always to the proviso, that in no case ought the cost to be 
 gi'eater than that of asylum maintenance. If, then, we in Victoria are 
 to adopt this i)lan, we must start cautiously and on a small scale, by 
 asking each medical superintendent at first to arrange himself for his 
 own jjatients on certain broad lines, reporting at once to the Inspector 
 of Asylums, then to visit and report (quarterly on each patient, the 
 inspector also visiting when in the district. As the cases would be in 
 the immediate district of each superintendent, I do not think that for 
 some time the supervision so arranged would be too heavy a duty ; but 
 as cases increased, and the system became more general, some one, such 
 as a deputy commissioner, might be ap[)ointed to assist generally in the 
 inspection of our asylums, but have this duty as a special one. 
 
 It might, perhaps, be thought that this treatment in private dwellings 
 might kill our present useful system of letting patients out on trial with 
 their friends ; but I think a statutory declaration as to abilit}' to pay, 
 and how much, being made prior to admission to the asylum, would 
 avoid imposition. If some such system were adopted, I think we ought 
 to use our endeavours to relieve ourselves of some of our overci-owding 
 by entering heartily into the scheme ; and without raising objections, 
 carefully study the difficulties that may stand in the way, with the view 
 of either dissijjating them, or distinctly demonstrating the unsuitability 
 of our colonial life to such a method of caring for and treating the 
 harmless insane in a manner not more expensive to the State than 
 institutional control, and in such num1)ers as to make it worth the 
 trouble involved. 
 
 Having thus far given sufficient material for discussion, 1 would like 
 to lay before you something of what has been done in Scotland on this 
 method of treating the insane in private dwellings, and this I am able to 
 do through the kindness of Dr. Sibbald, of the Scotch Lunacy Board ; 
 Dr. (Jlouston, the Physician Superintendent of the Koyal Edinburgh 
 Asylum, Morningside ; and my old friend, Dr. Turnbull, of the Fife and 
 Kinro.ss Asylum ; all of whom have for some time been liberally 
 Bup2)lying me with inforn)ation.
 
 902 INTERCOLOXIAL MEDICAL COXGRESS OF AUSTKALASIA. 
 
 Mainly then, Scotland de}iend.s ou the Poor Law, through its officers, 
 to provide the guardians and the medical attendant, the Lunacy Board 
 carrying out the inspection by Deputy Commissioners. Each asylum 
 has its district, and each district its \;u-ious jiarishes, with their 
 Inspectors of Pooi-, and Union Doctors, who have to attend and provide 
 physic for all paupers within a radius of from a few miles in some places 
 up tea great many in others; and for each quarterly visit to, and rejjort 
 on, a boarded-out lunatic, he receives the sum of two shillings and six- 
 pence, in addition to the small annual salary for A\hich he contracts to 
 serve the Guardians of his Union. 
 
 These officers of the Poor Law Board receive a code of insti'uctions 
 from the Lunacy Board, setting forth the procedure for placing pauper 
 lunatics iu private dwellings under its sanction, and the conditions on 
 which sanction is granted, from which it will be seen that the Poor 
 Insjjector has a great deal to do, and yet with his help, Superintendtnts 
 of asylums have been able to vigorously put in practice a system of relief 
 to their overcrowding. 
 
 " Procedure for jAacinij Pauper Lu'aatics in Private hweJlviajs under 
 Sanctiort of the Board, and Conditions on luhich their Pesideuce- 
 in Private Dioe/llnc/s is Sanctioned. 
 
 " Pauper lunatics who do not i-equire asylum treatment may, on 
 becoming chargeable, remain in private dwellings under suitable guard- 
 ianship, with the sanction of the Board, which is granted on the 
 application of the Ins|)ector of Pooi-, accompanied by two medical 
 certificates according to Form D. 
 
 "Or they may be removed from establishments for the insane, and be 
 placed under suitaljle guardianship in |)rivHte dwellings under one or 
 other of the procedures described. In these latter cases, the application 
 for the Board's sanction (which is only necessary when the patient 
 remains a pauper) must be made in the manner desci'ibed in Rule 16, 
 after the j)atient has been discharged, and need not l)e accomi)anied by 
 any medical certificate unless such be sjiecially called for. 
 
 " Not more than one pau{)er lunatic can be legally j)laced in any 
 })rivate dwelling, unless the occupier of such dwelling hold a special 
 license from the Board. This license is granted on a{)plication by 
 Inspector of Poor, in accordance with the regulations laid down. 
 
 '• The sanctions granted by the Board for the reception of lunatics 
 into private dwellings, whether singly, or in numbers not exceeding four, 
 are valid only for the particular house, and the particular guardian 
 named in the application; and no Insjiector of Poor shall remove any 
 pauper lunatic so sanctioned to any other dwelling, or shall change his 
 guardian, or make any alteration in the nature or amount of the 
 parochial allowance, without intimating the facts to the Geneial Board. 
 
 " Pauper lunatics sanctioned by the Board to live in private dwellings 
 must be comfortal)ly housed, sufficiently fed and clothed, and otherwise 
 suitably provided for. They must Ije placed under thechai-ge of properly 
 remunerated, efficient, and trustworthy guardians, whose duty it shall 
 l>e to carry carefully out the Board's directions to persons receiving 
 pauper patients. 
 
 *' Every pauper lunatic, whose residence in any private dwelling has 
 been sanctioned by the Board, must be visited within three weeks after 
 
 1
 
 HOUSING OF THE INSAXK IN VICTORIA. 903 
 
 bucli sanction lias been giiinted, and at least once every three months 
 thereafter, b}- a medical man appointed to perforin that duty by the 
 Parochial Board of the parish to which the lunatic is chargeable, unless 
 the General Board shall, on special application by the Inspector of Poor, 
 otherwise regulate such visits; and the medical officer shall, at every 
 such visit, enter in tiie visiting-book for pauper patients in private 
 dwellings, which shall be kept in the house in which the lunatic resides, 
 a report of the mental and l)odily condition in which he found the 
 lunatic, with any suggestions or recommendations for improving the 
 condition of the patient which he may think desirable ; and any medical 
 person who shall make any such entry without having visited the 
 patient within seven days previous to such entry, is liable in a penalty 
 not exceeding ten pounds for every such oftence. 
 
 " Suggestions or recommendations for improving a patient's condition, 
 recorded Viy the medical officer, shall be at once reported V)y him to the 
 Inspector of Poor of the jtarish to which the lunatic is chargeable, who 
 shall either see that they receive innnediate effect, or shall report to the 
 (reneral Board his reasons for not carrying them out. 
 
 " It shall be the duty of the Inspector of Poor of the parish to which 
 an out-door lunatic is chargeable to visit the patient at least twice a 
 year, and to record the visit on its proper page in the book in wliich the 
 medical officer's visits are recorded; and in the event of the lunatic 
 residing beyond his jiarish of settlement, it shall be the duty of the 
 Inspector of that parish, if he does not visit the patient himself, to 
 jirovide for his being visited by the Inspector of Poor of the parish of 
 residence; in which case it shall be the duty of the Inspector of the 
 Jiarish of settlement to assure himself that these visits are regularly 
 made and recorded. 
 
 "If a pauper lunatic under the sanction of the Board is regarded by 
 them foi" any reason as untit for residence in a ])rivate dwelling ; or if 
 any of the conditions as to accommodation, guaidiansliip, treatment, or 
 visitation is not observed, the Boai'd may withdraw their sanction, and 
 require the patient's removal to an asylum ; and any paujter lunatic who 
 has been removed from an asylum, and boarded out, shall be sent back 
 to it within fourteen days after the Inspector of Poor receives the order 
 of the General Board to that eftect. 
 
 " No pauper lunatic residing in any private dwelling shall be removed 
 from the i)oor-roll unless by a minute of the Parochial Board granted at 
 a duly constituted meeting, and unless sufficient evidence be produced 
 to the Parochial Board that his care and treatment will be provided for 
 in a manner which they regard as satisfactory. When a pauper lunatic 
 who has been lemoved from an asylum is ordered by the General Board 
 to be sent back, the patient's relatives cannot lemove his name from the 
 poor-roll without tlie Board's sanction. 
 
 " When a jtauper lunatic in a private dwelling ceases to l)e chargeable 
 as an out-door jtatient, by removal from the poor-roll, or recovery, or 
 removal to an establishment for lunatics, or death, intimation thereof 
 must l)e given to the General Board within fourteen days. A notice of 
 recovery must be accom})anied l>y a certificate of sanity, and in cases of 
 death, the cause iihould be stated. Kemoval to an asylum must be 
 effected by application for a Sherifi's order on Form A.
 
 904 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 " Parliamentarii Grant in aid of the Cost of Maintenance of Paxq^er 
 
 Lunatics. 
 
 *' No claim for participation in the Pai'liamentary grant in aid of the 
 cost of )naintenance of pauper lunatics is adniitted, unless the General 
 Board give a certificate that the patient has been necessarily detained, and 
 properly cared for, in the place in which he svas maintained during the 
 period for wliich the claim is made. 
 
 " A claim made on account of a pauper lunatic maintained in an 
 establishment for the insane, will be invalidated : — 
 
 " (1) If there is reason to believe that his mental or bodily health 
 is injuriously affected by residence in the institution in 
 which he is detained. 
 
 " (2) If his condition renders him unsuitable for treatment in the 
 particular class of institution in which he is placed. 
 
 " (3) If the Board shall be of opinion that he is detained in an 
 establishment for the insane, notwithstanding that he 
 could be satisfactorily provided for in a private dwelling, 
 were reasonable efforts to find a proper guardian made by 
 the Inspector of Poor, and adequate payment offered by 
 the Parochial Board. 
 
 " Claims made on account of paujjer lunatics maintained in private 
 dwellings under the Board's sanction, will be invalidated, in the event 
 of any one of the following conditions not being complied with : — 
 
 " (1) They shall be comfortably housed, clothed, and fed. 
 
 " (2) They shall be in every way as well treated as other members 
 
 of the household. 
 " (3) They shall receive such personal care and attendance as will 
 
 ensure tlieir comfort and safety. 
 
 " (4) Every reasonable effort shall be made to improve their 
 condition, and contribute to their happiness. 
 
 " (5) The Inspector of Poor shall make two visits yearly to each 
 patient, and shall record them in the A-isiting book, as 
 prescribed by the Board. 
 
 " (G) A Medical Officer, appointed by the Parochial Board, shall 
 make four visits yearl}' to each patient, and shall recoid 
 them in the visiting book, as prescribed by the Board." 
 
 Motives of economy help the Parochial Boards to regard the system 
 Avith favour, since the average expense in boarding out pauper lunatics 
 is less than that required for their maintenance in asylums, and the cost 
 of asylum acconnnodation is altogether avoided. From this it will be 
 seen that lunacy and pauperism go hand in hand, the laws in each being 
 to provide for care and treatment ; lunacy producing pauperism, and 
 pauperism lunacy. 
 
 Concerning tlie guardians, the relatives are naturally preferred where 
 suitable, but strangers are found to do better in a laige proportion of the 
 cases. 
 
 To sum up, the general views in Scotland are, that " no one questions 
 tlie value of boarding out i)au])cr })atients, from suitable cases, suitable
 
 HOUSING OF Tin-: IXSAXK IN VICTORIA. 905 
 
 guardians, and proper supervision," bnt tliat such a combination is fre- 
 quently difficult to obtain, and that it is only a poor-house where a profit 
 could be made out of six or seven shillings a week, if the patients were 
 not neglected. It must also be remembered that there is no royal road 
 to the selection of the patients, as many likely ones prove unsuitable 
 soon after going out, and somewhat unlikely ones agreeably disappoint 
 us, yet the question is mainly a tinancial one, though mental improve- 
 ment occurs through its adoption, as it does in our existing probationary 
 system of trial leave. 
 
 " It has been frequently pointed out in the reports of the Board, that 
 the number of persons in a community who are treated as lunatics 
 d«;pends on various circumstances. Among the most im]>ortant are the 
 stage of develoi)ment in civilisation to wliich the community has 
 attained, the density of the population, the facilities which exist for the 
 treatment of persons as lunatics, and the relation of insanity to the 
 system of relief of the poor. From the complex operation of such 
 causes, the proportion of pei'sons treated as lunatics has been materially 
 altered in most of the Scotch counties since the enactment of the present 
 lunacy law. In the county of Suthei'land, for example, the number 
 of persons in establishments for the insane was in 1(^59 equivalent to 
 only 4') j)er 100,000 of the ])oi)ulation, and it was in 1886 equivalent to 
 27o per 100,000. In the county of Ai-gyle it was only 95 per 100,000 
 in 1859, and in 1887 it was 355 per 100,000. The changes in these 
 counties are no doubt chiefly due (1) to the jirovision of more con- 
 veniently-situated asylum accommodation ; and (2) to the operation of 
 the poor-law, in combination with the Government gi'ant in aid of 
 the maintenance of i)auper lunatics. Theie has been an increase in the 
 proportion to po{)u]ation of pauper lunatics in asylums in every county, 
 except in Midlothian, the increase for the whole of Scotland being 
 equivalent to a rise from 102 to 184 ])er 100,000 of the population. It 
 is lemarkable that, according to the figures in the table, there was in 
 the case of the county of Midlothian, instead of an increase, a fall per 
 100,000 from 185 to 173. Had the whole of Scotland theiefore been in 
 the ])o.sition of Midlothian, the total figvues would, as regards the 
 statistics i-elating to establishments for the insane, have given the 
 appearance of a decrease in the amount of pauper lunacy in proportion 
 to pojmlation, instead of giving, as they actually do, an a|)j)earance of a 
 large increase. It is remarkable also that the ])roportion which 
 Scotland as a whole has now reached should be almost exactly what 
 was shown Viy Midlothian at the beginning of the period to which our 
 statistics refer. This almost seems to justify the assertion that pauper 
 lunacy in Midlothian had, at the conunencement of the period, reached 
 or rather slightly exceeded what, under the jiresent social conditions, is 
 its normal amount. What may be maintained without hesitation is, 
 that if there had been, as is often alleged, an increased production 
 ■of insanity in the connnunity, the additional facilities furnished by the 
 law for })ioviding asylum accommoilation in all jiarts of the country 
 would have led to an increase in the ])roportion of the community 
 detained as jiaujjer lunatics in asylums in ^Midlothian not less than 
 •elsewhere. 
 
 " It will be observed that in these )emarks only those j)auj)er lunatics 
 have been dealt with who are inmates of e.stablishments, and that no
 
 906 INTEKCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 account has been taken of those resident in private dwellings. The 
 reason for this is that, in dealing with the question of the prevalence of 
 insanity in any portion of the community, there are certain advantages 
 in restricting our consideration to those who require detention. One 
 advantage is the fact that the persons dealt with are believed to require 
 detention involves the inti'oduction of a practical element, which gives a 
 degree of definiteness to their condition. The grounds which are held 
 to justify a certiticate of lunacy must always be more or less arbitrarily 
 determined ; but their arbitrary character is to some extent diminished 
 when it is necessary at the same time to determine that the patient 
 cannot be satisfactorily dealt with out of an asylum. The I'espon- 
 sibilities and obligations which are involved in sending a patient to an 
 asylum are calculated to exercise a steadying effect on the action of 
 those who give the necessaiy certificates, and to inci^ease tlie soundness 
 of statistics which are based upon them. 
 
 " But, though the class of paupers in private dwellings who are dealt 
 Avith as lunatics is perhaps more loosely defined than the class in 
 asylums, a glance at their position in the county of Midlothian is both 
 interesting and instructive. And here it may be well to allude to 
 a misapprehension which seems sometimes to exist. It appears some- 
 times to be supposed that the providing for pavqjer lunatics in private 
 dwellings in Scotland is a result of recent administration. The fact is, 
 that the number of persons provided for in this way does not bear 
 so large a proportion to the population of the country now as it did 
 when the present lunacy system came into operation. The number has 
 indeed increased from 1877 in the year 1859 to 2140 in 1887 ; but 
 this is more than 300 short of what would have been accounted for by 
 the increased population of the country. 
 
 " The position of pauj^er patients in private dwellings has, however, 
 been altered in important respects by the administration of the Board. 
 During the earlier years the eftbrts of the Board were directed mainly 
 to the sending to asylums of patients who were unsuitable for treat- 
 ment in private dwellings, and to the ameloriation of the condition of 
 those who, though suitable for such treatment, were inadequately 
 provided for. In pursuance of this coui'se, the number of pauper 
 lunatics in private dwellings was considerably diminished. But it was 
 presented from diminishing so much as it would otherwise have done 
 by the fact that a large number of persons pi'eviously unreported, Avho 
 were suitable for care in private dwellings, were during the same 
 period brought under the supei-vision of the Board. It was recognised 
 by the Board, from an early period of their administration, that 
 the providing foi' a certain number of pauper lunatics in pri-\ate 
 dwellings was one of the elements of a pi'oper system of lunacy 
 administration. The Board have not, it will be seen, introduced a 
 new mode of providing for pauper lunatics. They have only 
 f'ndeavoured to place under pi-oper regulation a mode of provision 
 which has always existed in Scotland, and which, indeed, has always 
 existed in every country. The ditt'erence between the system which 
 they have been enabled to establish and that of other countries, consists 
 in the fact tliat the patients so provided for are under the supervision 
 of a central authority, which re(|uires to be satisfied that they are 
 suitable for such treatment, and that they will receive it in a satis-
 
 IIOUSIXG OF TIIK IN'SAXK I\ VICTORIA. 
 
 907 
 
 t':ictory iii.-inner ; while, in most otlier countries, those who are so 
 provided for may be said to be merely left outside of the general lunacy 
 administi'ation. 
 
 "In order to understand fully the present position of the matter in 
 Seotland, it is necessary howe\"er, to allude to another important change 
 which has been brought about under the Board's administration. Tlie 
 position of the patients has been altered in a way which is chietly 
 indicated in the statistics of the Board, by the decrease m the number 
 of patients i-esident with relatives, and the increase in the number 
 resident with strangers. ^V few words are necessary to explain the 
 significance of this change. The extent of the change is shown in the 
 following statement : — 
 
 ActiKiI Xniiiher of Panprr Lunatic' in I'riiatf Direllinrii 
 
 Midlothian 
 Scotlantl 
 
 Midlotbiau 
 Scotland 
 
 \ IssT 
 
 f I85;i 
 
 i 18S7 
 
 With 
 
 Kelatives. 
 
 64 
 
 4(i 
 
 148-2 
 
 !t72 
 
 Witli Sfcrangoif 
 and Alone.* 
 
 ISft 
 
 395 
 
 1U)8 
 
 Proportionf! per 100,0(10 of Population. 
 
 1859 
 
 1887 
 1859 
 1887 
 
 With 
 Relatives. 
 '24 
 11 
 49 
 25 
 
 With Strangers 
 and Alone.* 
 12 
 44 
 13 
 30 . 
 
 Totals. 
 
 96 
 232 
 
 1877 
 2140 
 
 Totals. 
 
 36 
 55 
 62 
 55 
 
 " As has been stated in the Keports of the Board, the decrease in 
 the number of patients resident with relati^'es is not regarded as being 
 in itself a desirable change. The view of the Board has always been 
 that, where asylum treatment does not seem to l)e required, the patients 
 should be enabled to live as much as possible " in a way little removed 
 in its character from the mode of life which the}- would have led had 
 they not suffered from insanity." + For this purpose it is obviously 
 desirable that they should live with relatives, rather than with strangers. 
 Two reasons have led to an increase in the number of those under the 
 charge of strangers, and to a decrease in the number of those living 
 with relatives. One reason is, that relatives are not so frequently 
 Milling as they once wei*e, to undertake the care of the patients ; and 
 another is, that it often happens that the relati^es Avho would receive 
 them are unable, from unfitness either in tliemseh es or in their circum- 
 stances, to furnish such treatment and accommodation as are necessary 
 for the welfare of the patients. Tt is not given to exeiff one to have 
 those personal qualities which are recjuired in a good guardian of the 
 insane, and some who would, from family relationship, naturally be 
 tlieir guardians, are specially deficient in such qualities. Many of the 
 cases which, in the earlier years of the Board's administration, were 
 the cause of difficulty and anxiety, were tho.se in wliich patients were 
 
 * It is rarely, and only in very special circumstances, that a pauper lunatic is 
 allowed to live alone. There have, however, l)een a few such cases, and these have 
 heen tabulated along with those resident with >trangers. Their nuniher being so- 
 small, it has been thought unnecessary to separate them. 
 
 t Twenty-seventh Annual Eeport of the Board, page xii.
 
 ■^08 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 under the charge of incapable mothers, or other near relatives. Tt will 
 be easily imderstood, that the amelioration of the condition of such 
 patients while with their relatives is difficult, and often impossible, and 
 the removal of the patients to other care, against the wish of the 
 relatives is often found to be impracticable. A considerable number of 
 such removals have however been effected. But tlie chief cause of the 
 increase in tlie number of patients resident with strangers is, that the 
 circumstances of their relatives often make it impossil^le for them to 
 furnish the kind of accommodation and treatment which the patients 
 require. This remark applies especially to the case of pauper lunatics 
 belonging to urban parishes, and it is among these patients that the 
 great proportion of those now resident with strangers are found. In 
 urban districts, the majority of the relatives of pauper lunatics are found 
 in the heart of great towns, and such localities are unsuitable for a 
 lai-ge proportion of the patients. Due supervision, an adequate amount 
 of open air and exercise, and the provision of suitable occupation 
 cannot be obtained there ; and in such circumstances, the only 
 alternatives are either to keep the patients in asylums, or to place 
 tliem in sviitable localities with strangers." 
 
 A general discussion by those present took place, resulting in the 
 •condemnation of any huge system of cottage asylums being adopted, as 
 has been foreshadowed by the Yictoiian Government, the plan most 
 highly thought of being that of a combination of the block and cottage, 
 ■with a detached hospital for acute cases where all appliances for treat- 
 ment should be at hand. The boarding out of tlie harmless insane was 
 approved of, but as a system, it was feared that the conditions of 
 colonial life would militate against any marked success in such numbers 
 -as to warrant the large expenditure which would certainly be necessary. 
 
 Dr. Beattie Smith, in reply, remarked that he was pleased that his 
 views had met with such general acceptation, and urged that a willing 
 and energetic spirit be brought to bear on the subject of treatment in 
 private dwellings for the poorer classes, as a means of relieving oui- 
 overcrowding, if for nothing else; and that, although America had found 
 it " impossible to secure reliable and proper persons to take charge of 
 patients, except at an impracticable expense," Victoria ought to boldly 
 «trike out for herself, and demonstrate her own capabilities or tlie 
 revei'se in tliis dii-ection, so as to at once settle vipon a definite plan of 
 future extension of accommodation. 
 
 Tlie President, Dr. Manning, and several members of the Section, 
 accompanied +)y the Hon. Secretary, A'isited the Metropolitan Asylum at 
 Kew. After a careful inspection of the buildings, general arrange- 
 ments, and gi'ounds, the opinion was openly expressed that the institu- 
 tion had been markedly improved within the past few years, and 
 I'etlected nothing but praise on the officers concerned. 
 
 The separate building for idiots received a large share of attention, 
 as the sy,stem of treatment therein is entirely a new feature in 
 Australian asylums, tlie methods employed being a distinct advance on 
 those used in any of tlie other colonies. 
 
 Other memljers of Congress visited tlie asylums, and were pleased 
 ■with tlieir reception and what they saw.
 
 SECTION OF PHAEMACOLOGY. 
 
 PRESIDENT'S ADDRESS. 
 
 By Barox Sill Ferdinand von Mlklleu, F.R.S., K.C.M.Ct., Pli.D. 
 
 Govcrument Botanist of Victoria. 
 
 Gentlemen, — Through the generous sentiments of the President and 
 the Councillors of the Congress, it devolves on me now to open the 
 pioceedings in the section for Pharmacology, or what may be regarded 
 as equivalent for Therapeutics, Materia INIedica and Pharmacy unitedly, 
 a highly honourable task indeed, on which however I enter with the 
 greatest diffidence. 
 
 Though in Pathology our knowledge be ever so accurate for diagnosis 
 and prognosis of the characteristics and course of diseases ; though in 
 Physiology our cognisance of vital processes be ever so intimate of 
 normal conditions, and contrastingly of morbid changes, even if all 
 this be ever so well supported by Chemistry and Microscopology in 
 the minutest details ; though Surgery be ever so dexterous and 
 experienced, guided by Anatomy even in most subtle particularities ; 
 yet treatment may fail, if through Therapeutics cannot be brought to 
 bear the most judicious selection of renaedies, and if through Pharmacy 
 the genuineness and purity of medicinal substances cannot be secured. 
 Therapy in its widest sense is constantly called into requisition by 
 all other branches of applied medicine, to yield the weapons to be 
 wielded for subduing human sufferings from whatever ailment. Through 
 Therapeutics the treatment in most cases assumes its practical bearing, 
 or at all events receives powerful aid for final curative accomplishment. 
 Indeed, Medicine gains therewith mainly its expression of reality, 
 and renders therewith culminating efforts. What the Aeneis said 
 so long ago — Scire potestates herharuni usumque medendi, will indeed 
 liold good for all times. 
 
 Being taken back cursorily in our reflections to the dawning of our 
 [)rofession, we may also here with veneration approach the founder, 
 particularly in its pathologic aspects, of scientific medicine. Hij»pocrates, 
 much more than 2000 years ago, employed already in a rational method 
 some of the very remedies which even under the same designation 
 still hold a place in therapeutic estimation at the present day ; the
 
 910 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Hellebore, Mallow, Rue, Euphorbia, Soapwort, Sumach, Chio-Terebinth, 
 Ai-istolochia, Pomegranate, Fennel, Chanioniile, Mint, Pennyroyal, 
 Thyme, Iris and Squill were among his medicinal treasures ; and the 
 Mvrtle, used by this descendant of the Asclepiades, seems to have offered 
 to him already an antise})tic, closely akin to that of our Eucalyptus trees 
 here. 
 
 I will not detain you with explicit ol)servations on the much larger 
 display of vegetable medicines used by Theophrastos, Dioskorides, Galenus, 
 Pliuius and others among the leading ancient physicians, though many 
 plants were ordered then as they are prescribed now ; and — what is 
 fascinating to contemplate — thus stood the test of all ages. 
 
 lu the able surgical address given by our honoured President at the 
 Adelaide Congress, he pointed especially to the two greatest achieve- 
 ments in recent advances of medicine — those of anjesthetic applications, 
 and antiseptic treatments — both originating in the latter half of this 
 century or nearly so, and both pertaining more jjarticularly to that 
 branch of science, represented by the Section in which we are now 
 assembled here. Indeed, only through these auxiliaries new courageous 
 yet justifiable operations came within the range of possibility, and 
 sui'gery could thus make the extraordinarily rapid strides during the 
 last few decades towards its culminating development in the present 
 day. Therapy, again, is indebted for this vast extension of its scope 
 chiefly to organic chemistry and microscopic biology. AVhat a splendid 
 co-o])eration of men of genius ! What a suljlime triumph of united 
 mental force for the gTandest of worldly purposes ! For general 
 medicine and almost equal in importance to the two agencies mentioned. 
 Therapy has also yielded more lately— as you are all aware — chemical 
 concentration, and therewith largely the means of hypodermic injection 
 for multifarious administration ; these are two factors in pathologic 
 calculations, to gain results of almost unerring exactitude. Perhaps I 
 should not have alluded to all this, had we not to invoke these methods 
 for novel experiments, to be instituted also here with Australian 
 material. Armed with these i-equisites, we obtain facilities for watching 
 effects, least disturbed by counteractions, on the living organism, and 
 we are enabled to draw logical conclusions therefrom, applicable in 
 professional exercise subsequently. Thus the questions will become 
 gradually solved, how far each medicinal substance, chemically definable, 
 affects the constituents, either singly or connectedly, of any particular 
 organs of the living body, and how far morbid elements, invading or 
 developed, would really be singled out, to be seized in each instance for 
 restoration of normality. 
 
 What chemistry thus has done in comparatively recent times for 
 Therapy, may be instanced by two cardinal remedies, Ijoth undoubtedly
 
 PRESIDEXt's address — SECTION OF PHARMACOLOGY. 911 
 
 destined to hold a permanent place in medicine. From so 
 unpromising a material as coal-tar, were not only evolved the 
 uiisurpassably brilliant colours of aniline, and the marvellous saccha- 
 rine (important already as a remedy in vesical affections), but it also , 
 yielded phenol, one of the most powerful antiseptics, now universally 
 applied in surgical and hygienic Therapy. Phenol again stands in close 
 chemical relation to salicylic acid, in which we possess one of the best 
 among recent offers to the materia medica, especially for internal use ; 
 but both, in reality, are among the wondrous legacies from a former 
 world of vegetation, which, though lifeless in its remnants, is rej)lete 
 still with iucalculaV)le riches even for us in medicine. 
 
 Etherisation began through American thought in 1846. Chloroforni, 
 as another of the glorious gifts from chemical research, came into use 
 almost simultaneously ; but Phenol, although isolated as long ago as 
 1834, by Runge, was rendered available for Phenolisation only in 1801, 
 through the ingenuity of a British surgeon ; and Chloral, though among 
 the earlier discoveries of Liebig, we know medicinally only since twenty 
 years, so that many of us here have utiliseil these important aniesthetics, 
 antiseptics antl hypnotics from the commencement. 
 
 With vastly improved microscopic instruments, which 200 years ago 
 would have charmed and amazed a medical worker in minutiis like 
 Loeuvenhoek, were made those significant revelations particularly in our 
 -days, through which so largely si)eciric forms of diseases could biologically 
 be defined and evolutionarily traced. Although these startling observa- 
 tions pertain mainly to the pathologic dominion of medicine, yet thereby 
 also Therapy stepped into a new phase of its offerings, inasmuch as the 
 great principle of inoculation can now be widely extended, but — let us 
 hope — guardedly, to be always restricted within due bounds. The 
 continuous application of the microscope is now-a-days also indispensable 
 for therapeutic and pharmaceutic research, t(> study organologically and 
 histologically the sources as well as the products and educts of j)lant-life 
 and whatever else lies within the cyclus of therapeutics, not only for 
 an accurate knowledge of what — thus far — we do possess in the materia 
 medica, but also to lead us on comprehensively in rational comparisons 
 to extended and independent researches, particularly so in a country 
 almost new, like ours. 
 
 Before I allude to what may most interest this distinguished assembly, 
 to Australian data, some, I trust, of originality — it seems preferable to 
 -single out a few of the most modern gains, which promise to be of 
 permanency for therapeutics. The Cola-seed of Western Africa, 
 although described by Caspar Bauhin fully 300 years ago, while he was 
 Professor of Medicine in Basle, has only now entered into the materia 
 medica; it allays thirst like Coca-leaves, and thus also should prove
 
 912 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 acceptable to diabetic patients ; but like the Guaraua-PauUinia from 
 South America, it affords also copiously Caffeine, and may therefore be 
 entitled to notice for preparing a refreshing and mildly stimulating 
 beverage ; indeed the Cola-paste, like that of Guarana, has recently 
 become an article of commerce. The Pilocarpus may now be regarded 
 as a fairly established and welcome acquisition, more so still as its 
 active principles, an oil and an alkaloid, can readily be isolated ; the 
 sialagogue action of the plant seems not yet sufficiently appreciated, 
 and may point to some value in diphtheria. Strange to say, a similar 
 property has lately been ascribed even to our ordinary garden tulip; 
 while the lovely lil}' of the valley of our home-countries, which we 
 easily could naturalise in forest-glens, claims also admission now, 
 supported by high authorities, among them Dujardin-Beaumetz. Yet, 
 as shown by Labbee and mentioned by the great therapeutist just 
 named, Matthioli, the physician of the Emperor Maximilian II, more than 
 300 years ago, insisted already on its value as a cardiac sedative; while 
 See and other physicians now place Convallaria next to Digitalis, with 
 tlie advantage of being a comparatively harmless substitute, indicated as 
 particularly eligible in mitral diseases with hydrops, its efficacy 
 depending on two glucosides. As regards Melbourne literature, a brief 
 reference to the Convallaria occurs already in the edition of 1885 of 
 " Select Plants for Industrial Culture and Naturalisation." Let us lay 
 stress on this resuscitation of one of the best known of all plants for 
 medicine, to show how even the most valuable may sink undeservedly 
 into oblivion. If Strophanthus should fulfil the expectations set on it 
 as a cardiac tonic, then a clue would be given to the probable medicinal 
 worth of a large sei'ies of other apocynaceous plants, some occurring 
 also in this part of the world ; and the maxim, that natural affinity 
 often indicates similar medicinal properties, would be brought to a 
 further test. Quite in a different direction suddenly turns up a plant, 
 as familiar to us as the tulip or lily of the valley, one from which we 
 would least expect any utility for strictly medicinal purposes, namely, 
 the Fagopyrum, because two practitioners in the United States, Dr. A. 
 M. Duncan and subsequently Dr. P. S. Root, have demonstrated that 
 the groats-grain of Fagopyrum in cake-form is safely available for 
 diabetes-patients, notwithstanding the starchy but evidently peculiar 
 contents of the grain, the use of which does not increase the glycosuria. 
 Such a fact is again significant as showing how an article, familiar 
 for centuries as a food, may escape therapeutic recognition for lengthened 
 periods. 
 
 Passing on to a different turn in our subject, we may ask, what future 
 is before the Sulphonal 1 It was discovered and recently introduced by 
 Professors Kast and Robbast, and subsequently more particularly by
 
 PUESIDKXT's address — SECTION OF PHAnMACOLOGV. 913 
 
 Professors Schwalbe, Guttmann and Otto as a hypnotic free of danger 
 and signally effectual, when the agrypnia arises from purely nervous 
 irritability, no unjileasant subsequent effects being observed; it is further 
 claimed for this new remedy, that it produces a normal sleep, and acts even 
 after long use of narcotics, is tasteless and devoid of odour, affects neither 
 the digestive nor the respiratory organs, according to a connected i-eport 
 by Dr. Nevinny. Should all this be attainable in a majority of cases only, 
 almost a kind of panacea would be secured for an endless number of 
 sufferers. The Sulphonal is a solid combination of sulphurous oxide, 
 with a certain proportion of carbon. It seems preferable to either 
 Amylene-hydrate or Paraldehyde, with an action more prolonged than 
 that of hj'drate of chloral, and with this further advantage — so far as 
 we are hitherto aware — of causing no subsequent functional impairments. 
 Beyond the well recognised Amylene-hydrate and the Nitrite of Amyl, 
 various other chemical compounds of the Amyl-series seem forthcoming 
 for therapeutic purposes, some of a complexity, in the long array of their 
 chemical symbols, that only a thoroughly niatheniatic mind can grasp 
 their constitution ; but it is quite beyond the scope of this address to 
 enter into particulars of this promising subject. 
 
 But here it might suggestively l)e also asked, could not some other 
 safe and controlltible means be devised, to lower the bodily temperature 
 in all sorts of fever, and perhaps also in insomnia, such slight and 
 cautious cooling to extend particularly towards the nervous centres. 
 Curious as mildly sleep-inducing is even a pleasant fruit, that of the 
 North-American Casimiroa, approaching in affinity to the Orange-tribe, 
 but yet foreign to our tables. 
 
 How for periods of great length the exact origin of some drugs may 
 remain obscure, is exemplified by the Chinese Stai'-Anise ; for it was not 
 many months ago, that Sir Joseph Hooker became enabled to identify 
 and describe the particular lUicium (I. verum), which furnished during 
 three centuries the star-anise, chiefly as a component of a cough-tea of 
 great popularity, particularly used on the continent of Europe. 
 
 It might reproachfully be asked, why with such a host of novel 
 plants to experiment on, as we possess in Australia, no ampler records 
 of their medicinal properties are extant. But for such purposes real 
 facilities are solely afforded in hospital-practice, and even there only 
 sparingly ; because practitioners are hardly justified in their ordinaiy 
 calls to enter on trials of this kind, unless by preliminary tests on 
 organisms, other than the human, a fair insight has been obtained of 
 what may be expected from any altogether new remedies ; and even 
 then, in experiments on higher vertebrata, conflicts may be encountered 
 with some small part of the community, should vivisection require 
 exceptionally to be resorted to. INIoreover such experiments are in their 
 
 2n
 
 914 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 results but too often negative, and then rather discouraging. In one 
 direction however wide progress has been made ; it is this : the diagnoses 
 of 9000 species of flowering plants of the fifth continent l^ecame 
 reliably fixed, whereby simultaneously a firm basis was gained for 
 applied science in all its ramifications, to trace with every accuracy the 
 vegetable products of Australia, including those for medical use, 
 to their specific sources. Perhaps this is not much ; still it should be 
 remembered, that our institutions all had to be built up in these young 
 colonies by the present generation or the one just passed away. More 
 perhaps might have been done, bvit individual life is too short for 
 progressive science. What however thus far has been accomplished, 
 may stimulate into extra efforts, which otherwise the practitioner in 
 his almost restless life, or the academic teacher in his already onerous 
 calling might not carry out connectedly nor extensively. But what an 
 immensity of working material is placed before us also for therapeutics 
 in a new continent, often with the charm of absolute novelty ! If we 
 are — so far — much in arrear as early colonisers of a continent, of which 
 however large portions are not yet even geographically opened up, 
 instances like the following should be remembered, that even the 
 highly powerful alkaloid Cytisin, first produced by Husemann and 
 Marne from the seeds of the common Laburnum-tree of gardens any- 
 where, has never yet entered any jiharmacopoeia, though in experiments 
 with animals its formidable action on the spinal cord and peripheric 
 motor-nerves was readily perceived, on incautious administration to the 
 extent of paralysis, the muscular system however remaining unaffected. 
 So it is also only through recent researches of Schmiedebei'g, that the 
 medicinal similarity of the common Oleander — through its glucosid 
 Neriin — to Digitalis became demonstrated ; and yet this handsome 
 garden-bush was mentioned already as poisonous in the remotest 
 records of antiquity. A commencement has however been made here. 
 Thanks to the erudite aptitude displayed in therapeutics by Dr. 
 Bancroft, both species of Duboisia, as you know, have, with some slight 
 aid of my own, been physiologically investigated, of which enquiry 
 advantage was promptly taken in ophthalmic surgery. Let me also 
 remind you here, that one of the best kinds of Catechu can be i)repared 
 from Australian wattle-bark. 
 
 We shall listen with particular interest to the information, which 
 will be offered by Dr. John Reid in regard to the active principle of an 
 Australian Spurge. The small herbaceous Euphorbia Drummondi, here 
 referred to, might almost be considered identical with the E. Chamaesyce 
 from the countries at the Mediterranean Sea, one well known already to 
 Dioskorides and Plinius, and specially referred to in their writings. A 
 congeneric herb E. })ilulifera, which from the warmer regions of Asia has
 
 PKK8IDKNt",S ADDKKSS — SKCTION OF PlIAiniACOLOGY. 915 
 
 establislietl itself iu Eastern Austrulia as a weed, seems to be iiiqcli 
 used as a domestic medicine in China; and, to judge from Australian 
 experiences, has evidently a sedative action on the respiratory organs. 
 having been particularly lauded in asthma. Thus a wide Held for 
 en([uiry is opened among these kinds of plants, numbering over half a 
 thousand sj)eeies, variously dispersed through the world, about twenty 
 occurring iu Australia, one of tliem big and cactus-like in the remotest 
 no)'th of Queensland. Without intending to anticipate discussion, T 
 may briefly observe, that in the original analysis of the highly acrid 
 " Eu])horl)ium " (obtained chiefly from North-African succulent shrubby 
 species) as instituted by Brandes, and also in some few subsequent 
 analyses, what may be the real effective constituent in the copious 
 resinous com])ound could chemically not be isolated. Possibly an oily 
 alkaloid may e.\ist in the milk-sap of Euphorbia, just as Lobelin in that 
 of Lobelia. Flueckiger has shown the Euphorbon to be closely allied to 
 Lactucerin or Lactucone. In all likelihood, a very similar princi})Ie 
 pervades more or less the niilk-sa}) of all Euphorbias, accompanied b}' 
 other modifying ingredients. 
 
 It would be tiresome ]>eriiaps, to enter into many technicalities ; 
 but this much I may be allowed to say, that four large orders of plants, 
 mainly or almost enti)-ely Australian — the Goodeniacese, Myoporinee, 
 Candolleaceae and Epacrideie, remain, as regards medicinal or even 
 simply chemical experiments, almost untouched. Whether the bitter 
 principle of some Goodeniacete is merely tonic, and whether the noxious 
 properties of some Myoporinaj have therapeutic .significance, remains 
 yet unascertained. .Special laboratory arrangements are needed, to 
 work with advantage on subjects like these, for systematising from a 
 physiologic jjoint of view, e.specially when on a new line of investigations 
 we are really without any guidance whatever. 
 
 The Bitterbark of Riverina and other tracts of East Australia, from 
 Alstonia constricta, is locally very celebrated as a tonic, and even as 
 efi'ectiial in ague; it was chemically examined in this City, quite 
 independently of the researches of Hesse. Oil of Santalum, officinal 
 only since some years, is obtainable in a remarkable proportion 
 from the fragrant wood of the West-Australian Santalum cygnorum. 
 
 Leguminosse— ordinarily the second largest of groups in the universal 
 empire of plants— stand for the purposes of medicinal research next to 
 Myrtaceie in importance, so far as Australia is concerned, but are in 
 their display of qualities much more varied. Though they yield somt- 
 plants of great moment for human sustenance and by far the largest 
 portion of alimentary pasture-herbs, yet they include in their wide 
 embrace also some of the most deadly, such as the Calabar-bean. The 
 uninitiated would be lulled into security also here, were he to meet 
 
 2n 2
 
 916 INTEKCOLONIAL MEDICAL COXGKESS OF AUSTRALASIA. 
 
 some of the dangei"ous yet innocent looking members of the order. 
 Erythrophlceum Guineense, one of the ordeal-trees of the wild and 
 superstitious hordes of Western Africa, was shown l>y a Melbourne 
 citizen, when he was in the field many years ago, to have almost 
 its counter-part in an Australian tree of wide tropical distribution 
 {E. Laboucherii), whereas quite lately the existence of a third species 
 (E. Fordii) in South-China has been demonstrated. In this genus we 
 have again an admirable example, how we can often argue from 
 systematic affinity also on the utilitarian properties of plants. Thus 
 the Erythrophlcein is likewise largely developed in the Australian tiee. 
 According to Lewin, a local anaesthesia, extending occasionally to the 
 length of two days, may be produced by it. Some melancholy interest 
 attaches to our Erytlirophlreum, because it was the ill-fated Dr. 
 Leichhardt, whose place of perishing is not even yet known, who 
 through his first glorious expedition along the northern ])ortion of the 
 Australian Continent, brought it as " Leguminous Ironbark-tree " under 
 notice, not however suspecting its medicinal significance. Indeed, the 
 clue to the virulence of these trees was given by the negi-oes, who 
 employ their plant also to stupefy fish, just as the Antilleans do the 
 bark of the medicinal Piscidia, the autochthones of North America 
 branches of Gelsemium, and the Australian and some other nomads 
 often sprigs of some Tephrosias and Tribulus for the same purpose. 
 Abrus, even longer known than the Cola, became recognised in its 
 seemingly unique importance only within this decade, first by De 
 Wecker ; as a plant of all the tropics it extends also to Australia, 
 where it was noticed already in 1699 by Dampier : its usefulness 
 in Trachoma and Painius was proved also here by Mr. Rudall and 
 other ophthalmic surgeons, notwithstanding some danger of atrophy of 
 the conjunctiva possibly arising from the use of this seed, as pointed 
 out particularly by Knapp and some other surgeons. If I rightly 
 remember, Martius already alludes to some therapeutic power of the 
 Abrus in his " Specimen Materia? Medica; Brasiliensis," published 
 in 1824 soon after his return from South America. Sattler seems 
 to have discovered a particular micro-organism, which has been sup- 
 posed to set up the fermentive inflammation, by which it is sought 
 to destroy the morbid layer. The use of Abrus-seed has latterly 
 been suggested in the treatment of Epithelioma. Curious to record, 
 the spores of PufF-balls have been recommeiided for the same pur- 
 pose. I should forestall the learned and zealous honorary secretary 
 of this Section of the Congress, were I to discuss, if even only pre- 
 liminarily, the interesting data connected with the poison-shrubs of 
 South-Western Australia, species of Gastrolobium and Oxylobiuin. 
 Dr. Grant will bring before you the new observations, instituted
 
 I 
 
 president's address — SECTION OF PHARMACOLOGY. 917 
 
 purposely by Dr. Rosselloty at tlie instance of Dr. Waylen, the Chief 
 Medical Officer of Western Australia ; this will be all the more worthy 
 of your attention, as the particular group of these simple-leaved harsji 
 leguminous shrubs is restricte<l to this part of the world. Let us hope, 
 that at ii future meeting of the Congress the toxicology of the v-etch-like 
 Swainsouas will also become elucidated in the interest of medicine. 
 Moi-eover, they do not stand alone in this respect, inasmuch as some 
 species of the closely allied genera Astragalus and Lessertia elsewhere 
 are also known to contain j)owerful principles never yet studied. The 
 cerebral derangements, caused to horses particularly by Swainsouas, 
 ■especially S. Greyana, the feared Darling-Pea, have long been witnessed, 
 but never been physiologically traced to their origin ami in their course. 
 Dr. Frederick Lloyd of this city ascertained in another leguminous 
 plant of ours, the shrubby Coodia, deleterious properties, and even our 
 native Indigofera is held in susincion, while the use of Daviesia latifolia 
 as a substitute for hops is actually forbidden on account of injuriousness. 
 And why do I allude to all this, which may seem foreign to our 
 present subject ? Because, as recent therapeutics have given us 
 Pilocarjnn, Duboisin, Cocaine, Physostigmin, Curarine, &c., leaving 
 inorganic substances out of consideration, so we cannot foretell what 
 may be revealed to us for the benefit of Therapy, if the indications 
 just given are methodically followed up. Nevertheless, we all feel that 
 we should be cautious not to burden the stores of materia medica with 
 superfluous additions, such as the Gonolobus Condurango of transient 
 glory. It remains a remarkable fact, that among the LtO,00() kinds of 
 flowering plants of the universal vegetation, only a few Cinchonas 
 give us cpiinine, for which we have as yet no real equivalent in any 
 other plant through all the wide world. Cinchonas are indeed a 
 glorious gift ! Surgeon-^Iajor Di-. Geo. King, the eminent Director of 
 the Botanic Garden of Calcutta, brought within reach of even the 
 unprosperous millions of fever-sutferers in India the unseparated semi- 
 crude alkaloids inexpensively from Indian plantations, the area of which 
 is now jjerhaps larger already than the whole remaining Cinchona- 
 forests of South America. It might in addition be added here, that 
 thi-ough the whole of East Australia in temi)erate, frostless mountain- 
 regions Cinchonas might be reared millionfold. Cinchonas rii)ened 
 even germinable seeds not many miles from Port PJiillip. What a 
 cai)ability therefore for wide m(;dicinal culture I 
 
 Should our amply disper.sed Myriogynes be compared, on account of 
 their sternutatory ))roperties, rather to Convallaria than to Arnica, the 
 natural aflinity being largely with the latter, or does the Myriogyne 
 j)Ossess properties of its own ? Could Leptandrin, as an American 
 Cholagogue of recent introduction, be obtained from our own similar
 
 918 IXTEUCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Veronicas and also from those of New Zealand ? Ought the 
 particular Gratiola, which fringes our brooks, to remain unnoticed, 
 when the European ranked amongst the foremost hydragogues in the 
 widest sense of tlie word through three centuries, so much so that the 
 name "gratia dei " was applied to this herb, as significant as that 
 of " Cascara sagrada " for Rhamnus alnifolias 1 What is the precise 
 tliera[)eutic relation of our Boronias and Eriostemons to the allied 
 Bucco-bushes of South Africa 1 Can Senna be obtained from any of 
 our Cassias'? Can we dispense with Chirata. by using our own 
 Erythrtea here? Can the very potent acrid principle of the Palm-like 
 Cycas- and Zamia-species be chemically detined, having hitherto, like 
 the active ingredient of Croton-oil and of many delicate fragrances, 
 eluded separation as distinct substances 1 Are the alkaloids and the 
 aromatic oils of the four Australian JMonimiaceous Sassafras trees from 
 as many colonies closely akin 1 What is the precise position of the 
 seed of Cassia Absus, used for ophthalmic complaints already by the 
 ancient Egyptians, in the therapeutic system, this plant extending 
 naturally to Queensland ? Do any of the Australian species of Croton 
 yield an oil comparable to that of the Indian C. Tiglium, or a bark 
 similar to that of the Antillean C. Eluteria 1 In what way does the 
 blue-flowering Grass-lily of Western Australia (Agrostocrinum) affect 
 the visual apparatus of sheep feeding on this plant, so as to cause 
 blindness, and what conclusions can be drawn therefrom 1 What 
 is the nature of the intensely bitter principle in some of our Pittos- 
 porums ? How far can Australian Lobelias replace L. inflata ? Can 
 Cocaine be remuneratively obtained from the two species of Erythroxy- 
 lon, peculiar to tropical Australia 1 Have the powerful properties of 
 Zygophyllum and Didiscus, manifested by their action on pasture- 
 animals, any counteracting value in some of the morbid affections, with 
 which the therapeutist has to cope ? 
 
 Such are some of the questions, which to solve on our lines of 
 research devolves especially on us as Australians. Let us strive by 
 united efforts all over this great land of ours to put together an Australian 
 Materia jNIedica, not a mere collection fiom vague traditions or 
 crude empiricism, but supi)orted by all auxiliaries of recent medicine, 
 biology and chemistry, so as to render such an o[)us worthy of our time 
 and of our country. 
 
 For Western India a vegetable Materia Medica has just been finished 
 by Surgeon-major W. Dymock ; a publication in a similar sense for the 
 I5razilian empire is under progress by Dr. Peckolt. IVIr. J. H. Maiden 
 recently commenced to collect in literary form the Australian data 
 liitherto extant. You will all be cognisant, that my presidential 
 colleague on this occasion, Dr. Thomas Dixson, ably translated Professor
 
 PKESIDENt's address — SECTION OF PHARMACOLOGY. 919 
 
 Sclimiedeberg's " Elements of Phanuacology." From Sir William 
 INIcGrp.gor, the recently appointed (Tovernor of British New Guinea, 
 we may expect a closer study of the particular form of paludal 
 fever and the Beri-Beri, whicli rage so severely in some of the lowlanda 
 of his territory, and on the treatment of which His Excellency, as an 
 experienced [)hysician, can bring professional knowledge to bear. 
 
 It is not genei'ally knovvn, but should not be overlooked at this 
 auspicious Exhibition-period, that the Prince Consort, during his studies 
 at Bonn, was especially devoted to medicine, of which His Royal 
 Highness indeed became a graduate. To this teaching may be traced 
 his wide conception in planning grantl enterprises for the furtherance 
 of knowledge in the most practical sense ; thus, through his original 
 thoughts and methodic measures, were for the first time brought 
 together, in keen rivalry, yet in peaceful contest, the products and 
 industries of the wliole globe — an achievement, which ever since in 
 brilliant repetitions exercised a mighty influence on the scientific and 
 technical progress of the world — an influence which had its reaction 
 also on medicine. 
 
 In the Royal Society of England, in the Institute of France, in 
 the Academia dei Lincei and in the Academia Cajsavea Leopoldino- 
 Caroiina, all originating in the seventeenth century. Medicine has 
 always been amply represented ; indeed, the last-mentioned institution 
 was called forth in 1652 by Dr. Bausch, originally for medicine, and 
 devoted for a long time its efiorts to that science solely. The 
 Ohirurgical Academy of Paris arose as distinct in 1731 already. I have 
 laid some stress on this, because it shows, that our hope will not be 
 futile that this great organisation of oui-s, for the furtherance of medical 
 science, will prove one of unimpaired perpetuity, and will connect 
 closely the special achievements of successive generations here in our 
 far southern latitudes. 
 
 From the medical ranks arose leaders in whatever direction of pro- 
 gressive thought and inventive ai)plication ; and why do I mention this 1 
 because it was through medical studies in their manifold bearings, 
 that a firm foundation was laid to that contemplative and methodic 
 research combined with the utmost of practical tendency, from which so 
 many discoveries emanated in the most diversified directions ; thus 
 Medicine gave us Copernicus, the founder of the planetary system ; 
 Linnteus, who first and for all times established the dual names for 
 organic Ijeings as indisiiensable for rigorously systematising ; Jussieu, 
 who through the first third of this century was Dean of the medical 
 faculty of Paris, and who long before constructed for plants that .system 
 of natural aflinity, which except in one minor direction can never be 
 superseded in grand totality nor in general principles; Davy, who
 
 920 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA 
 
 Stands fortli as the discoverer of the alkaline bases and the condensability 
 of various gases, not to speak of his other multifarious discoveries ; 
 Cuvier, one of the most extensive workers in comparative anatomy 
 and almost its originator ; Owen, as the worthy successor to Cuvier's 
 fame, who will ever remain a lustrous ornament also in medical 
 science ; Berzelius, as the most universal genius which Chemistrj' 
 ev^er possessed ; Schiller, as the noblest in sentiments and the sub- 
 limest in wording among German i)oets ; De CandoUe, as one of 
 the most extensive and philosophical among phytographic writers ; 
 Hooker, the foremost now both as a botanic traveller and as a 
 systematist, and who through part of the present decade held the 
 highest position of science-honor in Britain, as occupant of what once 
 was Sir Isaac Newton's chair, and for a time also that of Sir Benjamin 
 Brodie ; Huxley, one of the most laborious among elucidators of 
 organographic development. I will pause ; it is enough for our present 
 purpose; but the subject is one of inexpressible grandeur! Indeed, 
 Medicine has sent investigators leadingly into all other fields of know- 
 ledge, where they have been among the most luminous ; and that same 
 science of ours is sure to supply bright spirits also in future ages, far 
 beyond its own specialities. 
 
 Perhaps in no other division of the great realm of medicine is the 
 literary material so overwhelmingly ample as in the Section which 
 brings us at this hour together, because the special worker in any 
 other branch is bound to refer frequently — nay almost constantly — to 
 ])rogressive thei'apy, and indeed is often involuntarily adding to its 
 riches. As writings in these directions of ours are so ramified and 
 pervade medicine in all its bearings, it would be a hopeless task, to enter 
 on an extensive disquisition even of what has thus far been brought 
 before us within the reach of the English language in compai-atively 
 recent days. Clearness of method, logical expression, comprehensiveness 
 of view, carefulness of record characterise all the principal new pro- 
 ductions in their totality ; but while building up is going on anew, 
 sometimes more of what has fallen into absolute decay might be cleared 
 away. Occasionally what is asserted as positively established and undei' 
 Tacitus' Relata rejero accepted, will yet have to pass the ordeal of 
 closer, more varied and extensive scrutiny. 
 
 As regards zoologic jiroducts, obtainable for therapeutic purj)oses, I 
 will refer only to three — the Moschus, the Castoreum and the Dugong- 
 oil ; in reference to the latter its exact value in therapeutics, viewed 
 from a physiological standpoint, was first brought under notice by the 
 still active practitioner, Dr. Will. Hobbs of Brisbane, nearly forty 
 years ago, and as the article can now be got well prepared, it 
 should commend itself to moi'e exten.sive use. As the Halicore
 
 president's address — SECTION OP PIIAHMACOLOGY. 921 
 
 extends from tlie Indian Seas to the Queensland shores, tliis herbivorous 
 Cetacean becomes to us of particular interest. Castoreum, as so costly 
 and as not perhaps superior to other autis{)asmodics, might well be 
 discarded, although it carries the therapeutic renown of centuries with 
 it, indeed since Hippocrates' time ; but it is at all events gratifying to 
 mention, that after the Beaver, through merciless hunting, Ijecame 
 extinct also in Britain, this curious and intelligent animal got latterly 
 re-introduced for naturalisation. Musk from the Central Asiatic ]Musk- 
 deer seems warrantably retained in all Pharmacopoeias up to latest 
 time ; though not much |)rescribed in English practice, on the European 
 Continent it has been a cardinal remedy, to arouse promptly the sunken 
 energy of the general nervous system, and was much in use to calm the 
 spasm of the last passing away of vitality. It may be of greater value 
 in epileptic sufferings, than is generally supposed. The naturalisation of 
 the Musk-deer in our higher mountain-regions, particularly in our Alps, 
 would be worthy of l^eing included in the able efforts of our 
 Acclimatisation Society. 
 
 On substances with metallic bases for medicine, I shall not dwell in 
 this address ; the newest metals have hardly yet been tested for us 
 specially ; prepa)-ations however from long-known metallic elements have 
 variously been increased with signal advantage in the treatment of 
 disease. 
 
 A few words only from my })lace on medical education, because the 
 moment seems opportune. Tlje phytologic part of the studies at all 
 Universities might be so extended or re-arranged, as to enable the 
 subsequent physician, should he be thrown into an isolated region, to 
 gather for iiis local wants whatever may indigenously be available, 
 through recognition of generic types or specific forms, allied to those with 
 which he became by early studies acquainted as ordinarily officinal ; 
 and here it may be further an apt opportunity to observe, that if on 
 lonely cheerless professional rides or drives through any comparatively 
 new country merely some few miscellaneous flowering or fruiting 
 branchlets were slipped into an envelope, most likely some additional 
 material for constructing the " Flora of the World " would be secured, 
 perhaps even for a new pillar or corner-stone. By collecting excursions 
 into Nature's free fields, the knowledge of plants and indeed of other 
 of her treasures is more permanently impres.sed on the memory, than by 
 any other method of learning. Such tours need not necessarily ])e 
 connected with arrangements of Univer.sities, whei-e anyhow the study- 
 work is already so overwhelming, as science-organisations in all the 
 University-cities afford the needful facility, notably also in this 
 metropolis of ouj-s its lai-ge and most active Field Naturalists' Club. 
 Training of medical students also in this direction has called forth the
 
 922 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 career of some of the greatest zoologists and phytologists of this and [)ast 
 ages. 
 
 Much through pharmaceutic aid, our greatest achievements for 
 Australian therapeutics have been witli the Eucal3'ptus. Introduced 
 experimentally as regards its oil to notice already by the earliest 
 medical officer of New South Wales, Surgeon-General John White, 
 alluded to as a substitute for Cajuput-oil in a departmental report of 
 mine in 1853, brought before the Exhibitions of 1855, and more 
 jDX'ominently those of 1862 and 1867, the value of this oil was 
 recognised as a medicament of wide-reaching destiny ; subsequently 
 the hygienic effect of Eucalypts was also studied, so that, as you know, 
 now to Eucalyptus one of the foremost places is assigned in thera))eutics. 
 But to Mr. Bosisto is due the credit of rendering the Eucalyptu.s-oil 
 accessible in every hospital and ])harmaceutic establishment of the 
 globe. While giving to the pi^oduction commercial dimensions, he 
 further brought some other active princi[)les of the Eucah'ptus under 
 notice, though tliese kind of trees had some renown already much 
 earlier, Kino of E. rostrata for instance having been used with predilec- 
 tion in chronic diarrhcea, such as is apt to occur in tropical countries. 
 This is not the place to enter on a disquisition of the multifarious 
 uses, into which Eucalyptus has been drawn tentatively or permanently 
 for medicinal ap[)lication, whether as an antiseptic even for gauze- 
 dressing, or for inhalation from va[)Our-atomizei's ; whether as a rival 
 of an antispasmodic of old date, or as an antipyretic of recent time ;, 
 whether as a hygienic factor of wide regional scope, or as a local disin- 
 fectant, because the main results thus far attained were put together, 
 partly from a treatise by Professor Hugo Schultz, not very long ago for 
 a special article in one of our Australian professional periodicals ; still 
 many other values have since been attributed to our Eucalypts, among 
 the last being A.. Marenski's observations on the efficacy of the oil in 
 paralytic affections. But I would wisli you as Australians to reflect 
 what our clime might be, if instead of the salubrious Eucalyptus-forests 
 we met through vast regions those kinds of trees, from the mouldering 
 foliage of which various forms of malarial fever would arise, dreaded 
 in so many other tracts of the warm zone ; and it may fairly come 
 within our notice on this occasion, that young growing Eucalypts, to 
 us so handy here, are placed in the wards of hospitals in various 
 places of the P^uropean Continent, to ameliorate tlie air and subdue 
 contagion, quite irrespective of the cheerfulness which the foliage 
 imparts. How easily could something similar be done anywhere here. 
 Need I draw your attention to the vastness of the myrtaceous vegetation 
 throughout all Austialia, and in forms strongly antisejitic. Even 
 Cook's surgeons foreshadowed ingeniously our comj>aratively recent
 
 PRESIDKXt's ADDKKSS — SECTIOX OF PIIAn.MACOLOGY. 923 
 
 clearer discernments, 1)\- usinj;' foliage from Leptosperniuni for an 
 antiscorbutic Tea, given to the sick of the crew, while the great 
 navigator stayed in New Zeahmd ; hence the popular name of "Tea- 
 tree " also for so many Australian shrubs, even if not arborescent. 
 
 It is a gratifying fact, that in this city pharmacists first strove to 
 obtain for their profession that raised and lecognised status, of which 
 it now can bo proud, a movement which from here soon extended 
 to the other Australian Colonies. Here also they established their 
 first college. A word of recognition must be given to the enterprising 
 chemists and drug-merchants, who, as fellow-colonists of ours, have 
 started factories of their own, the display from some of them at the 
 Centennial Exhibition being magnificent. The now numeious pharma- 
 ceutic societies all over the globe are within their own .sphere 
 grandly advancing the intrinsic interests of their calling, as Pharmacy 
 is bountl as a powerful auxiliary to keep pace with the quick advance- 
 ment of medicine. Under sucli auspices, we can autici[)ate that the 
 pharmaceutic gentlemen, while gradually scattering establishments of 
 theirs over the whole Australian continent, will seize the splendid 
 op})ortunities afforded them for such original researches, as can only 
 be carried out in native fields. How would a Sonder, Rabenhorst, 
 Kuetzing, Mitten and Boeckeler have rejoiced to win laurels on 
 virgin .soil of continental ex|)anse, previously untrodden by civilised 
 man ! Workers from their ranks must be inspired l)y the glorio\is 
 achievements from the time of 8cheele and Chaptal to that of Oersted 
 and Dumas, from that of (Tmelin and Hose to that of Flueckiger and 
 Att field. 
 
 It would be an incalculable l)Oon, if an intfsrnational pharmacopteia 
 could authoritatively be established, with weights and measures of an 
 uniform standard, doubtless finally everywhere according to the decimal 
 system. But to avoid more readily the occurrence of numeric errors in 
 the writing or interpretation of figures, it might be be.st in prescribing, 
 to use distinct letter-designations for the decimal jn-oportions of grammes 
 and litres, should these standards ever be adopted as universal. In the 
 United States the re-issue of the Pharmacopoeia is decennial ; this acts as 
 an incentive, to bring timely together all additional data, meanwhile 
 gained, for .systematic and conforraous insertion. Not all Pharmacopa^ias 
 are " up to the times" as regards phytographic nomenclature, so as to 
 render it consonant with every recent discovery. 
 
 Whoever had an opportunity of seeing the prescri[>tions, kept with a 
 kind of sanctity as heirlooms in old family-shrines, even only from about 
 150 years ago, must have been astounded at the multiplicity of the 
 ingredients constituting some of these extraordinary compositions, which 
 were regarded as a sort of talisman in many a hou.sehold then. Never
 
 924 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA, 
 
 theless, some of the modes of cure in vogue about that time in many 
 cases may have come undeservedly into disuse, for instance the copious 
 internal administration of olive-oil against corrosive poisons. Quite 
 rightly the newer turn in prescribing has been towards simplification, 
 but not tliat thereby in any manner a leaning to particular doctrines is 
 to be indicated. It may be difficult or even impossible, to follow 
 up observingly the action of any medicinal substance in conjunction 
 with other potent remedies, possibly antagonistic to each other physio- 
 logically as well as chemically ; the effect then of each single 
 coijiponent is apt to be lost sight of, nor can its action be fully con- 
 trolled, even if our knowledge of the mutual relation of the ingredients 
 were in each case perfect. 
 
 J^ooking to the future, we must be afi-aid and therefore prepared, as 
 maritime journeys are more and more shortening, to see sooner or 
 later also epidemic diseases invading Australia, such as the deadly 
 <Jholera Asiatica and Ty])hus icterodes, of which we hitherto remained 
 free ; we will never be able to ward them off entirely, though we are 
 bound by the best of sanitary measures and the most experienced 
 treatment to subdue at any time their formidable outbreaks and ravages. 
 
 Divei'ging for a moment from the special tojiic, of which on this 
 grand occasion you have made me the exponent, I would ask you all 
 to consider, whether the principle could be extended, so thoughtfully 
 initiated by the Leaders of this Congress, to offer from these youthful 
 lands invitingly the hand of professional brotherhood to the vast 
 fraternity in the older and oldest homes of progressive thought. 
 Already on this occasion one of the Indian Dei^endencies of Her 
 Majesty has accredited otiicially to us an able representative ; this 
 must arouse and justify a hope, that any invitations to depute 
 medical emissaries would meet with a })erhaps extensive response, 
 when authoritatively and distinctly emanating from us for the next 
 Congress, and when directly conveyed to all the Universities of the 
 Avorld. Tentatively no Couiacil could well take at once from new 
 colonies so bold a step ; but the interests of Australia are assuming 
 such magnitude as to direct the eyes of the whole intellectual world 
 gradually to these far southern regions also. Doubtless it would be 
 felt at the medical faculties anywhere, how wide a difference exists 
 between a general invitation such as could only be made in the first 
 instance, and a subsequent direct call to recognise and aid our honest 
 -aspirations by representative emissaries of theii's. In the latter case, 
 we not only welcome the individual visitor, but also the public 
 <lignitaiy. If even only a limited number of Universities could for 
 €ach of the medical gatherings in Australia set free a delegate, 
 how would they be cheei'ed by us, what boundless hospitalities would
 
 president's ADDIiESS — SECTION OF PIIAKMACOLOOY. 925 
 
 be shown, how eagerly woukl facilities be aftbrded to the illustrious 
 comers for all professional enquiiies of theirs, what treasures of 
 original knowledge and unique experiences would we gain from them, 
 and how immensely inspiring would their appearance among us be, as 
 the bearers of greetings from the remotest lands. And how would an 
 over-worked Professor or a long-harassed Practitioner rejoice in the 
 exchange for once of a northerly winter with an almost continuous 
 spring of ours in the far south, gaining new health and strength 
 for prolonging a celebrated career. All this would not be without 
 a hope of his gaining even professionally new knowledge locally 
 by personal inspection, and with a likelihood of further expanding- 
 his own views by various observations in a course of travel through 
 these colonies. Altered forms of diseases would come under review 
 due to our clime or other local circumstances ; sanitary and hospital 
 arrangements here, our University work and the course of prepara- 
 tion for it, material enrichment of Museum Collections — all these 
 would attract attention, and also the very novelty of nature here 
 should enchant such an intellectual strangei'. "NVe may feel quite 
 convinced of this, that whenever in these latest colonies through 
 our science-organisations we may approach the venerable institutions 
 elsewhere, we would be met in a dignified spirit of kindliness, and 
 would at all events elicit in response a graceful encouragement from 
 many an illustrious personage ; we in turn then could arrange for repie- 
 sentation of these colonies at gatherings, similar to ours, abroad. To 
 us it would be a glorious beginning to connect us more closely with 
 medical science all over the globe. What a source of new inspirations 
 it would be, what a linking together in the chain of science ! 
 
 It is an immensely honoring position, accorded to me at the late 
 autumn of my life, to become connected with a movement, which will 
 link together historically in the great science of medicine whatever its 
 genius did attain or will yet achieve in this part of the world. Na 
 prouder obligation is imaginable, than that of addressing hundreds of 
 professional gentlemen, assembled in the greatness of their cause, and 
 worthily engaged on a mission the most sublime ! 
 
 Congresses, so auspicious as this, will tend to arouse a more general 
 interest for cultivating afresh by improved recent methods our wide 
 fields of enquiry, with the ])rospect of more abundant harvests. For us» 
 at this stage of the world's history, it is fortunate, that we live in an 
 age, when the search for truth is not endangered as at the time of Galileo 
 or Vesalius ! 
 
 When the grace of divine Providence has endowed us with faculties 
 and afibrded us o})portunities, we are bound to turn them to the best 
 account in whatever sphere of life ; you all do it in the daily exercise of
 
 "926 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 one of the noblest and most practical of all professions ; a glow of 
 exultino; feeling pervades you at each resultful instance of your 
 action, a grateful smile greets you at each of your successes ; and that 
 is really your best reward. 
 
 Centuries rolled on, a new western world was opened up with all its 
 wonders, to display new treasures also for medicine, and to increase 
 vastly its working power ; lastly, in youthful grace a new far southern 
 woi'ld emerged from the neljular dimness, in which it had been involved 
 since the creation's dawn, free at once to the access of the highest 
 civilisation, open to millions on undisputed ground, and blessed by the 
 most salubrious of all climes within the warmer zones. Centuries will 
 roll on and on again; we cannot foresee, what even in a single decade may 
 be accomplished ; but this much we can foi'etell, that the successes of 
 the world's works, in whatever direction, must always largely depend on 
 the influence and the boons of medical science. And this also may be 
 foretold prophetically, that the time will arrive, when whatever pertains 
 to diseases and their remedies will have been so extensively tested in 
 thousands of hospitals, and so specially been studied at millions of sick 
 beds, that the uncertainties, which still so much prevail, shall all have 
 been cleared away, and when therefore the physician and surgeon with 
 increased trust will enter on their responsible and elevated career. And 
 further, this we may rest assured of, that the fair fame of A.ustralia will 
 be sustained also by the natives of the soil on the field of medicine. 
 As now, so also in future, no other science will have so many independent 
 observers, so maxiy original investigators, and withal for so high and yet 
 so unselfish purposes all over the world. 
 
 It was fascinating to live through a great part of that century, which 
 — to all human forethought — will ever be the grandest for main- 
 discoveries ; and so it was enchanting also to witness the brilliant 
 development of medical knowledge, with the ready chances of rendering 
 its successive achievements at once our own. 
 
 Most of what we know is an inheritance from the toil of other minds 
 and the gain of former ages ; we sho\ild therefore in due gratitude also 
 strive to enrich by individual research the gifts which came to our share 
 from former generations ; and nowhere can more exalting opportunities 
 exist for such honorable tasks, than in the free fields of a new continent 
 under the a^gis of the British throne. 
 
 While closing the last of the sectional addresses at this great 
 intellectual gathering, may I be allowed to offer yet a few more vale- 
 dictory words, all the more so, as I can scarcely hope to meet you again. 
 As a mere " Superstes," who has almost })assed away, I might be 
 permitted then to say more particularly to the youthful students, who 
 toil within these solemn halls, guided by devoted preceptors, and
 
 MATERIA MEDICA AND PIIAHMACOLOny OF QUEENSLAND PLANTS. 927 
 
 preparing for entering professional life, that it is the medical practi- 
 tioner above all, from whom, with necessarily great natural talents 
 and a high standard of education, is required for his career an 
 earnest will, a due estimation of working time within the course 
 of individual life, a well calculated plan, a methodic arrangement 
 for what has to be effected as a connected total, an unswerving 
 adherence to a iixed purpose, an indisturbable perseverance and a 
 concentration of every faculty, to lead to gratifying and perhaps 
 triumphant success ; yet thereby, not to forego participation in rational 
 sociality, measured recreation, administration of charity, and above 
 all not thereby to sacrifice religious humility. The medical pz'ofession 
 in its united efforts indeed largely influences the tone of society; medical 
 science confers more worldly blessings than any other ; it is the most 
 closely interwoven of all with daily life, in all phases of human existence 
 throughout the world ; it is neither bound to nationality, nor to 
 language, nor to creed ; its codex is universal ; it brings most closely into 
 contact, whatever emanated from the cultured exercise of the human 
 mind; indeed, its objects are sacred and transcendental! 
 
 ON THE MATERIA MEDICA AND PHARMACOLOGY OF 
 QUEENSLAND PLANT.S. 
 
 By Tnos. L. Bancroft, M.B. Edin. 
 
 Queensland ranks among the richest of countries in plants used 
 medicinally. There are no less than loO medicinal plants, but the 
 majority of these are probably inert. Many are natives of Southern 
 Asia, where almost every plant is considered to possess curative pro- 
 perties. There is an account of the medicinal use of a number of these 
 given in the writings of Mr. F. ]M. Bailey. These plants, however, 
 with a few exceptions, have little interest to pharmacologists. 
 
 The following four plants are more especially worthy of mention, viz. : — 
 Abrus precatorius, the Jequirity ; Mallotus Plulij)pinensis, Kamala; 
 Melaleuca leucadendron, Cajuput ; Cissampelos Pareii'a, Pareira brava. 
 
 Of Solanaceous plants, there are several that have active properties, 
 viz. : — Solanum aviculare, Nicotiana suaveolens. Datura Leichhardtii, 
 Duboisia myoporoides, Duboisia Hopwoodii, the Pitury. 
 
 Tlie Duboisias are remarkable as an instance of species containing 
 different alkaloids. Dulroisia myoporoides contains Hyoscine, the 
 basis, according to Ladenburg, of the mydi-iatic alkaloids — Atropine, 
 Hyoscyamine, Daturine, and Duboisine. 
 
 Duboisia Hopwoodii, the Pitury, contains a liquid volatile alkaloid 
 *' piturine," which was first separated by Staiger. It closely resembles
 
 928 INTERCOLONIAL MEDICAL OONGHESS OF AUSTRALASIA. 
 
 " nicotine," if indeed it he not identical with that substance. It was 
 apparently proved to be nicotine by Professor Fraser and M. Petit, but 
 Professor Liversidge, of the University of Sydney, has since examined 
 this substance ; he found that it differed from nicotine in certain 
 reactions. It is worth mentioning that these two plants, possessing 
 active principles so widely different, both in their chemical and 
 r)hysiological properties, have been so confused by scientific investigators, 
 merely because they possessed the same generic name. 
 
 The genus C'ryptocarya, of the order Laurinea:^, contains a curare- 
 acting principle. It is, I believe, an alkaloid, closely resembling 
 Curarine. Professor Fraser has promised to experiment with this poison, 
 so before long something definite about it may be known. There ai-e 
 several species of Cryptocarya in South America, and notably one, 
 C. Guianensis. 
 
 It is Guiana where curare is obtained, and it is to the interest of the 
 natives, who collect this substance, to keep its source secret. It seems 
 that to inquirers, the natives always point to a Strychnos (chiefly 
 Strychnos Guianensis — see Trin. edit, of Wittstein's " Organic Con- 
 stituents of Plants "), as the tree from which they obtain the curare. 
 Some samples of curare contain curarine, brucine, and strychnine ; 
 other samples contain only curarine, wliich fact seems to point to the 
 juice of a Strychnos being added at times to enhance the poisonous 
 natui"e of curare. 
 
 Of Euphorbiaceous plants, there are many that apparently contain 
 the acrid poison of the order. The Excaicarias, of which there are 
 several, are notable as causing sore eyes, should the juice by any means 
 gain entrance into the eye. When striking the tree with an axe — 
 especially E. agallocha, the milky mangrove — one is apt to be splashed. 
 In the Gulf of Carpentaria, where E. parvifolia, the so-called gutta- 
 percha is common, new arrivals often cut a stick of the tree, and in 
 this way get the juice upon their hands and afterwards into their eyes ; 
 they then become for a time blind. This blindness, however, is only 
 of short duration, leading to no after efiects. 
 
 There are many species of Euphorbia ; two have become notorious, 
 viz., E. pilulifera, the asthma herb, and E. Drummondii. Why specially 
 these two, it is hard to imagine. " Drumine," the supposed active 
 principle of E. Drummondii, has been examined by several chemists in 
 England, and pronounced by them to be calcium oxalate. 
 
 The bark of Croton insularis might be used as a substitute for 
 cascarilla. The barks of Alstonia scholaris, Alstonia constricta, 
 Sarcocej)halus cordatus, the Leichhardt, and probably others, contain 
 excellent simple bitter principles. As antiperiodics, none of these 
 plants have any value compared witli arsenic or quinine. 
 
 The gums of Eucalyptus corymbosa, E. siderophloia, E. resinifera, 
 and many others, are good astringents, as is also the bark of 
 Beilschmiedia obtusifolia, the Queensland sassafras. There are fifty 
 odd species of eucalyf)tus in the colony, and many of these possess 
 essential oil in their foliage more or less resembling the commercial oil 
 of eucalyptus. Some of them contain eucalyptol, e.g., E. microcorys 
 and E. Baileyana ; others, such as E. htemastoma, contain menthol. 
 Some possess perfumes, as E. citriodora (citron), E. Staigeriana (lemon), 
 and E. dealbata (melissa).
 
 MATERIA MEDICA AND PlIAIJMACOLOGY OF QUEENSLAND PLANTS. 929 
 
 In GeiuiMuy, there is an idea that the oil of Eucalyptus g!o))ulu.s is 
 the most useful niedicinalh-, so this oil is manufactured there from 
 plants .<;-ro\vn in the south of Europe. Messrs. 8chimmel state : — 
 "That E. globulus contains GO per cent, of eucalyptol, while E. amygda- 
 lina contains none " — hence the reason why the connnercial oil is 
 despised. 
 
 (xildenieister, in Professoi- AVallach's Liboratory, has hitely investi- 
 gated these oils {Pharm. Zeit. August 22, p. 499). He tindsV-"That 
 eucalyptol is pi-esent in consideraljle quantity in the E. amygdalina oil, 
 and further confirms previous statements, that eucalyptol is identical 
 with cineol and cajuputol." 
 
 Messrs. Schimmel are making further investigations into E. amygda- 
 lina oil. They are of opinion that Gildemeister was supplied with a 
 mixed oil distilled from E. amygdalina, E. globulus, and probably 
 other species {Pliarm. Journal, October 29, 1888). 
 
 There can be no doubt that the commercial oil of eucalyptus, whether 
 containing eucalyptol or not, is extremely valuable when vaporised 
 with steam as an inhalation in the treatment of dij^htheria. Internally 
 it is tolerated better than turpentine, and appears to be quite as 
 etlicacious. There may be an error in regarding eucalyptol, and not 
 terpene, as the medicinal ingredient in eucalyptus oils. 
 
 There is a mistake often made in regarding eucalyptus trees as being 
 antimalarial. Why, it might be asked, is it then that people get ague 
 repeatedly while living in eucalyptus forests 1 The error originated on 
 account of certain malarial distiicts, where there were few or no trees, 
 ha\ing been rendered non-malarial by the growth there of eucalyptus. 
 The reason, of course, is that these (juick-growing trees have dried up 
 these localities. Other trees would have done the same. The error 
 Tiiight be overlooked but for the fact that some persons have traded 
 upon it, and sell pi'eparatioii.> of eucalyptus, stating the same to cure 
 ague. 
 
 The pseudo-bulbs of an orchid (cymbidium) are used successfully at 
 times by bushmen to check diarrhavi. Mr. C. Hedley states " Proc. 
 Ivoy. Soc, Queensland," vol. \, part I, p. 12) : " If the pseudo-bulbs of 
 cymbidium canaliculatum are grated up and boiled, a body is pi-oduced 
 not to be distinguished from arrowroot. Delicate children have been 
 i-eared on this, when accidents \\i\\e cut off from them other supplies." 
 
 Two leguminous plants are well known as being poisonous to sheep, 
 namely, (iastrolobium granditlorum (poison-bush), and Swainsona galegi- 
 folia (Darling-Pea). Althougli these plants have been often examined, 
 Ijoth in the colonies and in (Jennany, no poisonous princijile has ever 
 l)een discovered in them. Already forty-five plants growing in the 
 colony have acquired a reputation as being more or less poisoi\ous to 
 stock. These plants, with several exceptions, are probaljly inert. 
 Almost any plant, under certain conditions, will poison sheep. 
 
 Erythrophkeum Laboucherii is said by Baron Von Mueller to 
 contain erythrophkein, the active principle of E. Guineense. 
 
 The gum of Acacia Cunninghamii makes a good adhesive mucilage; 
 it is, however, dark in colour. 
 
 Tlie pods of an acacia growing in the Gulf of Carpentaria district are 
 rich in saponin. Mr. Bailey is of opinion that this is the acacia 
 named by A. Cunningham " Acacia delibrata." 
 
 20
 
 930 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Xantlioxyluin veneficum (Bailey), a small tree, lather uncommon 
 even where I discovered it growing on the Johnstone river, contains 
 an exceedingly poisonous principle, which however has not yet been 
 separated. It appears not to be an alkaloid. Tlie action it causes, 
 wlien injected into warm-blooded animals, seems much like that of 
 strychnine; yet upon frogs, it does not cause tetanus. A particle of an 
 alcoholic extract of the bark will, if placed upon a frog's back, cause 
 great excitement — the frog jumps violently about until it becomes, in ;i 
 fev/ minutes, liaccid. When first I examined this poison, I erroneously 
 .supposed the excitement to be tetanus. 
 
 The genus Daphnandra, of the order Monimiaceee, is very interesting, 
 as possessing several alkaloids of a stable and crystalline nature. In 
 their physiological action, they resemble somewhat the Digitalis grouj). 
 I have for some years now occasionally used a tincture of the bark of 
 Daphnandra micrantha in the treatment of heart eases, apparently 
 with good results ; my patients expressed themselves as feeling much 
 better, and the sphygmograph showed some improvement in the 
 condition of the pulse. Daphnandra kills frogs by its action upon the 
 heart, and kills warm-blooded animals by its paralysing effect upon the 
 spinal cord. Although I did not anticipate tliat any good would 
 result fi'om the use of any substance having a paralysing action upon 
 the cord, in the treatment of tetanus, yet I ti'ied Daphnandra in a 
 severe case of tetanus in a man. He derived no benefit therefrom, and 
 the last two days of his life he was kept, at his own desire, vuider the 
 influence of chloroform. Should a remedy ever be discovered for 
 tetanus, I believe it will be a substance having an injurious effect upon 
 the microbes that cause the disease, like the effect of salicine in 
 rheumatic fever, and quinine in ague. 
 
 The genus of Laportea, tree nettles or stinging trees, so common in 
 the jungles all over Queensland, has some interest to pharmacologists, 
 inasmuch as after being nettled, one is reminded of the fact for several 
 days, and in exceptional cases for weeks, whenever the nettled part is 
 wet. Upon touching watei', there is produced a sudden severe pain, it 
 is only momentary however. If the hand be the pai't nettled, the 
 secondary pain starts in the spot nettled, and runs up the arm and 
 down the corresponding side. No explanation has ever, as far as I am 
 aware, been given to account for the secondary pain. A juice made by 
 pounding the green leaves in a mortar gave no decided reaction with 
 litmus paper ; it was tasteless, and when injected into frogs, had no 
 action upon them. If the stinging hairs be carefully examined, and the 
 tops shaved off with a razor, a few will be seen to contain a minute 
 quantity of fluid, so small a speck is it however, that even with the 
 microscojje it is impossible to test its reaction with litmus. The juice 
 of Colocasia macrorrhiza plays the part of the dock in England as a 
 remedy for application to parts nettled ; it however seems quite 
 useless. 
 
 Tli<; adage, "If you gently toucli a nettle, it will sting you for your 
 pains," is not applicable to tree nettles, for in order to be stung, it is 
 necessary to Iiandle the leaves roughly, or brush against them with 
 some force. The fracture of the points of the stinging hairs is quit<' 
 audible, and one feels a prick when the point enters the skin ; in a 
 second or two afterwards, lie is conscious of having been nettled.
 
 POISONOUS ACTION OF OASTUOLOlilUM AND OXYLOBIUM. 931 
 
 T um indebted to my friend, Mr. F. 3r. J5;iiley, for Iiis kindness in 
 phicing in my huuds specimens of the two native species of Stryelmos, 
 viz., Stryelmos psilosperma and Stryelmos lucida. All pai'ts of S. 
 p.silo.sperma are bitter, but not so bitter as strychnine. 1 was unable to 
 kill tVogs with this plant. S. lucida is, on the other hand, extremely 
 bitter. So intensely and persistently bitter is this plant, that one 
 would imagine that it was very rich in strychnin<>. 1 was astonished, 
 howevei", to tind that I could not tetanise frogs with it. It was not 
 even poisonous to them. The frogs used, '' Hyla ccerulea," are very 
 susceptible to strychnine. 
 
 I had only one fruit and se\eral leaves — too small a quantity to 
 attempt any chemical analysis. 
 
 There are many other plants interesting pharmacologically, among 
 which may be mentioned the genera — Piper, Flindei'sia, Archidendron, 
 Harpullia, Pongamia, .Marlea, and Xanthiunu 
 
 1 
 
 NOTES OX THE POISONOUS ACTION OF SPECIES OF 
 (TASTRr>LoBlU.M AND OXYLoBlUM. 
 
 By Dr. IiOSskllotv, AViliiams Ki\er, Western Australia. 
 
 The plants reported on are kno\\n loctilly as (1) Heart-leaf Poison, 
 
 (2) York Road Poison, (3) Narrow-leaf Poison, (+) Bloom Poison, 
 (5) Box Poison. From the .specimens sent. Baron Von Miiller has 
 identified them as (1) Gast. bilobuni, (2) O. calycinum (Benth.), 
 
 (3) a G. allied to G. oxylobioides and G. microcarpum, (4) (r. ovalifolium, 
 (5) Oxylobium parviflorum (Benth.) 
 
 All of these plants have a powerful narcotic action, and it is a 
 valuable result that the species G. Ov(difolmiii, not pre^•iously 
 recognised as poisonous, is now known to be so. The symptoms are as 
 follow^s : — 
 
 (1) Bo.c Poitsoii (Oxijhjhiitia ijarvljiorum). — More virulent than York 
 Road poison, but being tallei- in growth, is not so much eaten by sheejj 
 except when in bloom, when they seek it, and it is \ery fatal. Effect 
 Oil Sheep. -Does not show its eftects for from eight oi- ten hours after 
 eating it. They then seem to go blind, run about nuich, and fall on tlie 
 ground in strong convulsions. They generally ha\'e three tits befoi'e 
 they die. Post-mortem appearances. — Heart goi-ged with blood almost 
 to bursting. Lungs not so much congested as with York Road. 
 iStomach and liver also nuich congested. Dogs eating the flesh have 
 similar convulsions, and bite anyone they come near. Pigeons and 
 other birds eat the seeds of all the poison-plants with impunity, Init 
 their entrails will poison cats or dogs, but not the flesh." 
 
 (2) York lioad Poison {Gicstrolobium calycinnm, Benth.)— It tak«'s 
 effect on sheep within six hours of eating it. Convulsions come on 
 in twelve hours. Sheep jump about, and muscles contract much. It 
 seems to pre\cnt both sheep and cattle from chewing the cud, by 
 
 2o 2
 
 932 INTEKCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 affecting the first stoiuacli. If the stomach is full Ijefore eating the 
 poison, there is less chance of recovery. In the fir.st stage, salt seems to 
 be an antidote, causing them to chew tiie cud. Post-mortem apjiedr- 
 ances. — General congestion of the lungs and stomach. Inner coat of 
 stomach easily peels off". It affects cattle similarly to sheep. Horses 
 are affected by trembling of the muscles, loss of muscular power, 
 swollen and di'ooping eyelids. Convulsions not noticed in them. The 
 poisoned carcases, if eaten. by dogs, do not affect them so much as those 
 of animals who have died from box poison. 
 
 (3) Heart-leaf Poison ((/. bilobum). — The effects on sheej) are sleepiness 
 and drowsiness. Acts in about the same time as box poison. Almost 
 harmless except when in bloom or seed. .Sheep eating it then seldom 
 recover. Lambs die in about six hours. Post-mortem appearances. — 
 Stomach and intestines, liver and lungs, much congested. It seems to 
 prevent urination and defiecation. Paralysis before death. 
 
 (4) Bloom Poison (G. ovalifolmm). — Exactly same effects. 
 
 (5) yarrow-leaf Poison. — Being less in qv;antity in tliese parts, has 
 not been much observed. 
 
 [From these few notes, it is of course impossible to determine the 
 exact physiological action of these poisons, Ijut it is sufficiently evident 
 that they all act very energetically on the ner%e centres. Two of them, 
 viz., Box Poison and York Road Poison, appear to be mainly convulsant 
 ill their action, producing symptoms somewhat similar to those caused 
 by spinal irritants ; while the other two. Heart-leaf Poison and Bloom 
 Poison, seem to have a paralysing action on both brain and spinal coi'd, 
 producing drowsiness, inability to evacuate bladder and bowels, and 
 motor paralysis. And it is notable, that the former two are I'espec- 
 tively a Gastrolohium and an Oxylohiuin, while the two latter both 
 belong to the genus Gastrolohium, so that tlie difference in physiological 
 action does not correspond to generic distinction. 
 
 Thei'e are several points of special interest in the symptoms produced. 
 
 (1) The length of time (six hours and upwards) which elapses before 
 tlie advent of symptoms. 
 
 (2) The alleged effect of Box Poison in producing blindness in 
 sheep. This may be compared with the similar action of a blue- 
 flowering Grass-Lily, growing in the same district. It is useless to 
 speculate as to its exact mode of production, but probably it may be 
 due to a special selective action on the visual centre. 
 
 (3) The poisonous action on dogs of the flesh of poisoned animals, 
 causing, in the case of Box Poison, convulsions similar to those of the 
 poisoned sheep. 
 
 (4) The immunity possessed by pigeons and other birds eating tlie 
 .seeds of all the poison plants, while? their "entrails," but not tlieir flesh, 
 are poisonous. This reminds us of tlie very great tolerance of opium 
 and morphia in tlie same animals. 
 
 (5) The observation that Gastrolohium ovalifoUum (Bloom Poison) is 
 also poisonous, a fact hitherto unknown to botanists. 
 
 It is to be hoiked that all these plants will be made the subject 
 of precise experimental investigation ))y pharmacologists, for it is 
 probable that poisons acting so powerfully on the nerve-centres will 
 Ite found to possess valuable therapeutical properties. — D. G.J 
 
 J
 
 BISMUTH : ITS PK015ABLE THERAPEUTIC POSITION. 933 
 
 BISMUTH : A CONSIDERATION OF ITS PROBABLE 
 THERAPEUTIC POSITION. 
 
 By Thomas Dixsox, M.B., CM. Edin. 
 
 Considering the extreme fretiiienoy of the use of this metalloid in its 
 many forms, and its undoiiljted value, it is astonishing to find how 
 various the theories of its action are, how little these help us in deciding 
 when to use it, and finally, how little of wliat is really known is given 
 in the leading text books in Britain. I have, pei'sonally, long had doubts 
 as to the validity and utility of the accepted theories in currency ten 
 years ago, viz., tliat bismuth trisnitrate acted as a coating powder. A 
 much-used modern text book (Bruce) desci'ibes its action as sedative 
 and astringent; wliile the best description pi-obably is that of the 
 epoch-making text book of Lauder Brunton, to which we will refer 
 presently. 
 
 The value of a theory is of course, at any time, to be estimated by 
 its helping us to form deductions which, when applied, lead to satis- 
 factory, or at any rate foreseen results. The less often these results 
 tally with our deductions, the less the value of the theory. Now, it is 
 not by any means a matter of indifference in the case of bismuth what 
 our theory may be, for, thanks to the " mechanical coating " theory, 
 several instances of poisoning have occurred, in some cases resulting 
 fatally. 
 
 As regards the indefinite description, " that bismuth acts as a sedative 
 and asti'ingent,"' one can make but little use of it. If we use such 
 terms, we must understand what is meant. Does bismuth act like the 
 typical sedfitive opium, or as the typical astringent tannic acid and the 
 salts of the metals '? If we merely imi^ly that it acts by lessening pain 
 in some unknown way, we could class the use of a blister in pleurisy 
 under "sedatives;" or that it lessened diarrhrea, we could class anti- 
 septics under the heading "astringents." Such a use of terms is _too 
 loose to do anything but mischief, unless most carefully defined. 
 
 "We will discuss the theories now more minutely : — 
 
 (1) The "mechanical theory," as it maybe called, states that the 
 powder formed in making the basic salts, the carbonate, and the oxide, 
 itc, distribute themselves when taken by mouth uniformly over the 
 stomach and intestines. Can any one conceive twenty or thirty grains 
 of a heavy powder coating tlie extensive surface of the human stomacli, 
 especially when this again is covered with a coating of nuicus- a body 
 which becomes more tenacious in inflannuatory states? The difficulty 
 of maintaining this theory is the greater when we remember tliat 
 bismuth powders rather by their weight tend to fall to the bottom of a 
 cavity, and that the powder is composed of crystals. Were we dealing 
 with mica, which forms ''smooth" powdei-s, we might have some ground 
 for using this theory pei-haps: it is inert too, and would be suitable. 
 
 (2) To compare bisnuith with charcoal, as Brunton does, is not 
 helping us much, considf-ring there are even several theories as to the 
 action of charcoal, and that chai-coal is a bulky, gritty, chemically 
 unacted-upon substance, of great chemical power, best sliown when it is 
 freshly burnt, and only perliaps of medical value under similar circum-
 
 934 INTERCOLONIAL MEDICAL CONUKESS OF AUS TKALASIA. 
 
 stances ; iu other woi-ds, a body whose action is not understood, a Ijody 
 as unlike bismuth, physically and chemically, as need be; and finally, 
 a body with no clear therapeutic affinity to it whatever. 
 
 (3) >Schmiedeberg"s theory suggests that as bismuth basic salts 
 readily assume tlie neutral form in presence of acids by dissolving in 
 them, we liave tlie slow characteristic action of astringency (seen in 
 metallic salts), by which, in presence of albumen, the salt splits up the 
 acid and base, uniting with the albumen, and so forming precipitates. 
 This theory is not easy to disprove for the case of the stomach, but is 
 evidently unsuitable for explaining its influence in diarrhtea, for the basic 
 nitrate (say) would be the natural form of tlie salt so soon as it got to 
 the alkaline parts of the intestine ; in fact, very soon after leaving the 
 stomach. This theory, therefore, is insufficient. 
 
 (4) The arsenoid action. This action has long been mooted, then 
 cast aside and forgotten, till recently in Britain it is very hesitatingly 
 and unsatisfactorily given by Brunton, who drojjs it for the one above. 
 Let us hear what he says in the third Edition of his work: — "Tlie 
 soluble salts of bismuth, such as the citrate of bismuth and ammonium, 
 when given in large doses (how ?), have an action like that of antimony 
 or arsenic, and cause gastro-enteritis, witli fatty degeneration of tlie 
 liver. Small doses of the soluble preparations, or larger doses of 
 sparingly soluble preparations, have a sedative effect upon tlie stomach, 
 like that of minute doses of arsenic. The subnitrate is so sparingly 
 soluble in water, that its utility in gastric catarrli is probably due to 
 its mechanical action, like charcoal or binoxide of manganese. The 
 carbonate is more soluble in the gastric juice than the subnitrate, 
 and is supposed to be more powerful, and the same is true of citrate of 
 bismuth and ammonium. My own experience leads me to prefer tlie 
 less soluble subnitrate to either of the otlier pi-eparations." A resume of 
 his further information is the following : — '' The dose of the insoluble 
 preparations is given as 5-20 grains, while the soluble are given as 2-4 
 grains. He says, that the soluble bismuth and NH.. salt is more astringent 
 and irritant than tlie insoluble salts, and is inferior to the latter in 
 allaying irritation." 8uch is the essence of what our best British 
 autliority gi^■es us. The information lie gives is fragmentary perhaps, 
 yet it is decidedly a long .step towards the view now more accepted in 
 France perhaps, than in Britain, that bismuth is essentially, pharma- 
 cologically, a member of the arsenic family, and towards the view I 
 advocate " that its actions, therapeutically, are dependent essentially 
 upon this affinity,'' a view 1 have for some years taught. 
 
 In discussing bismuth, it is therefore our duty to see how far it 
 agrees with the other members of its group, and then what moditica- 
 tions of action characteristic of itself are distingyishable ; for though 
 ai'senic and antimony essentially are related, they neA^ei'theless have 
 their differences ; these differences are modifications or tones rather 
 than real differences, and the differences lietween bismuth and antimony 
 we will see are of a similar nature. 
 
 Let me first consider the chemical rehitionshi]> of these bodies, for it 
 gives the chief clue to our question. We have N., P., As., Sb., and Bi. 
 (Vd. has not been studied pharmacologically, and need not be discussed 
 here).
 
 BISMUTH : ITS ntOKAULK TIIRKAPEUTIC POSITIOX. 935 
 
 "We Hud that as we rise in tlie series, the oxygen compounds l)econie 
 less and less acid, and more and more basic, also more and more stable ; 
 there is a vast difference between NoO., and BioOg. To this oxidising 
 power, Binz ascribes the action of the gi'oup pharmacologically. 
 
 As i-egards the salts of these metals, we notice that arsenic is a feeble 
 Ijase, antimony a stronger, and bismuth the strongest ; that Sb. and 
 Bi. form salts which, thrown into great excess of water, yield oxy-salts, 
 which are insolulile in watei-, but more or less soluble in acid solutions. 
 iUit tJiese Ixxlies readily enough can be got to form a kind of double 
 salts sucli as tartarated antimony, by combining with an organic acid 
 and an alkali, e.r/., sodiocitrate of bismuth. 
 
 PhxtrmacoloijicaU;/ then, w<» have the oxides of the group becoming 
 hss caudic from N. to Bi. ; tliey lessen metabolism, and as a consequence, 
 ap2:)arently lower the ner\e sensil)ility and retlex irrital)ility, depress 
 the heart and circulation, and after each of them, we find fatty degenera- 
 tion of the livei', etc. In all tliese points we find a striking resemblance, 
 in which bismuth shai'es to the full, pro\ided it be got into the system, and 
 it can be got into the system by injecting into the blood, or hypodermically, 
 the sodiocitrate ; this salt, of course, having as such no other intrinsic 
 action such as the NHg and Bi salt might liave. 
 
 Therapeutically, we tind that arsenic and bismuth are used for some- 
 what similar conditions, and antimony is a sort of bridge between the 
 two. Arsenic is used well diluted, and in very minute doses J^ grain 
 (say) for painful affections of the stomach ; to get its effect, it is best 
 given before meals. Bismuth is given for the same. In lientei'ic 
 iliarrluea they both may be given similai'ly, and even in ordinary 
 diarrhoea some speak of arsenic being of value, while undoubtedly 
 bismuth is often exceedingly useful, but in what doses 1 very large ones. 
 
 In affections of mucous membranes more remote, we give arsenic, e.g., 
 phthisis, conjunctivitis, itc, in larger doses for this purpose. Anti- 
 mony is less used, except where we wish to produce the reflex effect 
 upon the bronchi from irritation of the stomach — an action which we 
 will tind even arsenic can produce, and bismuth itself still Ijetter. The 
 latter is never employed for its influence upon, say the conjuT\cti\a, 
 simply because no one has thought of it. I may suggest that it 
 certainly would be hard to ol)tain, but is (juite possible fi'om my theory. 
 Upon the skin diseases, we know how phosphorus and arsenic can act. 
 Antimony has not been so much used, but bismuth is thought very 
 highly of, applied externally — the only way to get it to the part. Upon 
 the nervous system, P. and As. have been found to have somewhat 
 similar indications. 
 
 Theoretically, this treatment of local (not too diffuse) aftections of the 
 skin by this group ought to l>e the best, inasmuch as the remedy is 
 aj;)plied directly to the part. The remedy acts slowly and persistently, 
 and has not injured the system before getting to the pai-t attiected. 
 Where the local aflection is due to a constitutional diathesis, of course 
 arsenic oi- phosphorus would be the best to give. 
 
 Before I continue, I must remind you that, of course, bisnnith has 
 uften other bodies present in it, but it is extremely pi-ol)al)le that many 
 troubles due to bismuth lia\ e lieen ascribable to the presence of ansenic 
 (n- lead, so often contaminating it in earlier days. The essential actions 
 of bismuth have been elicited witli chemically tested pure si)ecimens.
 
 936 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Comparing Sb. and Bi. we tind the resemblance clearer than evei'. 
 Sb. is not SO absorbable; Bi. is still less so. If we apply tlie chloride, 
 &c. of Sb. to the tissues, it is a caustic — a corrosive irritant; the 
 eori'esponding bismuth salts are so too. This is due to the action of th<' 
 easily detached acid of course. 
 
 But give the tartarated antimony by mouth, and we get certain 
 symptoms ending in emesis. We find that the sodio or ammoniocitrate 
 of bismuth acts in the same way. In fact, the former has received the 
 name of "bismuth emetic" (like our "tartar emetic"). Its action 
 corresponds dose for dose with the Sb. salt. Now this is one direction 
 where we, specially in Britain, have missed our mark, and explains wliy 
 citrate of bismuth and ammonia is a misunderstood body. Here we 
 need only allow ourselves to be led by our knowledge of the antimony 
 salt, and all would be simpler. The dose of four grains seems simply far 
 too large. It is hard to see, indeed, how it is tolerable at all in such doses 
 in the system, and I cannot help tliinking tliat there must be many 
 cases of slow poisoning (I do not say death) unrecorded, where tJiis 
 absorbable salt was alone to blame. Of course, why As. and Sb. and 
 Bi. say in minute doses in the stomach are sedative, and in large, 
 irritant, we need not here discuss; but this apparently irritant and 
 very extraordinary action on the part of our "sedative" bismuth is 
 quite clear directly we remember its family relations, and prepares us 
 for the subniti'ate having the same. 
 
 And is bismuth trisnitrate really unabsorbed ? Well I know of no 
 experiments where there were given by the mouth small doses of the 
 annnoniocitrate (and this salt could be easily worked with), but contrary 
 to the tendency of the theory, I may say that we have two important 
 facts — first, that while we cannot produce constitutional poisoning by 
 giving the trisnitrate, no matter how lai-ge tlie dose given to animals, 
 even Ortila proved that bismuth appeared in tlie urine (liver, spleen, Arc. ) 
 of animals, and the same has been found with man. And fui-ther, 
 when applied as a dressing to wounds several deaths have occurred, 
 showingtlie characteristic signs of bismuth poisoning; as a soothing inert 
 insoluble powder acting by forming a sheathing, the bismuth could not 
 possibly poison ; but if we drop this theoryandrememberthat a very .small 
 amount absorbed of any member of this group will produce toxic signs, 
 and that bismuth can be absorbed under conditions not fully understood, 
 we at once are on our guard ; so too Bricka and Lyirbal and Lazonsky 
 have found bismuth in various secretions. 
 
 To understand bismuth, whetlier used for the intestines or the skin, as 
 compared with As. (as the type), we must think of iodine and iodoform 
 and iodol. The cliief active liody in each of tliese is the iodine ; yet for 
 say an ulcei', the iodoform is incomparably better than iodine, for the 
 first would simply exei't its action with, I might say, explosive energy : 
 the latter giving of its iodine slowly and persistently, aftbrds the 
 same influence that the continuous slow evolution say of iodine vapor 
 miglit have — gentle, yet firm in action. Now, bismuth trisnitrate 
 is really, as seen by its appearance in the urine, slowly given oft" in the 
 intestine in a soluble form (not yet understood), jierhaps never in 
 sufficient amount to be poisonous to the system, yet from the very 
 potency of the members of tlie series, (piite sufficiently to exert ;i 
 powerful effect locally.
 
 A \OTB ON DRUMINE: IS TIIKHK SUCH A BODY? 937 
 
 The bulk of a bisnuith salt becomes combined with the Ho8 in tlie 
 intestine, and appears as tlie sulpliide, this fact explaining,' why tlie 
 bismuth does not get into tlie Ijody in quantity sufficient to cause tlie 
 symptoms of poisoning, whicli are very striking, in so far as they differ 
 from the other members of the group, by one set of appearances, viz., 
 blackening with ulceration. We could in fact imagine that we 
 had a case of As. poisoning, witli strange blackening of those parts of 
 the intestinal canal wliere H„1S is given off. We have the nausea, 
 vomiting, diarrhcca with tenesnuis, uncei'tain movements, tetanic 
 spasms, emaciation, albuminuria, granular casts, and death in paralysis ; 
 but there is stomatitis, with swelling and ulceration of the mouth, as 
 well as of the colon. The blackening is seen best at the edge of the 
 gums and in the colon, and ends readily in ulceration. The explanatioii 
 is simply this : — Bismuth, coming fi'om the blood, meets the sulphuretted 
 hydrogen, which has permeated slightly into the tissues, and becomes 
 deposited as B.^Sj in the capillaries, blocking them, and so causing 
 necrosis and ulcers. 
 
 In acute poisoning we see, as in As., clonic and tonic spasms, ending 
 in deatli in a spasm, the blood pressure falling through paralysis of the 
 centres for the vascular nerves, and through weakening of the heart's 
 action (paralysis of the motor ganglia in the heart). 
 
 Where are we to place the citrate, carbonate, and oxide of bismuth '? 
 Well, these would be e\en more soluble in the acid of the stomach tlian 
 the subnitrate ; this acidity, we know, is very variable, especially 
 intense in catarrhal states, and thus we get an extremely uncertain 
 energy of these salts. The trisnitrate is more suitable therefore, simply 
 as being less soluble, or it may be better to use a substance which is not 
 dependent at all on the factor of acidity, viz.. As. ; we give our dose of 
 this, and can graduate it witli certainty. When we wish to treat 
 intestinal affections, we must choose a body which will get to the 
 intestine, and hence bismuth trisnitrate is preferable. Tii the stomach, 
 the trisnitrate is dissolved probably by the acid ; and in the intestine, 
 probably by the alkaline salts forming double salts. From this we can 
 see tliat, especially in the stomach, we nmst be prepared for the 
 subnitrate even showing irritant symptoms through dissolving in excess 
 in the acid of the stomach, and so getting into an active state. I 
 think then, we may deduce that bismuth is "arsenic with its wings 
 clipped ; " that where arsenic can be used, it is better to use it, as being 
 far easier to graduate the dose of ; but when we Avisli the arsenical 
 effect to be continuous, or we wish it to get the arsenical effect in the 
 intestine, bismuth will supply the desideratum best. 
 
 A NOTE ON DRUMINE: IS THERE SUCH A BODY? 
 
 By Thomas Dixsox, M.B., CM. Edin. 
 
 Euphorbia Drlmmoxdii. 
 In seeking the answer to the question of the existence of an alkaloid 
 in the above, I may state that tlie plant was sent me l^y .^Ir. Bauerley, 
 the well-known collector, and was thus genuine.
 
 938 INTERCOLONIAL MEDICAL CONGRESS OF AUSTHALASIA. 
 
 The first experiment of injecting hyi)oclermici\lly a large quantity of a 
 strong solution of the carefully dried and filtered extract of the herb, 
 with about 60 per cent, absolute alcohol and water, was negative in the 
 case of the frog and guinea pig. 
 
 In seeking signs of an alkaloid, I took an infusion of four ounces of 
 the herb, obtained by weakly acidulating the water with acetic acid. 
 This was filtered from the herb next morning, and treated with neutral 
 acetate of lead, and then, after filtering, with basic acetate. The pre- 
 cipitates were washed, and then carefully had their lead removed by 
 sulphuretted hydrogen. This was done to the original filtrate also. All 
 the fluids were carefully dried at a low temperature of about 150", but 
 in no case did the solutions give any trace of an alkaloid with phospho- 
 niolybdic acid, &:c. 
 
 Finally, the search was made for drumine, as isolated by Dr. Reid. 
 He suggested, in his pai)er in the Australasian Medical Gazette, to extract 
 the plant with a weak acid solution. This I did ; then filtered, pre- 
 cipitated with ammoniii, washed the precipitate with weak ammonia 
 water ; re-dissolved it in weak hydrochloric acid, passed the solution 
 through charcoal, and thus obtained a clear colourless fluid. Ammonia 
 added produced a co})ious flocculent precipitate, which was filtered from 
 the fluid, and carefully dried. Examined microscopically, it showed 
 crystals according with Dr. Reid's description closely. Some were placed 
 on a platinum pan; it darkened considerably, but left after heating in a 
 red heat, a large amount of a white ash, soluble in HCl. The original 
 powder was soluble in strong hydrochloric acid, not in acetic acid, and 
 effervesced without blackening with Hg SO4, leaving a white precipitate. 
 I could not find that watery alcohol, chloroform, or ether dissolved it at 
 all. though of course hydrochloric acid did. 
 
 Thus the substance was chiefly oxalate of lime, po.s.sibly only that 
 body. I did not trouble to see if part of it were phosphate of lime, as 
 the question was as to the j^resence of drumine. 
 
 ON THE DOSAGE OF IODIDE OF POTASSIUM, WITH 
 ESPECIAL REFEPvENCE TO THE TREATMENT OF 
 PSORIASIS. 
 
 By William M. Steniiouse, M.D., CM. Glas. 
 Honorary Physician, Dunedin Hospital. 
 
 In the Jlrifis/i Medical Journal of January 7, 1888, there appeared a. 
 leading article on the treatment of jisoriasis by heioic doses of iodide of 
 potassium, as recommended by the Norwegian physicians. Dr. Greve 
 and Dr. O. Boeck, and carried into exhaustive trial by Dr. Haslund. 
 
 When this article came under my notice, it so happened that I was 
 treating a case of inveterate and very chronic psoriasis, with but 
 iuditferent success. It is true that the affection yielded readily to local 
 treatment, especially to the ap[»lication of chrysoi)hauic acid, but no
 
 ox THK DOSAGE OF IODIDE OF POTASSIUjM. 939' 
 
 soonei' was the treatment suspeiuleil, than the tliscase returned in all its 
 virulence. The internal exhiliition of drugs appeared after a year's patient 
 trial to exercise no influence whatever upon the disease, although 
 arsenic, tar, iodide of potassium, chrysoplianic acid, iodoform, and 
 sulphide of calcium had all been put to a fair trial — the arsenic itself 
 lieing pushed to the extreme limit of toleration. Of all these drugs, the 
 potassium salt alone was thought to have had some controlling effect, 
 although this was difKcult to decide, local treatment having been carried 
 on simidtaneously. But theie was no doubt about this fact, that the 
 iodide had relieved my ])atient of dyspeptic symptoms from which she 
 had long suffered, and which are so often associated with psoriasis. 
 The largest dose administered was thirty grains a day in ten-grain doses. 
 
 Having lead the article in question, in which doses of from thirty to- 
 fifty grammes in a day were said to have been administered successfully, it 
 occurred to me that the case I was then treating was a favoural)le one 
 for testing the curative power of the drug when given in enormous 
 (loses, and the tolerance of the human subject for such doses. 
 
 ]n view of the warning contained in the last sentence of the editorial, 
 I determined to proceed warily, and not to begin the treatment until I 
 had fully explained to the patient and her father the enormous doses I 
 proposed to prescribe, and the inconveniences and risks the treatment 
 would entail. Both the young lady and her father agreed to leave 
 the case in my hands, and it only remained for me to carry out the- 
 treatment so as to subject my patient to as little danger as possible. 
 Here it may be as well to explain that the patient was twenty years old. 
 and had suffered from general psoriasis — the face and head alone 
 escaping — of a severe tyj)e since her fourth or fifth year, and that she 
 had been frequently under severe and prolonged treatment without 
 receiving permanent relief. 81ie was of a full habit, and with excellent 
 general health, her only comjjlaint being slight dyspeptic troubles, and 
 she had also a marked tendency to coryza. 
 
 The plan I adopted was to Ijegin with a moderate dose and increase it 
 gi'adually week by week until the disease was found to yield to the- 
 remedy, or the limit of my patient's tolerance of the drug was reached. 
 
 Accordingly on March 8, 1888, she began to take thirty grains three 
 times a day. 
 
 On the 2-lrth 1 saw her next, and found that she was able to take the- 
 do.se with perfect freedom, and accordingly it was increased to sixty 
 grains three times a day. I .saw her next on April 5, and now I found 
 a considerable change in her condition. The psoriasis was untouched, 
 but her j)ulse had become veiy rapid, 120 in repose, and nnich faster 
 after a little exertion, and .she had lost flesh to the extent of seven or 
 eight pounds at least. She also comi)lained that her strength was gone, 
 and that she had no inclination to do anything but only to rest. There 
 was no headache, no coryza, no conjunctivitis, and on the other hand 
 she had lost her dyspepsia. 
 
 As she was still willing to persevere, I resolved to continue the same 
 dose of iodide, 120 grains per diem, but to add to each dose five grains- 
 of tartarated iron, and three minims of tincture of strophanthus, and I 
 also enjoined her to confine herself to the sofa. I did not .see her again 
 till April 23, but had frequently heard of her in the interval as going on 
 all right. On this visit, I found she was more tolerant of the drug than
 
 "940 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 she had been. Her juilse was still quick and frequent, sjiiall and soft, 
 showing an absence of arterial tension, but it only counted 100 as com- 
 pared with 120 on my former visit. There was no further falling off' in 
 flesh, although she had lost a good deal of her normal stoutness, with 
 which effect she was very well pleased, and she did not complain so 
 much of want of strength. On inquiry, it was found that the drug had 
 ^exercised no influence on her uterine functions, which were going on 
 regularly. Her appetite also remained good, and she was quite free 
 from dyspepsia. The dose she was now taking was 150 grains three 
 times a day, which I told her to increase to ISO grains, which she was 
 the more inclined to do, as the disease was visibly yielding. 
 
 On May lo, the dose was increased to 210 grains three times a day. 
 I then saw her on the 19th, and found her quite tolerant of the medicine, 
 and greatly improved in respect of the psoriasis, which was fast dis- 
 appearing. To continue the same dose till my next visit. Saw her 
 again on June 2, found her still improving, although she felt weak and 
 little inclined for exei-tion. To continue the same dose until the skin 
 was quite clean. 8aw her again on June 13, and found her Avell. The 
 only trace of the affection was to be found on the knees and elbows, on 
 which were still a few thin scales. The skin of the rest of the limbs and 
 the body was soft and white. I now resolved to reduce the dose in the 
 ■same manner as it was increased, but more rapidly. I therefore now 
 ordered 150 grains three times a day, and at the same time prescribed 
 an ointment of iodide of potassium and lanolin, in the proportion of one 
 part of the former to four of the latter, with which she was instructed 
 to inunctuate her knees and ell)ows. 
 
 On June 28, the dose was still further diminished, the whole of her 
 body being now entirely free from her reluctant foe. On July 16, the 
 dose was down to ninety grains three times a day, tlie patient keeping 
 fi'ee from disease. On August 3, the drug was discontinued, there being 
 still a trace of the disease on the elbows and knees. 
 
 On August 23, I saw her again, and found indications of a return of 
 the psoriasis. She expressed lierself as feeling better than she had done 
 for years, having lost all her dyspepsia, and her tendency to corpulence. 
 Her pulse was 70, strong and equable; both sounds of the heart clear 
 -and full, and she expressed herself as feeling e(jual to any exertion. 
 
 The whole quantity of the iodide used between March 8 and August 3 
 amounted to 100 ounces. Its influence over the psoriasis did not appeal- 
 until the dose reached 360 grains daily, in three doses of 120 grains 
 each. Thereafter, the disease rapidly disappeared. 
 
 The importance of the case seems to lie more in the largeness of the 
 doses employed, than in the ultimate effects of the treatment. The 
 ^fleets of the treatment |)roved that iodide of i)otassium in excessive 
 doses succeeded where ordinary medicinal doses had entirely failed. It 
 Also proved that such doses can be administered with safety, although 
 not without considerable inconvenience, as it was quite impossible for 
 my [)atient, when the dose had reached 120 grains a day, to use any 
 •exertion. It would therefore seem that, in enqjloying the drug thus 
 lieroically, it will be necessary to enjoin strict caution upon our patients, 
 confining them to their room, and as much as possible to a horizontal 
 Attitude. Also, owing to the marked effect of the largest doses in 
 weakening the action of the heart, and in producing an anaemic condition
 
 TriE EFFICACY OF CHI.W TIIIPEXTIVE IX CAXCEH. 941 
 
 of the blood, the exliibition along with the iodide of some heart tonic,, 
 as digitalis, stvophanthus, or couvallaria, with iron, would seem to be- 
 indicated. In the case now under notice, the administration of five 
 grains of tnrtarated iron and five minims of tincture of stro]»hantlius 
 had the happiest eftect upon the general condition of the patient, and it 
 is doubtful if without these it would have been possible to Jiave pushed 
 the iodide to the extreme dose given, or to have continued it for t he- 
 requisite period. 
 
 Another lesson to be learned from this case is, that the supervention 
 of iodism seems to belong to small doses or to an early stage only of tlie 
 administration of iodide of potassium. For a few days my patient 
 complained of slight headache — frontal i)ain — and also of some coryza, 
 but these symptoms quickly passed of}', and never troubled her again. 
 There was on the other hand no gastric irritation produced, which has 
 been set down by some observers as one of the first symptoms of 
 iodic intoxication ; on the contrary, as we have seen, there was marked, 
 relief, nay, up to the present, complete cure of chronic dyspej>tic 
 troubles. A second train of symptoms belonging to the nervous system, 
 and which have been described as a form of iodism, as neuralgia, 
 ringing in the ears, convulsive movements, disturbed intelligence, 
 ophthalmia, salivation, vomiting, polyuria, and cutaneous eruptions, 
 was conspicuously absent. Neither was there anything like atrophy of 
 the mamma or of the ovaries, if we are to judge of the latter by the free 
 continuance of the catamenia. 
 
 Two further questions of an important and practical nature would 
 seem to arise out of this case. If it is necessary in a case of psoriasis to 
 give doses of from 300 to 600 grains daily of iodide of potassium before 
 the disease is reached, is it not likely that in many other diseases the- 
 profession has failed to procure the benefits of this drug, owing to the- 
 smallness of the doses administered ? In such an intractable disease as 
 chronic interstitial pneumonia, I have lately seen marked benefit from 
 large <loses of iodide combined with cinchona ; formerly I iised to order 
 only five grains in such cases, lately I have given thirty with ad\"antage. 
 The second question is this ; when we find a disease yielding to heroic 
 doses of iodide of potassium, is it not presumptive evidence of a remote 
 syphilitic origin ? Viewed in this light, future research may show that 
 all cases of psoriasis spring from remote syphilis. 
 
 SOME EVIDENCE ON THE EFFICACY OF CHIAN 
 
 TURPENTINE IN CANCER. 
 
 By H. E. AsTLES, M.D., F.R.C.R Ed. 
 
 Physician to Out-patients at the Melbouruo Ho.spital. 
 
 After a short historical sketch, Dr. Astles proceeded : — I now bring 
 liefore your notice two cases of my own, which T think are of interest, 
 not only because a sufficient time has elapsed to enable me to say thai; 
 the patients are cured, but also from the fact that these cases were seen 
 by others, and, moreo\ er, by men holding a prominent position in the- 
 profession : — 
 
 On January 17, 1884, a lady, about 34 years of age, was brought to 
 me for an opinion upon her case, f^he had formerly been a patient of
 
 942 IXTEUCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 mine, l)ut had only required my services at her continements, and advice 
 occasionally for little functional ailments. She stated that during my 
 -absence in Europe she had been treated by the gentleman who had 
 taken my practice in Adelaide for an offensive dischai-ge from the 
 womb, with frequent lucmorrhage and much pain; that Mr. Coi'bin had 
 seen her in consultation, and both doctors were agreed that the disease 
 was cancer. I was able to contrast her then anjvmic and cachectic, 
 appearance with her pi-evious healthy look. Upon examination I found 
 the OS somewhat dilated, and a fungoid cancerous growth involving it 
 and the posterior portion of cervix. The diseased surface, where it was 
 not bleeding, had an ash-colored appearance. As the mobility of the 
 uterus was considerably affected, there was probably more than the 
 epithelial form of mischief. 
 
 After taking chian turpentine for a month, the pain, which had been 
 very severe at night, al^ated, the discharge lessened and lost its otfensi^•e 
 character. 8he continued the treatment up to July, when I found the 
 uterus was comparatively free. The blood and discharge had stopped, 
 and a healthy mucous membrane had replaced the cancerous growth. 
 Her old healthy look had regained its appearance, and she had increased 
 in weight. 
 
 My patient then left Adelaide to rejoin her husband at Broken Hill. 
 About twelve months after this she became pregnant, and in due 
 course gave birth to a healthy child. A few months back I I'eceived a 
 letter from her husljand, who stated that his wife continued to enjoy 
 good health. 
 
 In January 1887, a young man, about 1*8 years of age, a clerk in a 
 wholesale druggist's, consulted me for a growth at the back of the 
 tongue. It was conical in shape, and in circumference as large as a 
 filbert nut. It was situated moi-e to the left than to the right of the 
 mesial line, at the base of the tongue. It had given him but little 
 inconvenience, but had slightly altered the character of his voice. 
 From the patient's age, healthy look, well-noui-ished condition, and 
 absence of glandular enlargement, a hope was entertained that the 
 mischief was not malignant. 
 
 On February 15, Dr. Gardner saw him with me, when it was decided 
 that it should be removed by the galvanic ecraseur, which he did on tlie 
 18th. Two days after the operation, a fungoid growth sprang up. I 
 then placed him on chian turpentine. Ten days after the operation, it 
 was larger than ever. I had by this time received, through Dr. Gardner, 
 a microscopic section of the part removed, which had been examininl 
 by Professor Watson, of the Adelaide University, and pronounced 1)y 
 him to be epithelial cancer. At this stage Dr. Gardner advised the 
 removal of the entire tongue, as the only chance open to him. The 
 patient i-efused to submit to any further operation, and asked to see 
 i)r. Davies Thomas in consultation, who concurred in the opinion that it 
 was malignant, and thought that it must come to extirpation. I put 
 tlie case fairly before the patient in writing, telling him I promised 
 nothing as a result of tlie chian turpentine treatment, merely that it 
 was the only drug that offered any chance of success. He decided to 
 go home to England to see again, as he said, his parents. By the end 
 of Maix'h there Avas an undoubted diminution of the growth. In April 
 he left for England, taking with him a sufficient supply of the medici})e
 
 NOTES ON THE EXTERNAL USE OF SULPHATE OF IRON. 943 
 
 to last the voyage. I received a letter fi'om him in England stating 
 that he was nearly well. Professor Clay, who had seen him, also wrote 
 to me, saying that he had progressed admirably. In November last I 
 wrote to Adelaide asking if anything had lately been heard of him, 
 and received the reply that a fellow clerk of liis had just got a letter 
 from England saying that he was in splendid health, and weighed l'2S 
 stone, which was considerably more than he did in Adelaide. 
 
 T have been treating for the last two months at the Melbourne 
 Hospital an out-patient, a woman about 50 years of age, with scirrhus 
 of the cervix. She has certainly Ijenetited by the chian turpentine 
 treatment, and at a later date T hope to jJublish the particulars of her 
 case. 
 
 Looking over the I'ecorded cases of success, one naturally asks the 
 question, how is it there are so many failures'? Might it not be 
 answered, that we must not expect cures where the destructive process 
 was extended beyond all jDOssible limits of recovery. As Professor 
 Clay says : — " Chian turpentine must not be expected to build up a new 
 uterus." And we must rememljer that, from the extreme scarcity of 
 the drug, an impure article is constantly sold, said to be made up largely 
 of resin, Canada balsam, and the essential oils of fennel and junipei". 
 What good results could be expected from the administration of such 
 a compound ? Also, that it chietly seems to be in the epithelial form 
 of the disease that we must look for success. 
 
 In this paper there is no attempt at more than the mere narration of 
 facts; for surely every instance of a successful case, among the many 
 who pay the death penalty of this dire disease, should act as a further 
 inducement to the profession at large, to continue their investigations 
 of a form of treatment wJiich has pi'oved beneficial in other hands than 
 those of Professor Clay. 
 
 NOTES ON THE EXTERNAL USE OF SULPHATE OF 
 
 IPtON. 
 
 By Colin Henderson, M.A., 31. D. 
 
 Castlcmaine Hospital, 
 
 I wish to bring into notice a remedy which is not new, but which I 
 have applied in a new manner for many years, and have found of great 
 use in the external treatment of diseases of certain kinds, and in suigical 
 injuries. The substance to which I allude — sii]i)hate of iron in granular 
 crystals — was first I'econmiended as a topical remedy by Velpeau, to 
 whom I admit I am indebted for the idea of using it, not only in 
 erysipelas, but also in other diseases of a similar nature. I use it in a 
 two-fold form of api)lication. The fir.st T have called the " glyceride of 
 iron," and is made by dissolving one drachm of the sulphate in just 
 sufficient boiling water, and then adding to that one ounce of glycerine. 
 "The lotion" is one ounce of this glyceride to five and a half ounces
 
 944 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 each of chloroforra water and of camphor water. Of course, either the 
 glyceride or the lotion can be made stronger, but the strength which I 
 have named has seemed to be sufficient. 
 
 I have used the glyceride with excellent results in the following 
 diseases in which the skin is affected, painting the part thoroughly, 
 covering it with muslin, which is also painted over and kept moist with 
 the application, and allowed to remain undisturbed for forty-eight hours. 
 In ervsipelas, and in its minor form erythema, the effect is most satis- 
 factory. The pain is relieved, the inflammation ceases to spread, and 
 desquamation rapidly follows, leaving the skin underneath quite sound. 
 
 In cellulitis, the same result is obtaineil, if the application be made 
 earlv. In whitlow, and in those analogous cases commonly called 
 poisoned finger, I have given gi'eat relief and a speedy cure, by wrapping 
 the part in hot water lint, soaking this well with the glyceride, and 
 covering it with oil-silk. In chronic eczema, and in eczema impetiginodes, 
 it acts in the same way as in erysipelas, quickly producing desquamation 
 and a sound skin. 
 
 To its excellent effect in diphtheria, I wish to call particular attention. 
 A mop of cotton wool, soaked in the glyceride, and used as a swab to 
 the throat, two or three times a day, is the best topical application I 
 have yet found. The membrane speedily ceases to form, and with its 
 disapiiearance there is always a marked improvement in the patient. [ 
 do not recollect a single fatal case, in which this treatment has been 
 adopted sufficiently early. 
 
 " The lotion " I use in all cases of wounds and bruises, which are 
 likely to be followed by inflammatory action, such as violent cuts and 
 stabs, compound dislocations and fractures. Muslin, wetted or 
 irrigated with the drip bottle, is kept on the affected part till all chance 
 of inflammation is past. The same plan I have followed with good 
 effect in burns of the first degree. It decidedly relieves pain, subdues 
 inflammation, and acts antiseptically. I am of opinion that its action 
 as an antiseptic is the explanation and foundation of its virtues. It is 
 said to have a microbicide power of 1 in 110, while carVjolic acid is 
 stated to have one only of 1 in 30. It is employed by the vine-dresser 
 to destroy " oidium," and by the farmer for "smut " in wheat, while the 
 Health Officer recommends it for destroying typhoid germs. It prevents 
 low cell growth, whether that be vegetable or animal ; hence, it would 
 be useful, I believe, in forms of tinea — a disease in which I have not yet 
 tried it. In all these cases, almost of daily occurrence, in which I have 
 made use of it, I am quite satisfied that it is a remedy of high value. 
 It possesses other advantages besides — -it is cheap for hospital use, it is 
 non-poisonous, it is odourless, and its taste as a glyceride is not 
 un})leasant — no small advantage to children having their throats swabbed. 
 It is a styptic of some power, and although applied in a liquid form to 
 incised wounds, does not prevent healing by first intention. In any 
 case, in the way in which 1 apply it, it does not cause any pain. 
 
 It lias one disadvantage — it stains sheets, towels, and linen, but the 
 marks may be removed by a hot solution of oxalic acid, or binoxalate of 
 potash, well rubbed into the fabric (3j ad Oj). This drawback of course 
 does not affect its therapeutical character.
 
 NOTES 0\ TWO CASES OF SNAKE-BITE.' 945 
 
 NOTES ON TWO CASES OF SNAKE-BITE. 
 By J. S. TinvAiTES, M.B. Melb. 
 
 J. B., was l)itten by a tiger .snake on the back of the right hand, about 
 1 2.30 p.m. on November 25th. Had .some difiiculty in shaking the snake 
 oti". He killed the snake and tiien tied a piece of rag round the wrist, 
 and made a small incision in the skin o^■er the bite, and only a drop or 
 two of blood came away. He then walked a mile to tlie nearest 
 neighbour, and by that time the poison had aftected l^oth his gait and 
 speech, and the neighbour thought he had been drinking. A piece was 
 tlien cut out (at least half an hour after bite), and whisky administered. 
 They then started to drive him down a distance of about thirty miles, 
 and sent a messenger on to warn me. I met him about four miles from 
 my residence, at 5.30 p.m. He had to be held on the seat of the buggy, 
 and had not lieen able to speak for some time, although he had had his 
 whiskers pulled, and been pinched. His pulse was very weak and 
 rapid ; pupils dilated greatly, and face very pale. I got into the buggy 
 and injected 10 m. liq. strychnia^. In a few minutes he would .speak 
 when spoken to, and his pulse improved greatly, and he could walk 
 with some assistance, but legs xevy shaky. Removed the ligature of 
 dress stuff which had been tied very loosely, and had evidently been 
 useless, as the hand was hardly swollen at all, and I could put my 
 tinger under it easily. He kept up fairly well till 8.15 p.m., when he 
 collapsed altogether; I then injected 20 m. liq. strychnia?, which brouglit 
 him round in a short time; but he collapsed altogether again at 9. 15 p.m., 
 when I injected 15 m. liq. strychniie, and in a few minutes after he got 
 slight twitchings about the face and neck, and fi'om that time he kept on 
 improving. I gave .stimulants occasionally until morning, when he felt 
 (juite Avell, but a little weak and Aery sleepy ; did not allow him to go 
 to sleep till evening. Patient had been dosed pretty considerably witli 
 whisky on the way down to keep him going. 
 
 A. D., aged 13, was bitten about 5.30 p.m., on December 14th, by a 
 tiger snake, on the outside of left leg, midway between the knee and 
 aixkle. The snake hung on for some time. She tied her garter tight above 
 the knee and x"an home, a distance of three-quarters of a mile. A large 
 piece was then cut out, and another good firm ligature put on above 
 the knee. Whisky was administered freely, but she vomited several 
 times. 
 
 I first .saw her at 10.20 p.m. and she was quite pulseless at wrists, 
 cold as a stone, and I could not detect her breathing ; could just feel 
 heart fluttering, pupils insensible to light. Injected 17 m. licj. strychnia;, 
 and applied artificial heat. In about two minutes she sighed once or 
 twice, and then began to breathe in a jerky manner. In about ten 
 minutes, on pulling her haii-, slie opened her eyes and looked round, but 
 could not recognise anyone, and pupils acted to stimulus of light. In 
 a short time she would .speak when spoken to, but could not see at any 
 distance. She kept on improving, and her sight gradually returned, 
 and in about four or five hours seemed quite well, but rather weak. 
 I gave small do.ses of .stimulants occasionally till morning, and did not 
 let her go to sleep till next evening. 
 
 2p
 
 946 INTEKCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 T noticed particulai'ly in this case, that when the strychnine began 
 to counteract the snake poison, the alcohol she had taken began to 
 act, and she became semi-intoxicated, talking loudly, swearing, &c. ; 
 this gradually wore off, and she then became very quiet. She is 
 naturally very timid and reserved. 
 
 After tlie reading of tlie foregoing paper. Dr. Augustus Muklleh 
 added a few remarks. 
 
 NOTES ON SOME INDIAN DRUGS, WITH EXHIBITS. 
 By Dr. Kiktikar. 
 
 With a view to simplify the arrangement of the preparations, I shall 
 describe them according to their natural orders, with their native names 
 as known in Western India. 
 
 N.O. Ranunculace.e. 
 
 (1) Acoaltam heterophylluvi (Atiwish).- — The preparation exhibited 
 is a powder of the tubers. It is a popular remedy with the native 
 physicians in debility after malarial fevers. Its special value lies in its 
 being a non-poisonous ])re]>aration containing an alkaloid called atishie, 
 which, though bitter, is only a harmless tonic. Aconitine is entirely 
 absent from this powder, although tlie analysis of Wassowicz shews 
 that there is aconitic acid in the root, along with a mixture of oleic, 
 palmitic, and .stearic glycerides, cane sugar, vegetable mucilage, &c. 
 (Dymock). As an anti-periodic, even when the fever is on, it is given 
 in doses of from twenty to thirty grains of the powdered root thrice 
 daily. It is given as a tonic in doses of five to ten grains, thrice daily. 
 
 (2) Coptis teeta (Mamird). — The preparation exhibited is a powder 
 of the dried rhizome. It owes its value to the presence of berberine in 
 a soluble condition, and has been used as an intestinal tonic, especially 
 where there is a tendency to a chronic catarrh of the bowels. The dose 
 of the powdered rhizome is from five to ten grains thrice daily. 
 
 (3) Thalicratura foliolosmti {PlUjarl). — The preparation exhibited is 
 the powdered root. Dr. Dymock, of Bombay, has administered it in 
 the for:n of a tincture ; and he finds, from his experience in the 
 European General Hospital, that it is "a good bitter tonic, comparable 
 with gentian." It is known to the native druggists of Bombay under 
 the name of Plaranga, and owes its therapeutic property to berberine, 
 which is found in large quantity in the roots, and is readily soluble 
 therefrom in water. It gives a tone to the bowels, and improves 
 the appetite during convalescence from malarial fever. Dose — Five 
 grains of the powder thrice daily. There is also a watery extract made 
 of the root, which may be given in do.ses of two grains thrice daily. 
 
 N.O. MENISPERMACEiE. 
 
 (4) Tlnospora cordifolia {Gulwel or Garola). — Tlie preparation 
 exhibited is a powder of the stem which may be used in making
 
 NOTES 0\ SOME INDIAN DRUGS, WITH KXIIIUITS. OJ-J 
 
 an infusion in tlie i)ro[)ortion of one ounce of the powdei' to ten Huiil 
 ounces of cold water. The medicinal value of the jilant is due to 
 a small quantity of berlierine. It is used as an alterative and tonic, 
 and has enjoyed the rej)Utation amonj^ the ancient Hindoo writers 
 of being an apla-odisiac, but as the drug is never prescribed alone as an 
 aphrodisiac, its reputation is of a doubtful nature. Dose — -One to three 
 ounces of the infusion. There is a starch obtained from tlie roots 
 and stems of this plant which goes under the name of GulAceliclie Salica 
 (the starch of Gnlirel), whicli is very similar to arrowroot in appearance 
 and effect. It answers not only as a remedial medicinal agent in 
 chronic diarrhoea and some forms of obstinate chronic dysentery, but is 
 also a valuable nutrient when there is intestinal irritability and inability 
 to digest any kind of food. I have myself had (ixperienco of the 
 usefulness of this starch. Dr. Dymock says, through not having been 
 washe'd, the starch has been found to retain some of the bitterness of 
 the plant. I have tasted the starch myself and have not found it bitter 
 to any appreciable degree, probably from the fact that ni}-- specimen was 
 difierent, but I have no doubt that the starch has- some medicinal 
 property in it from the minute traces of berl)erine which the plant 
 contains. I think also that this dnig is useful whei'e there is an 
 acid diarrhoea, due to acidity of the intestinal canal or acid dyspepsia. 
 It is useful in relieving the symptoms of rheumatism. There is another 
 l)reparation of this plant — the succus prepared from the fresh plant. 
 It acts as a powerful diuretic. It is prescribed by the ancient Hindoos 
 in gonorrhoea, with advantage. Considering that in the earlier stages 
 of gonorrhoea we now try to reduce the acidit}' of the ui-ine by alkaline 
 mixtures, it is probable that this drug acts by reducing the acidity of 
 the urine in gonorrhoea. The do.se of the succus is from one to two 
 drachms in water, milk, or honey, thrice daily. 
 
 (5) Cocculus villosus (variously named Vasaiwel, Tduvel, I'diii, or 
 Pdrvel). — There are two preparations of this plant : — (a) A liquid 
 extract obtained from the root, and [h) A syrup prejiared from the 
 leaves. It is a common hedge plant in Western India, especially in the 
 Koukan, where it is generally used as a refrigerant in febrile disea.ses, 
 and also as a gentle laxative. It has also been extensively used as an 
 alterative in chronic rheumatic, and venereal diseases. Dose of the 
 syrup — One to two drachms in water or goat's milk. Dose of the liquid 
 extract — A drachm in water or goat's milk, thrice daily. 
 
 N.O. Capparide.k 
 
 (6) Cleome viscosa {Kd)i/>huti). — The px'eparation exhibited is an oil 
 obtained from the seeds. The plant has a great reputation as a remedy 
 for chronic otorrhea. Its action is chiefly anti.septic, as it contains a 
 powerful volatile principle not unlike in smell to that of the mustard. 
 This active ijrinciple has besides stimulating properties. The plant is 
 highly viscous in every part, and is covered over with hairs, which are 
 capped with sticky glands, and smell powei-fully. The i)lant was known 
 to the ancient Hindus as " Adityaljhakta," as its delicate flowers of ricli 
 golden hue are seen at tlieir best at sunrise, and hence called " Devoted 
 to the Sun." 
 
 2p 2
 
 948 INTEKCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 N.O. PlTTOSPORE^. 
 
 (7) Pittosporimiflorihundmn (Yekadi). — The preparation exliibited is- 
 a tincture. It contains a volatile oil, which is said to act as an anti- 
 septic and stumulant to the mucous membrane of tlie bronchi. The 
 dose of the preparation is a drachm and a half, thrice daily, in water or 
 honey. 
 
 N.O. GlTTIFER.15. 
 
 (8) Garcinia mangostan (Jlaiu/i'stihi). — There are two preparations — 
 a }towder and an extract (liquid), usefid in chronic diarrhcea and chronic 
 dysentery. The value of these pre[)aiations lies in the yellow resin 
 which the rind of the fruit contains — a characteristic of the fruits of the 
 Guttifers. The resin acts like all other resins, as a stimulant to the 
 mucous membrane of the intestinal canal. I am not sure whether the 
 crystallisable substance, vianr/ostine, which Schmidt has obtained from 
 the rind, has any particular therapeutic property. It is worthy of a 
 trial, as the preparations are largely used l»y the Natives of Western 
 India in chronic cases of intestinal catarrh. Waitz recommends a 
 decoction of the powdered rind as an external astringent application. I 
 liave no doubt that the resin adds to the value of this local remedy, by 
 mechanically constricting the parts gently — an effect very often 
 produced by uniform light bandaging. 
 
 (9) Ccdophyllum inophyUum {Undi). — The pi'eparation exhibited is 
 an oil from the seeds. It is known in Ceylon as Domha, and used for 
 burning. It make a good embrocation in chronic rheumatic arthritis. 
 It has a slightly stimulant action on the skin. 
 
 N.O. Malvace/E. 
 
 (10) Ada7isonia digitata {GoraJcli-chinch). — The jjreparation exhibited 
 is an extract prepared from the bark. Dose — About thirty to forty 
 grains a day, in small doses, every third or fourth hour, in intermittent 
 fevers. The fruit pulp is acid, and makes a verj- pleasant refrigerating 
 drink. When unripe, the fruit }>ulp is mucilaginous, but as it gets ripe, 
 it assumes the appearance of dry pith, containing dry powdery acid 
 starch-like stuff, enclosed in bundles of fiVtre, and surrounding the seeds. 
 Walz has extracted an active principle from the bark, called Adansonin. 
 The pulp is an astringent in diarrhrea, like gallic acid. 
 
 N.O. RUTACE.!-:. 
 
 (11) Toddidea acideafa (Jangll Kdli viirchi). — The powder is obtained 
 from the root. It has been recommended by Dr. Bidie, of Madras, as a 
 bitter tonic in debilit}', after malarial fevers, and in convalescence from 
 exhausting diseases. I have tried it in the malarial cachexia of fevers, 
 and find that it acts as a good stomachic tonic, improving the appetite, 
 and aiding digestion. An infusion of the root powder, in the proportion 
 of an ounce to ten fluid ounces of boiling water, makes a capital pre- 
 jtaration. Dose — One to two ounces twice or thrice daily. Four years 
 ago, I obtained a few pounds of the root from Di-. Dymock, and tried 
 them with great advantage. The root contains a bitter principle, the 
 exact nature of which is yet unknown. It was once known in Europe
 
 XOTKS ON 80ME INDIAN DKUGS, WITH K.XHimTS. OiO 
 
 nnder the nauie of Lopez-root, as a remedy for diarrhcea, probably from 
 the large quantities of yellow resin which its vascular and cortical 
 systems contain. " The bark," says Dr. Dymock, "is remarkable for its 
 large cells, tilled with resin and essential oil. 
 
 (12) ^Ef/le marmelos {£<.el/>hal). — The preparation exhibited is a 
 preserve of the fruits in sugar. It will be observed that the specimen 
 is clear ; there is no trace of muddiness, indicating fermentation. The 
 slices of fruit are solid, succulent, and not jagged. The latter condition 
 occurs in fruit that is preser\-ed when it is ripe. It is worth}' of remark, 
 that nearly all the English and even Indian ]n-eparations of bael are 
 made when the fruit is ripe. This is a mistake. When the fruit begins 
 to get ripe, and sugar appears in the pulp, the medicinal value of the 
 fruit is reduced, if not lost altogether. The fruit should be unripe for 
 preserve. In this state, there is round the small seed a mass of 
 mucilage, which is a great agent in allaying irritation in the catarrhal 
 inflammations of the intestines. The native physicians, especially the 
 celebrated Vaidya Prabhuram Jivauram of Bombay, a venerable man 
 learned in ancient Hindu medicine, and not unwilling to profit himself 
 by the advanced researches of European therai)eutics, insist, in their 
 preparation of the preserve, on using the fruit quite unripe, when the 
 rind is green. The unripe fruit alone is highly astringent. The ripe 
 fruit, on the other hand, is a mild laxative. This must be remembered 
 if the preserve is to be used for the one or the other purpose. It is a 
 common household remedy in Western India, as effective as it is 
 handy, especially Avhere there is a tinge of scurvy in the patient. 
 
 N.O. Leguminos.e, 
 
 (13) Poti'/'tinia glabra [Kwanjd). — The oil exhiljited is pressed out of 
 seeds. It is an exceedingly useful oil in cutaneous eruptions of the 
 inflammatory tyjje — as, for instance, in chronic eczema after the " weep- 
 ing " stage. It is an emollient of the best kind, and I have used it 
 with or without oxide of zinc with great benefit. It is used in pityriasis 
 and scabies, but I am not sure of its properties as a parasiticide. 
 
 (14) Bauhinia parvifiorn (a variety of lulncJian). — The preparation is 
 a kino, or dried extract obtained from the bark. Dose — 5 to 10 grains 
 in dysentery and diarrhcea of a chronic nature. I have never used it 
 myself. 
 
 N.O. Lytiirack.e. 
 
 (lo) Amiiianla hacci/era or A. vesicatoria {Aaya). — There is a liquor 
 from the leaves of this strange ))lant which, as its name indicates, is 
 " fiery " — quite a substitute for the Spanish blistering fly. Koxburgh 
 first introduced it into the Eui'opean world. It blisters the skin, if the 
 ethereal tincture is used as recommended by Dr., Dymock, " rai)idly, 
 ■eflectually, and without causing more pain than the liquor ei)is])asticus 
 of the British Pharmaco))aMa." Dr. Bliolanath Bose gives it internally 
 in chronic enlargement of spleen in the shai)e of juice of leaves ; but as 
 may be supposed from its vesicating eflect on the skin, the leaves are 
 extremely acrid, and as a consequence must, and do, produce gastric 
 irritation and positive pain. 
 
 J
 
 950 IXTERCOLONIAL MEDICAL COXORESS OF AUSTRALASIA. 
 
 (16) Lawsonia olha (Mencfi or Ile/iud). — The preparation exhibited is 
 an ointment made from the leaves. I do not know if this drug lias any 
 therapeutic value. The natives of India, especially the Mahoniedan. 
 males and females, use the leaves to dye tlieir hair, hands, feet, and 
 nails. The leaves are bruised with lemon juice, and put on the parts to 
 be dyed overnight, and sometimes for forty-eight hours. A rich scarlet 
 staining of the parts is ol^tained. The dye is produced by the action of 
 the acid of the lemon on a particular kind of tannin which the leaves 
 contain. 
 
 N.O. Myrtace.i^. 
 
 (17) Eiifjenia jamhulana (JAmlml). — The following preparations ai-e 
 exhibited : — 
 
 (rt) Powder obtained from the seed. Dose — .") grains thrice daily. 
 
 {h) Syrup obtained from the jiulp of the fruit. Dose — -A dessei't- 
 sfioonful to a tablcspoonful thrice daily, in water. 
 
 (r) Wine obtained from the pulp of the fruit. Dose — An ounce 
 thrice daily. 
 
 {(I) Acetum obtained from the i)ulp of the fruit. Dose — One to two 
 teaspoonfuls thrice daily. 
 
 The powder has been used by Deputy Surgeon-General Henry Blanc,, 
 of Bombay, with remarkable success in the treatment of diabetes. In 
 my hands, it has not fared so well, though I have given 30-grain doses, 
 thrice daily. In many other hands, it has failed equally. The seed 
 should be fresh, as it is liable to be destroyed by a kind of weevil which 
 attacks it soon after, and sometimes even before, the fruit is ripe. The 
 fruit is notably astringent to taste, though, when perfectly ripe and 
 fresh, it is refrigerant. The preparations of the fruit ai'e used in bilious 
 diarrhoea, and are highly astringent. 
 
 N.O. Umbellifek.e. 
 
 (IS) Il>/drocoti/le Asiafica (JJntmhi). — The preparation exhibited is a 
 succus obtained from the leaves. The dose for children is from ten to 
 twenty drops in honey, thrice or four times daily. It is good as an 
 intestinal tonic where there is catarrh of the mucous membrane, follow- 
 ing habitual constipation. It is mentioned in the old Sanskrit work of 
 (Jhakradalla. On the Malabar coast it is used in leprosy, but Dr. Hunter 
 who tried it in the Leper Hospital of Madras so far back as 18.55, says 
 that the drug is not a specific. When I was surgeon in charge of the 
 out-patients' department in the Jamsetyi Jijibhoy Hospital in 1886-87, 
 I tried this drug in the anpesthetic variety of leprosy. At the instance 
 of my friend Dr. Anno Moreshwan Kunte, B.A., M.D., who has charge 
 of the Incurable (Leprosy) Asylum, attached to the Jamsetyi Jijibhoy 
 Hos[)ital, and has recently had great experience in the treatment of 
 leprosy, T tried ten grains of the powdered leaves of this plant in 
 about fifteen cases. It had a distinct effect on tlie sensory nerves. 
 There were no doubt an improvement in the cases. The anpesthesia 
 disapi)eared. I think that the cutaneous peripheral branches of the 
 troiihic nerves were stimulated, and the development of the tubercles- 
 
 I
 
 NOTES OX SOMK INDIAN DRUG'S, WITH EXHIBITS. 951 
 
 stopped. In the mixed form of lein-osy wliere there are both tul>ei-cles 
 and anaesthesia, if the latter can \>e stoi)ped the tubercles will not form, 
 as the further degeneration of the parts supplied by the nerve.s is 
 etlectually stojjped. Here is a good Held for further research. I must 
 state howevei-, that I never used the powder in advanced cases of leprosy, 
 and used it only in the anaesthetic form. Dr. Knnte bears me out in 
 my experience. It is recognised by the " British Indian PharmacoiKeia." 
 
 N.O. Co.Ml'OSIT.E. 
 
 (19) SphercnitJiKS Indices {Gurak/i-miindi). — The prepai'ation exhibited 
 is a water, containing in solution a very small quantity of the viscid oil, 
 obtained from the i)lant. It was known to the ancient Hindus as au 
 intestinal parasiticide, and is mentioned in Sanski'it works as muuditihd. 
 It is used as a diuretic in Java, and is excreted by the kidney and skin ; 
 both the urine and persjdration of {)ei'sons using it smell of the volatile 
 oil. It is a powerful altei-ative and tonic. 
 
 (l2f>) Blumea (several sj)ecies), commonly known in Boudjay as 
 Ji/idi/ibnrdd.— The preparation exhibited is an insect powder made from 
 the leaves of tlie various wild species of Blumea and Anona squamosa. 
 The Blumeas have a rei)Utation of destroying tieas. The powtler of the 
 Anona appears to be added to heighten the action of the Blumea leaves. 
 They are both possessed of powerful smell, and contain large quantities 
 of volatile oils in every part of the [)lant. In Bombay, floors attacked 
 l)y fleas are brushed or swept with bundles of the blumea plant, dried 
 or fresh. 
 
 (21) Edipta alba vd prodrata {Mdkd or Blhrungi Rdj). — The prepara- 
 tion exhibited is a succus oV)tained from the leaves of the plant, which 
 grows very commonly by the way side and green alleys in Bombay. It 
 was vised by ancient Hindus as a remedy against hepatic and splenic 
 eidargements. Mr. Wood considers that the plant may some day 
 supersede taraxacum. Dose — One or two drachms thrice daily. 
 
 N.O. Apocynace^. 
 
 {'I'l) Alstonia .sdtolaris (Sdi/'H/i). — There are three preparations 
 exhibited — there is an extract, a liquid extract, and a powder of the 
 l)ark. From the powder of the bark an infusion is prepared (half an 
 ounce to ten ounces of boiling watei- infused for an hour and strained). 
 Tills plant has a parallel in the dry inland warm parts of Kast Australia, 
 in the alstonia constrida. which Bai-on .Sir Ferd. von Mueller says 
 {I'kh " Select Extra Tropical Plants " p. 30), is " aromatic-bitter, and 
 regarded as valuable in ague, also as a general tonic." The learned Baron 
 recommends that the sap of all alstonias should be tried for caoutchouc. 
 The tree was known to the ancient Hindus as saptaparna, i.e., having 
 seven leaves in a whorl, wherever they rise, unless abortive. It is still 
 used by the natives of India as a powerful tonic and anti-periodic. It 
 is known to the natives of ^lanilla as </i(a, from which an active 
 j)rinciple "ditain" has been obvained. Ditain is considered quite equal to 
 quinine in its anti-periodic pro|)ertii'S, and has the advautigeover quinine 
 moreover, of not causing the unjjleasant after-effects of "cinchonism." 
 My friend. Dr. Bhalchaudin K. Bliatwadekar, has used it in Baroila 
 successfully, when court physician there some years ago, ahnost as a
 
 952 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 «|iecific I am told in reducing enlargements of spleen of malarial origin. 
 The dose of the liquid extract is tive to ten minims thrice daily, that of 
 tlie extract is one to three grains thrice daily, and that of the powder 
 of the bark five to ten grains thrice daily. The drug is worthy of an 
 extended trial. There is an elaborate account of the chemical com- 
 ]>osition of this plant given in the "Year Book of Pharmacy" for 1881, and 
 the jilant has a recognised place in the " British Indian Pharmacopeia." 
 
 (23) Holorrhena anti-dysenterica {PCiudhrd, i.e., white Kudd). — The 
 exhibit is the powdered bark. This plant is entirely distinct from the 
 Kdid or black Kudd, known as Wrightia tinctoria, the bark of wliicli 
 has often been substituted for the Holorrhena, and found inert. In 
 selecting samples therefore of PdiuUint Kudd, this fact must Vie 
 remembered, as the Wrightia bark has not got the anti-periodic, tonic 
 and anti-dysenteric properties of Holorrhena. The root bark of 
 Holorrhena is bitter, that of Wrightia is only moderately so, if at all 
 bitter. The bark of Wrightia tinctoria, besides, colours the saliva reil. 
 Holorrhena bark has none of this property. It is essential to know 
 this diagnostic difference. In India, Holorrhena is largely used as a 
 remedy in dysentery and diarrhoea. The dose of the powder is ten to 
 twenty grains with opium. A decoction of the bark may be made l)y 
 taking two ounces of the bark, adding it to two pints of water, and 
 boiling it down to a pint. Dose — Half an ounce to two ounces, with 
 a suitable quantity of tincture of opium, four times a day. 
 
 (24) Flunieria acutifolla {Kliairchaynpd). — The preparation is an 
 extract from the bark of the tree, given in doses of from five grains to 
 iiiore. Extreme care should l>e taken in using this drusr. It is found 
 useful in intermittent fevers and gonorrhoea. I have i-eported a case * 
 which occurred in my practice in the ^Military Detachment Hospital 
 at Thana, where a jH'ivate swallowed about two inches square of the 
 thick bark to relieve constipation. He suffered violently from vomiting, 
 giddiness, and dilated pupils ; clammy sweats on the face ; cold extremi- 
 ties ; intellect clear. He recovered. Eight days subsequently, he had 
 exfoliation of the epidermal tissue of the whole body. The poisonous 
 ]:)roperties are in my opinion due to a glucoside having a purgative 
 action. It must be remembered that the plant is leafless for nearly six 
 months in the year; its glucosides, therefore, are abundant in the quiescent 
 state, tlie sap undergoing concentration, and rendering the active principle 
 obtainable in larger quantities from a given square inch of the Ijark, as 
 compared with what may be obtained when the leaves are out. 
 
 N.O. ASCLEPIADACE^. 
 
 (2.'5) Hemldesinus Indicus (Atia/d Mul ov Upalsar). — The preparation 
 exhibited is a liquid extract obtained from the fresh root. A drachm or 
 two thrice daily, in two or four ounces of fresh milk and sugar or warm 
 water, act as an excellent alterative, tonic, diuretic and diaphoretic. 
 Tlie plant is a well-known j)opidar remedy in India in all kinds of 
 constitutional debility, especially among children, who take it readily. 
 On account of its diui'etic proj)erties, it is of especial use in rheumatic 
 
 * Vide Brigade-Surgeon Lyons' " Medical Jurisprudence," Bombay, 1888, p. 200 ; 
 and vide " Bombay Medical and Physical Society's Transactions,'' vol. ix., nr\v 
 series, 1887, p. xiv.
 
 NOTES ON SOMK INDIAN DKUGS, WITH EXHIBITS. ^')'3 
 
 '.iffections, and in skin diseases arising from nial-nutrition and deficient 
 action of the excretory organs. 3Iy friend, Dr. Guerson da Cunha, of 
 Bombay, uses it largely, in a successful manner, as an alterative. 
 
 N.O. BlGXONIACE-E. 
 
 (26) Oro.ci/lum IiuUcnm, Syn. Calosaiifhus Iiidica [T'-tu). — The 
 pre|,)arations exhiljited are {a) powder of the bai*k ; (6) an oil obtaint'<l 
 by boiling the bark in teel or sesame oil ; and (c) a syrup of the bark. 
 The bark is used usually in tlie shape of a ))o\vder in from live to fifteen 
 grain doses thrice daily, or in the sliape of an infusion (one ounce of the 
 ])Owder to ten ounces of boiling water) an ounce thrice daily. Its chief 
 use is as an astringent in dysentery and diarrhoea. It is not nauseating, 
 and has thus an advantage over ipecacuanha. It is also a sudorific. 
 It is a very ancient remedy, and is described in the Sanskrit work of 
 Sliarangdhan. The oil is used in otorrhoea. The syrup is a very 
 agreeable preparation ; it also pi'eserves the active principle of the bark 
 better. A}iplied externally in the shape of a paste of the bark powder, 
 it is an anodyne in the swellings of rheumatism. 
 
 N.O. ACAXTHACE.E. 
 
 {'11) Adhdoda vasica (Adulsd). — The jn-eparations exhibited are the 
 succus and the mel from the flowering tops and leaves. The honey 
 of adulsa is mixed with ginger and long pepper. This is a very ancient 
 household remedy for asthma and bronchitis of a catarrhal and chronic 
 type. There are also among the exhibits some cigarettes made from 
 the leaves of this plant, which are effectively used in Bengal for asthma. 
 The dose of the honey is a teaspoonf ul or more three or four times daily. 
 Of the succus, a dessertspoonful in water. In selecting the plant, it 
 must be remembered that there are two varieties — the white and the 
 black adulsH, the " white " being variegated, and the " black " daik- 
 leaved. 
 
 (28) lihinacanthus communis ((Jajkarna). — There are two pre])aratioiis 
 from the root, viz., the powder and solution (tincture?), as Mr. Pareira 
 calls it, of the root. There is also an extract from the leaves, which is 
 mixed up with fresh lime-juice, and applied over ])arts attacked with 
 ringworm. I do not know whetlier the solution or the extract is the 
 better preparation of the two. Dr. Dymock says, " The extract is the 
 best." The powder also has to be mixed witli lime-juice, before it is used 
 as an application for ringworm. The analysis of Lilwrius show that the 
 ]»lant contains a dull cherry-i*ed substance, called rhinacanthin, which 
 seems to be related to chrysophanic and frangulic acids (Dymock). 
 Hence the value of the plant as a destroyfir of vegetable parasites of the 
 human skin. 
 
 N.O. AMAKANTACE.E, 
 
 (29) Amarantus spi/wsus {Ka.nt<; MAt or Tandult/a). — Syrup of the root 
 exhibited. It is useful in gonorrhtea, for stopping the muco-purulent 
 discharge and scalding, jjrobably acting as an emollient. Dose — A 
 teaspoonful or more in water, three or four times daily.
 
 954 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA, 
 
 N.O. EUPIIORBIACE.E. 
 
 (30) Croton ohlorir/ifoKuhi (Gansitr). — (Figured for the first time in 
 Kirtikar's " Illustrations of the Bombay Flora"). The powder of the 
 i-oot is exhibited. Dose — Tliree grains, or more, short of purging. •' In 
 the Southern Koukan," says Dr. Dyniock, " it* lias a reputation as a 
 remedy against snake-bite. The inhabitants of Goa, .says he, use tlie 
 bark for chronic enlargements of liver, externally (as a paste), and in- 
 ternally, and also in remittent fevei-. The value of the plant is due 
 [irobably to the resinous substance the bark contains. 
 
 (31) Eupliorbia pilalifera (DMkti Dudhi). — There is a syruj) and a 
 powder obtained from the whole plant. Half an ounce of the powder, 
 with t\vo quarts ot water, boiled down to a quart, makes a very good 
 decoction, of which a wineglassful may be given thrice daily, after 
 meals, in chronic bronchitis and asthma. It has been tried with benefit 
 at the J. J. Hospital, of Bombay. Of the syrups, a drachm given thrice 
 daily, in water. 
 
 (32) AcaJy})ha Indica {Klwhli). — There is the succusand the ethereal 
 tincture. The latter is a preparation used by Brigade-Surgeon Langley, 
 of Bombay, whose extensive pi-actice affords him many oppoi'tunities of 
 te.sting the value of his pre.scription. "The natives," says he, " use it 
 in congestive headaches. A piece of cotton is saturated with the 
 expi'essed juice, and inserted into each nostril ; this produces hfemorrhage 
 from the nose, and relieves the head symptoms." Twenty to sixty 
 minims of the ethereal tinctui'e frequently given to a child during the 
 day, in honey, act as an expectorant and nauseant ; very particularly 
 useful, therefore, in bronchitis in children as a substitute for ipecacuanha, 
 which acts as a depressant. In large doses, it is an emetic of equal 
 value. It has no tendency to act on the bowels like other euphorbias. 
 Dr. Ross ranks it with senega. 
 
 With these few observations, I proceed to describe three new plants 
 of medicinal value, which are not included by Mr. Pareira in his 
 ])amphlet, a few copies of which I place in your hands for perusal. 
 The plants, yet unrecognised medicinally, and of which I have 
 preparations here, are : — 
 
 (1) Casearia escuhnta [Modi, or Bitori). 
 
 (2) Sieriesheclia Orientalis (Piwald, Jjhdnf/rd or Sonki). 
 
 (3) Flemith/ia tuberosa (Bhdrtondi). 
 
 Casearia escnle)ita is a plant of the natural order Samydacea^ (Hooker), 
 and is known by the natives of India as Modi. In Salsette, it is known 
 as Bitori. It has a thick root, often reaching the size of two inches 
 in diameter, and Iiaving seven concentric rings. It is therefore called 
 Satjana, with seven rings, or layers. It has also seven distinct pro- 
 jierties as a medicine internally administered for hepatic congestion, for 
 luumorrhoids, and for the relief of the i)Ortal congestion generally. It 
 also acts in reducing splenic enlargement and jaundice produced by 
 splenic enlargements. It is useful for jaundice, as the result of duodenal 
 catarrh. It is also an excellent stomachic tonic. 1 have used it lately 
 with marked benefit, in the shape of an extract pi-epared from the root, 
 and it no doubt relieves the portal congestion, which promotes the 
 hteraorrhoids.
 
 NOTES ON SOMK INDIAN DRUGS, Willi K.Ml IKII'S. 955' 
 
 Siegesheck'ta Orientalis belongs to the N.O. Composltii'. In the 
 tribes formed in the re-classification of this N.O. in Bentham's " Genera 
 Plantaruni," this plant is consigned to the tribe U'eUaxthoido; (heads 
 lioterogamous, rayed, or rarely discoid, or with the ray suppressed, and 
 then homogeiipous). This plant is named by Linnreus in derision of the 
 high pretensions of one of his contemporaries — Siegesbeck — -who con- 
 temned his sexual system I I am sure, in thus expressing his contempt 
 for a literary enemy, Linnajns has unconsciously immortalised a name 
 that he would rather have had forgotten. The plant is known to the 
 natives of Bombay as Pivxild Bhdngrd, or Sonki. It is widely dis- 
 tributed in India. It is a hardy annual about two feet in height ; 
 tlowers in September, with yellow heads ; leaves ovate, cuneate at base, 
 acuminate, and closely toothed ; the \ipper ones oblong, lanceolate ; 
 the exterior scales of the involucrum, twice the length of the iiivolucrum. 
 — D.C. 1. c. 5, 495. The properties of the plant are those of a powerful 
 alterative, and it is made use of by the natives in syi)hilis. Whether 
 it has any eftect on the syphilitic virus or not, I am not prepared to 
 say. I recommend the plant a trial, which is well worth having. It is 
 lai'gely used by the natives of ^Mauritius, and I see from the British 
 }[edical Journal of June 25, 1887, that a syruji of its leaves is used by 
 Mr. Hutchison, of Glasgow, as an alterative in sy])hilis, scurvy, and 
 .scrofula, and that its leaves are used for poultices to gangrenous and 
 sloughing soi'es. The chief property for which Mr. Hutchison uses it, is 
 that of a cutaneous stimulant and parasiticide in ringworm. A tincture 
 with an equal part of glycerine is used morning and evening for killing 
 trichophyton tonsurans in tinea circinata and tinea tonsurans, and 
 microsporon furfur of tinea versicolor. It is also useful in killing the 
 parasite of tinea sycosis (Mentagrophyton). It is well worthy of an 
 extended trial in India in its new form of the syrup I place before you. 
 
 Flemimjia tuberosa. — This plant is described by Dalzell, and I 
 reproduce a brief descri))tion, Mr. President, fi-om your own work — 
 "The Select E.xtra Tropical Plants" — a copy of which you were so 
 gracious as to present me witli at our very first meeting in this city :— 
 
 It is found in Western India. It belongs to the natural order 
 Legum'mosfi'^ and is known to the natives of Bombay as Jlhdrfoadx. 
 The tubers of this herb are said to l)e edible ; they are generally of the 
 thickness and length of our thumb, pointing like a spindle at each end. 
 Baron Sir Von Mueller says that there is on record another species — 
 F. vpstita (Bentham) — cultivated for its small esculent tubers in North- 
 western India, where it ascends in the temperate region up to TOriQ 
 feet. Its chief use is, that it acts as a demulcent in diarrhcoa and 
 dysentery. I have here tablets prepared of it, from the jiowdered 
 tubers, by Mr. Pareira, which are deserving of a trial. Whether they 
 have any astringent property, or whether the roots act merely as a 
 demulcent and soothing agent in affections of the bowel, I don't know 
 from personal experience, as the preparation was put into my hands 
 just as I was starting for this colony. 
 
 All these preparations are quite recent, and I hope you will pardon 
 me if I bring them before you without l)eing able to say anything about 
 them of a sul)stantial character, in the shape of physiological and clinical 
 observation, from personal experience that would lead to their ready 
 introduction into medical practice. I am simjily desirous of showing
 
 956 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 how much European pharmacy is capable of doiug for the vast and yet 
 unexplored store of the indigenous products of India. 
 
 There are other plants, such as the Carica Papaya, and the Gipaneiaa. 
 sylveslre, which are now attracting deserved attention even in England, 
 — the one as containing papain, and the other as containing an active 
 principle lulling the sense of taste for sugar. The latter is looked upon 
 -as a remedy for diabetes. There is also a loranthus growing on 
 sti-ychnos nux vomica, which has been brought to my notice by a young 
 man who has diabetes himself, and who has himself found relief, and 
 given it generously to others. I have tried his pills, made from 
 l^owdered leaves (eight for four days, used with § ss ghee daily), but T 
 found that no ojood was done. 
 
 N0TE8 ON AN EXHIBIT OF INDIAN REMEDIES. 
 
 By R. Temple Wright, M.D., M.R.C.R Lond., RR.C.8. Eng. 
 
 Surgeou-Major H.M. Bengal Army. Civil Surgeon of Jaunpur. 
 
 Rulv. Belfe Co. (compound bael powder). — R. Bael fruit pulp), 
 -2 oz. (avoirdupois); am choor, 4 oz. ; ispaghiil seeds, loz. ; acacia gum, 
 1 oz. ; ginger, h oz. All these should be dried and ^jowdered separately, 
 then carefully mixed and pounded; then two parts of this mixture 
 should be mixed with one part of powdered sugar. Dose — One drachm 
 every three or four hours. It is very useful in diarrhoea and dysentery, 
 espiecially in children, and is by no means disagreeable, while it causes 
 none of the nausea of ipecacuan. Cost — Made locally in the dispen- 
 saries at the headquarters of districts, it costs about a rupee a pound 
 (say two shillings per 11).), in ordinary yeai's, when the crop of mangoes 
 is not deficient. 
 
 The botany of the above preparation is as follows : — 
 
 Jjael (^gle ^Nlarmelos), a large tree, natural order Rutaceie. The 
 medicinal part is the fruit, like a large apple, with a haxxl, thick, rough, 
 green, woody rind. This is cut open with a hatchet when ripe, or 
 three-parts ripe, and a coarse, yellow, stringy pulp is scooped out. 
 This is dried and powdered, and preserved in corked bottles for use. 
 
 It is also made into a syrup with sugar and water at once, whenfi'esh, 
 and then it tastes something like an apricot. It is called by the 
 natives bael sherbet, and is quite as efficacious in this form as in the 
 state of dried powdered pulp. 
 
 The liquid extract of bael is also efficacious when fresh, but it does 
 not keejj well, so tliis form has caused disappointment Avhen exported. 
 
 Aiiicltoor, made from mango fruit.- Mango Mangifera Indiea, natural 
 order Anacardiaceie, a tine shady forest tree. The medicinal part is 
 the unripe fruit, split open and dried in the sun, without the seed. The 
 seed is a veiy large kernel, forming about a third of the bulk of tiie 
 fruit, which may weigh from three to eight ounces. The kei'nel is 
 pounded, and used by the natives as a I'emedy against lumbrici, 
 hiemori'lioids and inenoi'rhajria.
 
 NOTKS 0\ AN KXItllilT OF INDIAN ItF.MKOIKS. 957 
 
 The native word for " maiiyo " is "am." The dried unripe fruit is 
 called " katai," i.e., soniethinti" acid, as they pound a little every day to- 
 eat as a relisli with their food. AVhen the katai is pounded, it is called 
 (i)n-ch'oor, or dm-sool, and is a \aluable anti-scorbutic if i;i\en in food 
 to the extent of an ounce pei- day. It is also used for cleaning- 
 lithographic slabs, removing iidv and grease. 
 
 litj>ri(//ti(l (seeds of plantago ispaghvda), natural oi-der Plantagineje. 
 When moistened, these seeds, whole or powdered, swell up, and are 
 very demulcent, often sto])])iiig diarrluea, wliich has resisted all other 
 treatment. 
 
 i'lacJioyia Fehvifuye.— \\\\v\i i|uinine could be ol)tained only from 
 Peru, the price was so high as to be prohibitory, so the (Government 
 of India obtained seeds and cuttings of various species of cinchona, 
 and planted them in India, on the Himalaya mountains in the north, 
 and the Neilgheri-ies in the south, where they have been acclimatised so 
 successfully that, after supplying its own State hospitals, Government 
 sells to the public cinchona febrifuge at twenty rupees per pound. On 
 its tins the following label is pasted, giving an analysis of the mixed 
 alkaloids in it : — 
 
 
 Analysis. 
 
 
 
 Quinine 
 
 
 . lL'-l(i 
 
 ter cent. 
 
 Quinidine . . . 
 
 
 . 00---)G 
 
 
 Cinchonine 
 
 
 . 2.5-00 
 
 
 Cinchonidine 
 
 
 . 34-98 
 
 
 Amorphous alk 
 
 iloid 
 
 .. 8-20 
 
 
 Ash 
 
 
 . 6-62 
 
 
 Water and colouring matter 
 
 . 12-48 
 
 
 Total 100-00 „ 
 
 It forms a brownish-yellow powder, having a disagreeal)le odour, and 
 such a nauseating taste, that it cannot be given in large doses, like 
 cjuinine, without causing vomiting. 
 
 To prevent this, it is made into pills of two giains each with gum 
 water, two of which are gi\en every three houi's, while fexer is absent. 
 Its effect as an antiperiodic is thus secured without Ijad i-esult, and the 
 drug is distributed to the million by native doctors, vaccinators, and 
 policemen. 
 
 The importance of it may be judged from the fact that fever causes 
 about three-fourths of all the deaths among the natives of India — all 
 other causes being insignificant, even including epidemics of small-pox 
 and cholera. 
 
 The death-rate from cholera is only 1-8 per 1000 in tlie very worst 
 parts of lower Bengal — a damp climate — while it is only 0-2 per 1000 
 in Sindh — a dry climate. 
 
 Erf. Jamholmui', Liquidtim (Kemp). — Fluid exti-act of the seeds of 
 JfimhvJ, natural order Myrtacete, Eugenia Jamljolana (Blanc), or 
 Syzigium Jambolanum (Waring). 
 
 It was first introduced into general use by Dr. J. H. Blanc, Bombay 
 Army, in 1844, as a most useful drug for diabetes. Dose — One or two 
 fluid drachms in watei- three times a day.
 
 ■958 IXTEHCOLOXIAL MEDICAL CONfiKESK OF AIJSTKALASIA. 
 
 While taking j.-uiibul the diet is not restrieted in any way, as jambul 
 has a remarkable power of preventing starch from being converted into 
 sugar, the urine in two or three weeks liaving its specitic gravity 
 reduced from 1042 to 1020. 
 
 It is carefully prepared from tlie fresh fruit every year, in Bombay, 
 by Messrs. Kemp and Co., who doubtless could also supply the other 
 things mentioned in this paper. 
 
 Joara IIkvI, or Fever Killer, a patent preparation of Mi'. Bowden, 
 Madras. It is like Warburg's Tincture, a combination of quinine witli 
 certain aromatic substances, which are poweiful diaphoretics; but it 
 has a fai' nicer taste than Warburg's Drops. It often cliecks inter- 
 mittent fever, when all other things have failed. Like all othei' 
 febrifuges in India, it sliould be pi'eceded l)y .i purgative — pil. podophyl. 
 being generally preferred. 
 
 OX A NEW :\IODE OF ADMINISTERING THE PROTOXIDE 
 
 OF IRON. 
 
 By Thomas Sheakman Ralph, M.R.C.8. Eng. 
 
 Associate of the Liinieau Society, Loiuloii. 
 
 It is both interesting and instructive to look back on the various 
 ferruginous prejjarations wliich from time to time have been placed :it 
 the disposal of the medical practitioner, to aid him in what no doubt 
 was the thing needed, viz., a further accession of iron in the circulatory 
 system, and when this effort proved successful, most probably the result 
 was favourable both to the patient and to the administrator. 
 
 One of my oldest Ferric acciuaintances was the " Ferrum tartarisatum," 
 and with this there was an ancient form — and a good one — -but which has 
 well nigh been cast into oblivion, with much likelihood of becoming a 
 rusty compound. For, as most of us know, or are likely to know, tli«? 
 old Oriffith's mi.xture. which has for its base a subcarVjonate of iron (or 
 rather a carbonate of the protoxide), while it was good and active during 
 its green coloured state, soon :issunied a rusty brown, and becaiue inert. 
 And the mixture also was not agreeable to tlie taste, owing to the 
 companionship of pulv. myrrha?. 
 
 These forms, with the old rust coloured oxide of iron, which yeaj's 
 ago was administered in very bulky doses, and seemed to l)e serviceable 
 in its emi)loyment, have all waned before fresh combinations of the base, 
 i.e., ferrum \uiited with some acid or saline. And each has had its day, 
 and number of patients, fair tibial, and share of approval, and have 
 bestowed, no doubt, a modicum of benefit. 
 
 Our lists of comliinations of ferrum may l)e classed roughly under 
 three groups : — 
 
 The metallic forms and the oxides, including the carbonated oxides ; 
 the saline forms, or those combined with mineral acids; and those 
 compounded with vegetalde acids.
 
 NEW MODE OF ADMIMSTElUXfi THE PROTOXIDE OF IKO\. 950 
 
 Tlie first group appears to me to he an unsatisfactory form, the 
 mtitallic base requiring some internal menstruum to introduce the iron 
 gratefully into the system, and the oxides ready at any time to become 
 iiiert by the absorption of oxygen in transitu. 
 
 Tl)e saline form tending to a styptic or astringent action, and as such, 
 perhaps, passing slowly and uncertainly into the blood system; or, 
 l)ossibly, the iron becomes engaged with decomposed ])roducts in tht? 
 stomach, and passes into the form of carbonate or peroxide. 
 
 The third grouji of vegetable acids and iron aj)pears to me to approacli 
 that condition of iron which closely resembles tlie above changed or 
 •decomposed form, the result of change in tlie stomach. 
 
 In none of these forms is the iron in a state of true jirotoxide, and 
 if this condition is the necessary one, and the best for absorption, then 
 all iron, which is not in proto-form, is likely to be so much waste; hence, 
 ])erhaps, came the necessity for the exhibition of large doses, as was 
 especialh'' the case in the use of the peroxide of iron, of which half 
 ounces were formerly given, and out of which the absorbents drew, or 
 obtained, a modicum of protoxide, or a form of iron readily absorbed, 
 the rest being useless lumber. 
 
 Phosphate of iron seems to suggest a means of sujiplying two 
 important elements for the blood and hard tissues, hence ])hosphorus has 
 appeared combined not only with iron, but also with lime — another much 
 wanted ingredient; as if in j)reseuting these two combined, iron and 
 phosphorus, we said to the system of our ))atient — Utrum liormii laavi.H 
 (i.ccipe. 
 
 Years ago tiiis consideration occurred to me, that if we could increase 
 the amount of iron and phosphorus in our cereal food, we should perhaps 
 be more successful in stealing our way into the systems of our patients; 
 but all this is speculation, perhaps a necessary one for the next and 
 rising generation to brood over, and supply a new formula, and boast 
 itself of the pharmaceutical and therajjeutic wisdom thereof. 
 
 The formula which I bring before your notice, I think, is likely to 
 supply to a great extent a needful active form of iron, and will prove a 
 pleasant, or at any rate, a non-disagreeable administration of an 
 im]iortant element to the animal economy. 
 
 I wish briefly to inform you that the formula which I advocate is one 
 in which the pi'otoxide of iron (the essentially active and advantageous 
 form in which iron can 1>e ])resented to the system), is in chemical 
 combination with albumin, and that under this condition the stomach 
 does not appear to be offended at its introduction ; and that it does not 
 act as a styptic, seldom causes constipation, and moreover is not in a 
 hurry to assume that peculiar complexion wliicli indicates a change of 
 value in its usefulness, i.f.., rustiness or ]>eroxidation. 
 
 The method of preparation requires to be strictly carried out, and 
 when it shall fall into the hands of a modern ])harmacist, I have little 
 doubt it will be more suitably prepared than 1 have been able to effect; 
 but the basis — the protoxide state — nuist be maintained. 
 
 T have made trial of it in children; also in those adults who have 
 seemed to require the administration of iron, and have found marked 
 and rapid beneficial results. I should like it to be tried in some cases 
 of pertussis, but more especially in tyi)hoid fever, when exhaustion 
 •comes on, from what to me seems little recognised in the progress of
 
 960 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA, 
 
 this fever, i.e., the loss of a large amount of iron in the foiia of 
 lisemoglobin, as well as in the direct loss of blood from the idceration of 
 the bowel structure. An effort in the direction of supplying this serious 
 loss is made by the employment of liq. carnis, which to my mind is by 
 no means a pleasant remedy, nor one which I feel inclined to recommend, 
 as I look upon it as stale food when compared with freshly prepared 
 meat broth. 
 
 Albuminate of the Protoxide op Iron. 
 
 Take thirty grains of protosulphate of iron, and dissolve it in about 
 six ounces of boiled water, and tilter. To this add liq. ammonite in 
 excess; gently stir, and allow the precipitate to settle; then syphon otf 
 the supernatant fluid, and add more water ; allow to settle again, and 
 when the precipitate has fallen as densely as possible, syphon oft" again, 
 and add about a teaspoonful of fresh white of egg; add more water, 
 and allow to settle thoroughly; syi)hon off carefully, and place the 
 precipitate in a shallow vessel and allow the excess of water to 
 evaporate in a water bath, at a temperature below the coagulating 
 heat of alljumen; when the precipitate has become well thickened, add 
 confectioners' sugar to thicken it still further, so that it can be made 
 into tablets. 
 
 ►Sixty from the above mass will make a convenient size, and each will 
 represent half a gi'ain of the sulphate, and constitute an ordinaiy dose 
 for a child.
 
 SECTION FOE DISEASES OF 
 THE SKIN. 
 
 PRESIDENT'S ADDRESS. 
 
 By James P. Ryan. 
 
 Chevalier of the Tjegion of Honour, Sec. 
 
 Gentlemen, — When thinking of a subject for the short address which 
 it is my pleasui'e as well as niy duty to deliver before you this 
 afternoon, it struck nie that a brief enumeration of the various kinds of 
 skin affections which have come under my observation, and a short 
 account of some of them, might not be without interest. 
 
 The experience to which I shall appeal has been gained during a 
 period of fourteen years at the Melbourne Hospital, the last year and 
 a half of which has been at the skin department, some fifteen years' 
 attendance on the Abbotsford reformatory schools, and from private 
 j>ractice. 
 
 Unfortunately no statistics are available, so that when speaking 
 of numbeis in relation to cases, I am but expressing an opinion. For 
 this reason, I am unable to say if diseases of the skin are more prevalent 
 here than in (Ireat Britain. But the varieties which come under one's 
 notice are much the same in Mell>ourne, Paris, New York, or London, 
 though the relative proportions in which they occur are probably 
 different in each place. For instance, scabies, which is common enough 
 in London or Glasgow, is less frequently encountered in New York and 
 Melbourne. Indeed, in Melbourne it is an uncommon disease. Nor is 
 the reason far to seek. It is for the most part found associated with 
 jwverty, dirt, and over-crowding — conditions which as yet are rare 
 in Australian towns. Then on account of our warmer climate, and the 
 plentiful supply of water which even the poorest in Melbourne have at 
 hand, general washing and bathing is more a custom amongst the 
 humbler classes here, than it is amongst the same classes in England. 
 
 The appearances classed as scrofuloderma — including lupus iu all its 
 forms — is certainly less frequently met with here than in the older 
 countries, very largely through the better feeding of our population. 
 
 Dr. Bulkley, in his manual of "Diseases of the Skin," gives an 
 analysis of 8000 ca.ses collected from private and hospital practice in 
 New York, showing the relative frequency of these diseases in that 
 city; and his tables, I think, express pretty accurately the relative 
 
 2q
 
 962 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 frequency of such diseases in Melbourne. Eczema there, as here, is the 
 commonest of all, and accounts for one-third of the SOOO cases. Then 
 come — 
 
 Acne in the Proportion of 12 per cent. 
 Syphilis „ „ 10 „ 
 
 Phthiriasis „ 5 „ 
 
 Piingworm „ 4^ „ 
 
 Psoriasis „ 4 „ 
 
 Urticaria „ 2| „ 
 
 Lichen „ 1^- „ 
 
 Zoster ,, 1 „ 
 
 And the others in varying proportions under 1 per cent. 
 
 At the Melbourne Hospital, the syphiloids occupy the pride of place, 
 no doubt through the fact that the great majority of patients suffering 
 from sy]>hilis are drafted into the skin department. 
 
 Sycosis (which only occurs twenty-seven times in Bulkley's 8000 
 cases) is common enough here, the non-parasitic form being the one 
 usually met with. The tinea tricophytina barbje is, I think, a rare 
 disease with us. Thei'e is a milder form of inflammation, eczematous in 
 character, which attacks the region of the beard and whiskers. Its 
 more superficial character, the fact of its often extending to non-hairy 
 parts, or its appearing simultaneously upon them, and its being easily 
 amenable to treatment, distinguish it from true sycosis. 
 
 I liave met with two cases of chloasma uterinum, and the occurrence 
 of the disease in lioth was coincident with i)regnancy. In one it was 
 pi-esent for the first time, in the other it had i*ecurred during four 
 pregnancies, disappearing after child-birtli, to make its reappearance in 
 the second or third month of carrying. In this connection, I may 
 mention a pigmentaiy syphiloderm in a young man who had had a 
 chancre five months previously, followed by other evidences of secondarj" 
 syphilis. The pigmentation was deeply marked, and spread out in maj) 
 form on the back of his neck, between and on the shoulders, and down 
 the arms to near the elbows. It bore a strong resemblance to tinea 
 versicoloi". To clear up the diagnosis, no local application was used, 
 and it disappeared under internal treatment by mercury. 
 
 Prurigo occurs only once in Bulkley's tables. I am aware that other 
 affections, such as phthiriasis, papular eczema, lichen urticatus, pruritus, 
 &c., are often classed as prurigo ; but I am convinced that it exists in 
 a form sufficiently characteristic to entitle it to a separate and distinct 
 name. Take the following case as an exam{)le, and I have come across 
 many others of a similar kind : — 
 
 A middle aged man, not over robust and of sedentary habits, is 
 suddenly attacked, most frequently during the night, by intense itching
 
 prksidkxt's Ai)nHi;8.s— section for diskasks of thk skix. 963 
 
 of the inside of one or botli knees, the affected area sometimes extending 
 half way u]) the thitrh. At tlje commencement, a number of small 
 pale-coloured papules may be seen, as well as felt, which are evidently 
 slightly enlarged papill.'e. The skin soon becomes infilti-ated from the 
 irritation produced by scratching, the papules are torn, blood is efl'used, 
 and in a few days the affected ])art shows the type of ordinary senile 
 jii'urigo. There is then thickening, increased pigmentation, a slight 
 fui'furaceous scaling, and, at tlie end of a week or ten days, the skin 
 has usually returned to its ordinary healthy condition. Many such 
 attacks may occur during the year, and the patient is convinced they 
 are most frequently brought on by indiscretions in eating and drinking 
 
 A disease which prevails hei'e amongst children more frequently than 
 is suspected, and which on account of its contagious properties should 
 be recognised and treated as early as jiossiple, is impetigo contagiosa. 
 The lesions begin as small separate red itapules, which vapidly develop 
 into vesico-i)Ustu]es, and dr}- into yellow or brownish crusts, and in 
 some cases of unhealthy sul»jects, they become ecthyniatous in character. 
 The disease affects by preference the hands and arms, the feet and 
 legs, the back and neck, ami it often extends to the face and trunk. 
 Here is the history of an out-break in a family, in which the father, 
 mother, and six children were attacked : — One of the boys, aged 12, was 
 away from home for some time, and came back with an eruption. He 
 usually slept in the same bed with -a younger brother, who soon took it. 
 Then an elder sister was attacked, who probably gave it to a baby in 
 arms, and it spread to the mother, father, and the other children. The 
 only member of the household who escaped, was a girl of 16, who acted 
 as maid of all work. Here the extremities were affected in every 
 case, the face in two, and in one a few spots were found on the trunk. 
 The question arises, might it have beeit scabies % T think not. The 
 eru])tion was more frequently found on the extensor aspects of the 
 limbs, it attacked the face, it showed no special j>redilection for the 
 wiists and interdigital spaces ; itching, though sometimes present, was 
 not a marked symptom, and though I made frequent searches, I failed 
 to find any trace of the cuniculus, or of the acarus itself. Then in every 
 case there was some febrile disturbance. The diseases with which it is 
 most likely to be confounded, are varicella, })ustular eczema, and scabies, 
 but I do not think there should be much difficulty about the diagncsis. 
 
 Amongst the rarer forms of skin diseases which have come under my 
 notice, I may mention dysidrosis, pemphigus solitarius, pityriasis rubra, 
 ichthyosis, and leprosy. The case of pityriasis rubra was a typical 
 example of the disease. The patient, a German about 30 years of age, 
 Lad had it for three years when I first saw him. He informed me it 
 began as a red, somewhat itchy patch on the chest and abdomen, and
 
 964 IXTEKCOLONIAL MEDICAL COXt;RESS OF AUSTRALASIA, 
 
 quickly, that is within a few weeks, extended over the whole body, and 
 tho.t it has remained about the same ever since. There was reddening, 
 but without any thickening of the entire skin, with the almost constant 
 formation and shedding of fine branny scales. Sometimes lai'ge portions of 
 the skin were quite smooth and glossy, and then the redness was most 
 intense. There was little or no itching, his urine was free from albumen, 
 and his general health appeared to be fairly good. He often complained 
 of feeling chilly, though he said he always felt better in the cold weather. 
 Hot bran baths appeared to allay temporarily the irritability of the 
 skin, l»ut although he had been under all sorts of treatment by different 
 medical men, from none did he derive any permanent benefit. 
 
 1 have seen only one well-marked case of dy.sidrosis, the cheiro- 
 poiupholix of Jonathan Hutchinson, for I believe the two are identical. 
 It occurred in a young and rather delicate woman, a seamstress by 
 occupation, and had existed for about two months when I first saw her. 
 The sago-grain appearance of the deeit-seated vesicles was sometimes 
 exceedingly well-marked. She got well in three or four weeks under 
 mineral tonics and bitters internally, the local treatment consisting in 
 keeping the hand constantly covered, and ai>i)lying lead and belladonna 
 lotion. 
 
 Zoster has come under my notice much more frequently in adults 
 than in children. The two following cases are of some interest : — A 
 man of 55 years had intercostal neuralgia for a week, when a crop of 
 papules ajtpeared in the site of the pain. Tiiey were situated on an 
 inflamed base, fresh ones appeared froni time to time, but at the end of 
 a fortnight they had died out, leaving liehind some discoloration, and 
 the neuralgia persisted for ten days longer. There was no vesiculation, 
 for I saw him frequently, and watched him carefully during the course 
 of the disease. In this case the skin lesion was very mild, or aborted as 
 Hebra terms it ; but the neuralgia vpas exceedingly severe and persistent, 
 and required for its amelioration the ahnost daily use of subcutaneous 
 Injections of morphia. Tlie other case was that of a delicate girl of 
 11 years, who complained of pain in the right side of her head. In a 
 couple of days a few vesicles appeared above the eyebrow and on the 
 temple, and the pain ceased. No fresh ones were formed, and the 
 disease rapidly died out, but she complained of something being wrong with 
 her right eye, and on examination I discovered a central corneal ulcer 
 evidently the i*esult of a broken down vesicle. The ulcer was tedious 
 in its healing, and left a facet or flattened spot (not a nebula), which 
 spoiled the curve of the cornea, and resulted in iiermanent astigmatism. 
 I have seen here only one case each of ichthyosis and leprosy, both of 
 which will by and by be more particularly brought under your notice. 
 Malignant pustule nuist surely occur in up-country districts if not near
 
 TREATMENT OF THE MORE FREQUENTLY MET WITH SKIN DISEASES. 965 
 
 town, and yet I have not met with it here, though I have seen it in ether 
 countries. 
 
 So far then as my experience goes, the skin diseases Avhich come 
 inider the notice of tlie physician in Melbourne are identical in 
 character with those which i)resent themselves to the medical ma)i in 
 Europe and America ; and as yet, neither climate nor surroundings here 
 have developed any novel feature in the etiology and morphology of 
 these affections. 
 
 NOTES ON THE TREATMENT OF SOME OF THE MORE 
 FREQUENTLY MET WITH SKIN DISEASES. 
 
 By R. L. Faithfull, M.D. New York, L.R.C.P. et L.S.A. Lond. 
 
 Eczema. 
 
 This form of skin disease is probably brought under the notice of the 
 physician or surgeon more frequently than any other, and not infre- 
 quently gives him the greatest amount of difficulty to treat ; for although 
 the prognosis is favourable generally as regards its curaljility, yet the 
 length of time and patience to bring this about differs widely according 
 to the form of eczema under treatment, as well as to the age, habits, 
 and general condition of the patient. The treatment being local, or both 
 local and internal, due attention should be paid to the pathological 
 condition, as well as to any co-existing constitutional disorder or organic 
 affection present. This being taken for granted, I take pleasure in 
 bringing to the notice of my professional brethren some drugs and local 
 applications with which good results have been brought about when 
 other remedies appeared to have failed, and which now I am in the 
 habit of prescribing, if not otherwise contra-indicated. 
 
 In cases of eczema attended with acute violent inflammation, intense 
 itching, swelling, and i)ain, I prescribe "jaboiandi" or " pilocarjnne," 
 alone or in combination with acetate or citrate of ])otash, digitalis, 
 aconite, veratrum viride, pulsatilla, or rhus toxicodendron ; and apply 
 locally some soothing powder, such as starch or chalk, etc., which, if it 
 is desirable, may be nnxlicated with any drug or fluid extract that is 
 soluble in alcohol, ether, or chloroform, in the following way : — Dissolve 
 the drug or fluid extract in any one of the above solvents, then carefully 
 and thoroughly mix in a mortar with pestle a given quantity of tliis 
 medicated solution, according to the requirements of the case, with a 
 given quantity of the starch or chalk, or any. other insoluble powder. 
 This being done, ]>]ace the medicated powder on a flat open dish to dry 
 (heat, as a rule, should not be employed in the drying process): when 
 thoroughly dry, it can easily be reduced to an impalpable powder, and 
 is then tit for ap]»lication. 
 
 The advantages of thus medicating powders for topical application 
 Are — (1) A much wider range of drugs can be used, and the >juantity of
 
 966 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 the medicament can be most accurately determined ; (2) tlie powder 
 absorbs the moisture present, and brings the medicament in direct 
 contact witli the diseased surface ; (3) it is generally well borne, can be 
 easily applied, is cool, cleanly, and effective. The disadvantage is the 
 cost "of preparing (propei-ly) small quantities of such powders, as it is 
 always advisable to have them fresldy made. 
 
 In some cases, oils or ointments are more grateful, and these can be 
 medicated in various ways according to the indications present. When 
 these are badly borne, soothing lotions of boracic acid, carbolic acid, or 
 the fluid extracts of calendula, phytolacca, or grindelia robusta, diluted, 
 may be advantageously used. 
 
 In the more chronic cases, I combine the pilocarpine with some of the 
 mineral acids or acid glycerine of pepsine, liq. pot. arseniatis, liq. sodae 
 ar.seniatis, oxalate of cerium, or nux vomica. , 
 
 Eczema of the scrotum and genital organs has yielded well under the 
 internal use of tinct. hoang. nan. conctd. alone or combined with acetate 
 or citrate of potash, together with one of the following local api)lications: — 
 R Hydrargyri oxidi flavi grs. x- xx, hydrargyri ammoniati grs. x-xv, 
 zinci oleatis 3j-3jss., vaseline ad. I}, mix with or Avithout the addition 
 of camphor grs. x-xv ; or should the above prove too stimulating, apply 
 the following : — R Bismuthi oleatis Sij-Siv, ungt. zinci oxidi ad. jj, 
 mix. 
 
 Eczema of the palms of the hands is one of the most obstinate forms 
 of this disease. In chronic cases, the following has proved most satis- 
 factory in removing the hard cuticle : — R Thymol, grs. x-xx, acidi 
 salicylic 3j-5jss., saponis mollis ad. 3 ij, mix. Hub a little of this well 
 in over the part once or twice a day, or every second or third day, accord- 
 ing to the effect produced, let it remain on from half to one hour, then 
 wash off with water as hot as can be borne, into which a teaspoonful of 
 pulverised borax to the pint has been dissohed, and after di-ying rapidly 
 by mopping with a soft towel, ap])ly one of the following ointments : — 
 R Bismuthi oleatis Sij, chloral cum camphora 3 j, acidi salicylic grs. x, 
 ungt. zinci oxidi ad. ^ j, mix. ; or, R Resorcin grs. xxx, glycerini 3j-3 ij, 
 vaseline ad. J ij, mix ; or, R Hydrargyri ammoniati grs. xx, hydrargyri 
 oxidi tiavi grs. xv, zinci oleatis 3j, vaseline ad. 3 j, mix. 
 
 Tertiary Syphilitic Ulcers. 
 
 The diagnosis of these is not at all times an easy matter, for obvious 
 reasons, but a careful examination into the history of the patient, the 
 situation of the ulcer or ulcer.s, and a thorough insi)ection of the rest of 
 the body, will generally throw sufficient light ui^on the case. Still, in 
 doubtful cases, which not unfrequently occur, specific treatment may be 
 the only means of clearing up the case. 
 
 These ulcers are prone to occur in subjects of oldstanding syphilitic 
 taint, and are generally due to one of the late lesions of syphilis, viz., an 
 ulcerating gummatous, tubercular or ecthymatous patch, but no matter 
 what may l«e the starting point, an ulcer is produced with the following 
 suggestive features : — The nlceis are circular, oval, or horse-shoe shaped, 
 excavated, with edges more or less hardened, regular, sharply cut, 
 j)erpendicular (sometimes slightly overhanging), and of a dull red or 
 livid colour, with a pultaceous floor, and a tendency to scab over if 
 exposed to the air. They are usually painless, unless through injury or
 
 NOTES ON A FATAL CASE OF PEMPHIGUS. 967 
 
 by their position they bccojue inflamed, or the periosteum becomes 
 involved in the ulcerative process, and if not treated, tend to pursue a 
 l)rotracted course. 
 
 In the treatment of these ulcers, the following prescriptions have given 
 me much satisfaction: — li. Potassii iodidi vel sodii iodidi 3j-3ii.j, 
 liq. ferri iodidi conctd. 3 j-3 ijss, glycerini ' ij, aqu;e chloroformi ad. 
 jviij, mix. One tablespoonful in water half an hour after meals. 
 II. Ext. erythroxylon cocie ti. ^j-^ij, ext. stillingia? fl. 3 v-^ ij, Syr. 
 menthai piperitte J ij, aquje ad. | viij, mix. Tablespoonful in water 
 an hour after meals. 
 
 It -was from Dr. Robert \V. Taylor, of New York, that I first 
 learnt the value of ext. cocje fl. in syphilis, as an adjuvant to specific 
 treatment. Lately, I have used the ext. kola nut. fl. (sterculia 
 acuminata) in doses of m. x-xxx or more, with equally as good results 
 as the ext. coca? fl. It is far pleasanter to take, and is not so apt to 
 disagree. Many patients, after having taken the " coca " for a short 
 space of time, complain bitterly of its nauseating and disagreeable 
 taste, and beg to have the drug discontinued. I now prefer using the 
 ext. coca3 in pills of grs. iij each. 
 
 In some cases, I find the additional use of mercury of the utmost 
 value, and my favourite ])rei»aration has been the tannate. 
 
 Local treatment consists in bathing the ulcer or idcers tiight and 
 niorning for ten to twenty minutes, with water as hot as can be borne, 
 then applying one of the following powders : — 11. Hydrastin 3j> 
 baptisin 3j, iodoformi ^ iij, mix, ft. pulv. Dust lightly all over the 
 ulcers, after bathing and mo})ping dry. R. LTngt. zinci oxidi ; apply 
 thickly upon a piece of lint large enough to cover the ulcerated 
 surfaces, cover over with a piece of indiarubber tissue, and bandage 
 snugly. li. Alnuin 3j, hydrastin 3j, baptisin 3j, zinci oxidi ^ '^j, 
 mix, ft. ])ulv. Dust lightly over the ulcers after bathing, if the iodofoim 
 is objectionable. For some time past I have used salol, alone or in 
 combination with iodol, zinci oleas, bismuthi oleas or .subnitras, 
 with results, if anything, better than those ])roduced by iodoform. 
 The above applications are certainly far pleasanter in every respect for 
 the patient. 
 
 Note. — The fluid extracts used are those prei)aved by Dr. E. E. Squibb, 
 of Brooklyn, New York ; and Parke, Davis and Co., Detroit. 
 
 NOTES OF A FATAL CASE OF PEMPHIGUS. 
 
 By Alfred Austin Lendox, M.D. Lond. 
 
 Lecturer ou Forensic Medicine in the University of Adelaide ; Honorary Medical 
 Officer, Adelaide Children's Hospital ; Honorary Assistant Physican, Adelaide 
 Hospital. 
 
 During the five years that I have piactised in Adelaide, with oppor- 
 tunities for observation at both our hospitals, I have oidy met with this 
 one case of pemphigus : — 
 
 Edith B., ait. 5, living at Kingston on the south-east coast of this 
 province, was admitted" under my care at the Adelaide Children's
 
 968 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 Hospital on July 5, 1886; and, with the exception of a week in the 
 ensuing November, remained there till September 23, 1887. Her 
 history was as follows: — Family history good; no member of it had 
 suffered from any special skin eruption. About Christmas 1885, an 
 epidemic of so-called '* native pox " occurred amongst the children at 
 Kingston ; all recovered except Edith B., who never got rid of it, 
 and seven months later she was sent up to Adelaide for treatment. 
 
 On admission, her general health seemed to be very good, and she 
 Was not feverish. There was no evidence of a syphilitic or of a 
 strumous taint, or of any lesion of the nervous system. She jn'esented, 
 however, the chai'acteristic eruption of pemphigus vulgaris, distributed 
 mainly into two great groups of blebs. The i^pper group occupied 
 the face (including the eyebrows and ear), neck, chest, both front 
 and back, and axillje, and comprised numerous tense bullae of the 
 size of a pea, and equally numerous scabs and stains of former bulla;. 
 The lower group occupied the front of the abdomen, the pudenda, 
 and upper part of the thighs, and embraced every variety of size 
 and stage of the lesion. Here were seen the early commencements 
 of the disease as small reddish papules ; the reddish ])apule a little 
 more advanced, with a bleb on its summit about the size of a pin'b 
 head ; the fully developed blebs of different sizes (some half an inch 
 in diameter), of ovoid shape, with smooth distended and translucent 
 cuticle, and clear yellowish serous contents ; other blebs somewhat flaccid 
 and pendulous, with perhaps some turbidity of the lower half of their fluid 
 contents; blebs still more flaccid from escape of fluid, with the cuticle 
 wrinkled and in some cases umbilicafced, or else no longer raised above the 
 surface, and showing a ring of inflammatory redness at their margins ; 
 excoriations of a quite superficial nature, and scabs from drying of the 
 eff"used serum ; stains of a rosy red or a deep purple tint, but always darker 
 at the circumference than towards the centre. There were single scattered 
 blebs seen here and there over the back and on the extremities, as 
 though the tendency were for the eruption to spread downwards, and 
 later on this proved to be the case. None were noticed on admission on 
 either the palms of the hands or soles of the feet. A very considei-able 
 amount of iri-itation accompanied the eruption, causing the child to rub 
 herself and aggravate her condition ; and at night-time the temperature 
 was usually somewhat raised, occasionally reaching 102° or 103°. For a 
 few days, tlie child was kept under observation without any drug being 
 administered, but owing to the rapid spreading of the eruption, Fowler's 
 solution was prescribed in ui. ij doses thrice daily, the dose being 
 gradually increased to m. vijss. tlnice a day, without any toxic 
 symptoms being produced. Under this treatment, altliough crops of 
 fresh sj)ots appeared from time to time, many of which ran an abortivt; 
 course, the disease gradually improved, the scabs cleared off', and only 
 the pigmented stains were left, which were observed to be of a much 
 deeper tint in cold weather. On the medicine being discontinued, a 
 few more blebs ai»i)eared, showing that the disease was suppressed but 
 not cured, but they all aborted when the arsenic was resumed. Dr. 
 Vaughan (the house-surgeon) made many painstaking observations of 
 individual bulhe, but no general conclusions could be drawn as to their 
 natural course of develo[)ment and duration, because, for example, of 
 two fresh papules noticed on the same day, one would speedily abort
 
 NOTES ON A FATAL CASH OF PKMPIIKiUS. 969 
 
 and the other perhaps run a protracted course until the scabs formed on 
 the seventi), or even as late as the tenth day. Moreover, the observa- 
 tions were vitiated by the fact of the child taking arsenic all the time ; 
 but I am convinced that whilst under the influence of this drug, no 
 fresh ci-ops had the same vigor or vitality as the original erui)tion. 
 One striking feature was noticed, and that was this, that the fresh crops 
 did not s])ring up in numbers like the vesicles of herpes" zoster, but when 
 one s()ot has appeared and matured in a fresh situation, others aj)))eared 
 in its neighbourhood as tiny satellites and subsequently coalesced with 
 the original bleb, suggesting some local method of infection, and the 
 stains left nfter the bullai liad disai)i)eared inteisected one another ; one 
 or two attempts, however, at inoculation in distant situations, failed. 
 On one occasion, hfematuria was noticed ; on another, an attack of 
 bilious vomiting, attended with pyrexia, induced me to discontinue the 
 medicine, but on the following day a bleb formed in the palm of the 
 hand. Several times subse(juently, wlien all the bulhe had disap])eared 
 and the medicine ])erlia})s had been discontinued, a pyrexial attack 
 occurred, and in a few days a fresh e)'U])tion of bullai was noticed. 
 Once the jiatient was sent out under the supposition that she was cured, 
 only to leturn in a Aveek's time and to remain in again several months, 
 during which time fresh blebs frequently appeared, but they were 
 seldom numerous, and tliey readily yielded to treatment — the arsenical 
 solution being ])ushed sometimes to the extent of ni. xvj thrice a day. 
 Wlien after some weeks no more bulla? had appeared, although we were 
 led to expect them on account of febrile attacks, she was finally 
 discharged marked with innumerable .stains, and the skin tinted 
 elsewhere with the peculiar brownish colour which is sometimes 
 associated with the prolonged administration of arsenic. 
 
 On Decenibei- 10, 1887, the child was admitted into the Adelaide 
 Hospital (the Children's Hospital being at the time full) under my care, 
 ■whilst I had charge of Dr. Verco's wards. Her condition was now 
 truly pitiable, as there had i-ecently been a much more exten.sive 
 eruption than had ever occun-ed before, the l)ody being covered 
 with ruptured bulhe, which were discharging ])rofusely, the abdomen 
 especially presenting an almost unifoi-mly excoriated surface, whilst a 
 few unruptured blebs were to be seen on the face and limbs ; there w^as 
 moderate pyrexia, ranging from 99° to 102°, with great restlessness and 
 delirium, and one was struck with general reseml)lance of her condition 
 to that of a ))atient suffering from a severe scald. The excoriated 
 surfaces were dressed with iodoform and boiacic acid ointment, and the 
 administration of Fowler's solution was at once commenced, in doses of 
 m. ij. increased by December 18 to m. vijss. thrice daily. This time, 
 liowever, the drug made no impi-ession upon her, profu.se diarrhoea and 
 later on vomiting set in, and she died of collapse on December 24. 
 Unfortunately, there was no ])ost-mortem examination. Various drugs, 
 chiefly combined with oiiium, were al.so administered to combat the 
 diarrhoea and exhaustion. 
 
 The only comment I would offer on this case (and J am quite aware 
 of the proverb qui s'excuse saccuse) is, that in my opinion the fatal 
 result was neither caused nor accelerated by the arsenic. The child's 
 condition on admi.ssion, and the severity of her constitutional symptoms, 
 Mere such as to warrant the belief that she would die from exhaustion,
 
 970 INTERCOLONIAL MEDICAL CONGKESS OF AUSTRALASIA 
 
 if only from want of sleep, in a veiy short time. Moreover, she had 
 benefited on so many occasions previously from the administration of 
 arsenic, and in much larger doses. The other symptoms of arsenical 
 poisoning, except the gastro-intestinal irritation, were absent ; and all 
 writers agree, apparently copying their remarks from the cla.ssical work 
 of M. Hardy, that diarrhcea is a fre(|uent complication, and indeed the 
 usual cause of death in chronic pemphigus ; and they have gone so far 
 as to mention bulla? of the gastro-intestinal tract, although M. Hardy 
 states that these have never been demonstrated to exist. He himself, 
 however, describes redness and ulceration of the mucous membranes. 
 
 A NOTE ON THE NEW ZEALAND BIRCH ITCH. 
 By D. COLQUHOUX, M.D. Lond., M.K.C.P. Loud., Dunedin. 
 
 In April, 1888, while staying a few days at Lake Te Anau, Mr. 
 Richard Henry, who has lived in the district for many years, spoke to 
 me about birch itch. Mr. Henry has worked at the natural history of 
 the locality for many years, and has had to spend a great deal of time 
 in the bush, much of which is composed wholly of the New Zealand 
 birch (really a beech). The disorder was a new one to me, and none of 
 the medical men to whom I have spoken of it could give me any 
 information about it. 
 
 Mr. Henry has given me the following account of his experience of 
 it : — " I made acquaintance with the birch itch while camped on Mani- 
 pouri plain, eight years ago. At tiist I atti-ibuted the intense itching 
 to the after-effect of sandflies, l>ut I soon found I was wrong. On 
 j)arts liable to friction from the saddle, or while working, I felt the 
 itch most severely — the ankles, toes and wrists, and especially the parts 
 between the thighs, itched most intolerably. t heard of birch itch, and 
 suspected I had caught it. I consulted an old resident — a run-holder — 
 who I heard was afflicted with it every summer that he remained in the 
 district. He told me that it always left him when he went to town. 
 I tried to cure it with kerosene, turj^entine, painkiller, and sulphur 
 ointment, all to no purjiose, Ijecause I had allowed it to get a good 
 footing, and had not persevered enough with the sulphur. During the 
 day I was comparatively at ease, but at night, when I went to bed, the 
 itching was something horrible, so much so, that on one occasion I got 
 out of bed at 11 o'clock at night, and plunged into the creek. This 
 gave me relief and a clue to a si)eedy cure, wliich I attained by the 
 application of dry sulphur and frecjuent bathing. Now I get seveial 
 attacks every summer, l>ut witli the above treatment it causes me no 
 inconvenience. Only about one person out of every ten is ever 
 attacked, even when they are working and living together; and while 
 one may be attacked exclusively on the limbs, another may be so on the 
 body. Many people deny that it is caused by a parasite, but maintain 
 that it is in the blood, and can be cured by change of air and diet ; 
 but I cure it several times every year, and last year I watched
 
 A NOTE OX THE XEW ZEALAND HlliCII ITCIi. 971 
 
 it SO closely, tliat it only succeeded in forming one little spot on iny 
 ankle, which was a great contrast to my experience of 1880. I am 
 most liable to it in very dry weather, when about rotten wood, or 
 among the peat moss, I also suspect that it attacks horses and dogs in 
 a slight ilegree. ^ly first notice of it is an indefinable and luiiocalisalile 
 impression of something moving on the skin. On looking at the place 
 the skin seems redder, which may be caused by friction, and there is 
 always present black dust of various shapes and sizes, a supply of 
 which must be in the clothes, for no matter how often I brush it away 
 it is there again. This dust I take to be the parasite or sjjore, and that 
 not one in a thousand penetrates the skin; but that when one does so it 
 irritates a large surface, because after a few days a pimple comes out 
 here and there, but nothing in proportion to the surface irritated. A 
 slight hot itchy feeling is always present, but periodically more 
 intense, especially in the evening. Un one occasion T was on an expe- 
 dition without sulj)hur, and caught the itch on my ankles. I put away 
 the socks I wore for a week or two, and then put them on again, when 
 I felt the itch again, which must have remained in the socks all that 
 time. T am almost certain that horses sufi^er from it, but as it causes no 
 loss, it is taken no notice of. 
 
 " It has been cold an<l wet weather here lately, and unfavourable to my 
 chance of getting specimens or scrapings; Imt for several days I felt 
 the itch slightly, and liave collected all [ could of what i think you 
 want for specimens." 
 
 Two gentlemen from Sydney University spent some time last summer 
 at Te Anau. One of them contracted the disease, and the other did not. 
 Professor T, was good enough in answer to my enquiries on the subject, 
 to send me the following account of his experience : — " The symptoms 
 are very simple. The skin round my ankles became red just where it 
 was rul)bed slightly l)y my boots. The irritation was very intense, 
 especially the first thing in the morning. I rubbed the place affected 
 with vaseline and flowers of sul])hur. In about a week I thought I was 
 right, and gave up using the sulphur, but the trouble recommencing. I 
 had to take to it again, and was not finally riglit till I had taken 
 advantage of the sulphur springs at Taupo for several days, T used to 
 keep my legs in the mud among the deposit of ferrous sulphide. Pro- 
 fessor S. was not attacked ; we lived exactly the .same life, except that 
 I went a great deal more into the bush. My own impression is, tliat the 
 disease is possibly connected with the ring of deposit of dehriK, which 
 always formed inside the top of one's boots." 
 
 J. W.. a farmer, aged 00 years, consulted me in July lS8t<, for eczema 
 of the face and some other troubles. He liad lived for many years near 
 Lake Wakatipu, and had a good deal of experience of birch itch. He 
 said that he had l)een working among birch for years, without b3ing 
 affected by the itch. On one occasion he had to clear a track through 
 the bush, and spent some days tearing up young birch trees. He had 
 then a severe attack of itch ai>out his fingers and face. Afterwards, he 
 could not ent^r a bireh forest without being attacked by the itch. This, 
 he said, was a general rule- — once attacked, a man is always liable to it. 
 
 He thought it was most easily acquired in 8i>riiig, but was also 
 tionblesome, to those sensitive to it, at other times. It was most 
 troublesome when the birch was much handled, especially if wet. He
 
 972 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 ]iad seen it mostly about the fingers, but it also attacked the face and 
 body, if neglected. It nearly always goes away on removing from the 
 neighbourhood of birch forests, but as most peoj)le use sulphur internally 
 and externally as well, its cure may be due to this treatment. 
 
 I have not seen any cases during the acute stage, but in the stage of 
 recovery the condition is such as might be found from many kinds of 
 skin irritation. I examined the scrapings sent to me by Mr. Henry 
 very carefully, but could find nothing but e{)ithelial debris, and small 
 fragments of vegetaltle tissue. The cause of the disorder is therefore 
 still to be sought. It may be a vegetable poison, like the poison oak or 
 dogwood of the United 8tates, or it may be an acaius. In the absence 
 of definite proof in any direction, it is useless to discuss hypotheses, and 
 I put these cases on record in the hope that some of us who ])ractise in 
 New Zealand may have the opportunity of examining patients in the 
 acute stage, and of studying the disorder whore it occurs. 
 
 ON SOME CA8ES OF ALOPECIA AREATA, AND 
 ITS PROBABLE CAUSES. 
 
 By D. CoLQUHOUN, M.D. Lond., M.R.C.P. Lond. 
 
 ' Lecturer on the Practice of Medicine, University of Otago, New Zealand. 
 
 The question of the causes of tinea decalvans or alopecia areata, is 
 raised from time to time, l)ut cannot be said to have been satisfactoinly 
 settled. The following cases are offered fo)' consideration, as a contribu- 
 tion towards the discussion of the subject : — 
 
 W. F. M., aged 26 years, a strong athletic young gentleman, consulted 
 me in October 1887. He had previously been under my care for 
 rheumatism, from which he had entirely recovered. A few weeks 
 before seeing me, he had noticed a bald patch by the side of his head, 
 and when I .saw him he had three well-defined and characteristic 
 patches of alopecia areata on the scalp behind the ears. His health at 
 this time was as usual excellent. I examined scrapings from the skin 
 and adjacent hairs with the microscope, but failed to find any parasite. 
 He i-ecovered in the usual way, after the application for some time of 
 cantharides. Since then, he has had another attack of alo})ecia, which 
 yielded quickly to the same treatment. 
 
 His family history is the chief point of interest in this case. His 
 mother died of Bright's disease, aged about 50 years. His father has 
 for many yeai-s suffered almost constantly from psoriasis of the face 
 and neck (the condition of the neck would be better described by the 
 term ichthyosis). A sister, aged 15 years, has been under my care for 
 seborrh(ea of the head, and psoriasis, and also for alopecia areata. A 
 bi-other, aged about 2-4 years, residing in Sydney, had about the same 
 time alopecia, involving nearly all the hairy surfaces. A brother, aged 
 17 years, residing in Dunedin, had several patches of alopecia ai'eata on 
 the scalp. A sister, aged 21 years, has had fre(pient and severe attacks 
 
 I
 
 SOMK CASKS OF AlJtI'ECIA AREATA, AM) ITS Pi;0I3AIiLE CAUSKS. 97,^ 
 
 of chlorosis. His graiulfiitlioi- ;ind great graiulfatlier were siiljject to 
 seAere attacks of gout, wliicli iii its ordinary forms has not attacked 
 any of the living members of the family. All tlie brothers and sisters 
 were as a rule healthy and vigorous, but they were all distinctly of the 
 neurotic type. 
 
 Joseph R., aged 7 years, was l)rought to me on August 9, 1888. 
 He had then three patches of alopecia areata on the parietal and 
 occipital regions of tiie scalp. These had existed for about three 
 months. His general health was fair. He had an attack of pleurisy 
 at about the time of theii- tirst appearance, from which he made a good 
 recovery. No accui'ate family history could be obtained, but his mother 
 had suttered from eczema of the hands oti'and on for many years. 
 
 Miss N.. aged 22 years, consulted me in October 1888. 8he had 
 then two patches of alopecia areata, situated syiimietrically behind the 
 ears, at about the margin of the hairy scalp. She had to leave England 
 some years ago on account of severe attacks of bronchitis every winter, 
 and sufters much from neuralgia of vai-ious branches of the fifth nerve. 
 There is a history of phthisis in the family, and lier mother informed 
 me that many of hei" relations suffer from gout, but so far as she 
 knows, none of them have ever had skin disorders of any kind. Except 
 for the tendency to bi-onchitis, the patient altliougii delicate and easily 
 tired, is of fairly sound constitution. 
 
 At the International Medical Congress held in London in 1881, 
 a discussion on the causes of alopecia areata was introduced bv 
 Dr. Liveing, who said that a belief in the parasitic nature of alopecia 
 areata was still widely entertained, and stated that the theme of his 
 paper was, that the clinical features of the disease cannot be explained 
 on the parasitic hypothesis. He called attention to the great tendency 
 of the disease to recur, to its slight yet notable tendency to appear in 
 different members of the same family, and to its association with 
 nervous disturbances. In the discussion which followed his paper, the 
 balance of opinion was against the parasitic theory, and some striking 
 instances wei'e given of the association of the disease with various 
 neuroses. On the other side. Dr. Vidal of Paris, Professor Hardy of 
 Paris, and Dr. Thin of London, adhered to the paiasitic origin of the 
 disease, at least in some cases, and cited examples. Pi-ofessor Simon, 
 ()f Breslau, thought the examples of contagion adduced might be 
 explained on the hypothesis, that there are tw^o distinct diseases Avitli 
 the same general features — one a trophoneurosis, the other a contagious 
 disease. 
 
 Dr. Pye Smith, writing in " Fagge's Practice of JNledicine "' on the 
 subject, says that he has no doubt the disease is not parasitic nor 
 contagious, and that he can see no sufficient evidence that it is a 
 trophoneurosis. 
 
 In the discussion mentioned, no special attention seemed to have 
 been given to the association of alopecia are^ita with other skin 
 disorders, or with gout. The influence of gout, in producing irritable 
 mucous membranes and skin troubles, is well known. That it has this 
 effect through the medium of the nervous system is probable, and I am 
 inclined to think that in two of the cases I have cited, the alopecia 
 areata may have been due to ancestral gouty taint. In the case of the 
 child, there was no evidence of gout in the family. Here the only
 
 974 INTERCOLONIAL MKDICAL CONGRESS OF AUSTRALASIA. 
 
 possible co-rehited disease, ;iscert;iiiied to liave existed, was tlie eczema 
 of the motJier, which may or may not Jiave been gouty. 
 
 In all the cases I ha^■e mentioned, I think tlie parasitic theory may 
 be excluded, and tliat the disease was due to some inherited predis- 
 position is particularly plain in tlie M. family ; in the case of the 
 brother who was suiiering in Sydney from alopecia, while his brothers 
 and sisters were attacked by it in Dunedin. Although T detected no 
 special anai-sthesia in any of the cases, they were all very tolerant of 
 canthar-ides. 
 
 There is still sufficient rloubt as to the actual cause of the disease, 
 to make it worth while incpiiring in such cases, as to the occurrence of 
 other skin disorders in tlie same individual or in relatives, and as to 
 gouty predisposition. In the meantime, it seems to me that the 
 evidence points to the disease being one of disordered nerve function, and 
 that to describe it as a trophoneurosis is convenient, and probably 
 correct. We must, liowever, look to increased accuracy in describing 
 and recognising minute clianges in the peripliei'al and central nervous 
 -system, for an exact patliology. 
 
 NOTES (m SOME SKIN ERUPTIONS COMPLICATINCx 
 
 URETHRITIS. 
 
 By R. A. Stihlin.;, 3I.B. Melb., L.R.C.S. Ed. 
 
 The lialsamic eruptions which head the list have been omitted, 
 although I find that in notes of over 1000 cases, treated both in dispensary 
 and private practice with copailja or cubebs, there were no less than 
 IGO who showed the well-marked papulo-erythematous blotches, bright 
 red in colour and ^'el•y irritable, with the copaiba odour of the skin. 
 
 Santal oil, although it produces the backache and gastric derange- 
 ment common to the action of all these nauseous drugs, has, in my 
 experience, in only one instance been responsible for a rash on the skin. 
 The patient was suffering from the arthritic form of gonorrhceal 
 rheumatism at the time, in both knees and one ankle-joint. The rash 
 consisted of rings of a rose colour, about half an inch in diameter, not 
 attended with itching, nor any perceptible elevation of the skin. 
 
 Apart from these medicinal eruptions, I have seen, on a few rare 
 occasions, a form of acute eczema, which was coincident with the 
 gonorrluea, and which seems to bear out the sui)position that the 
 absorbed poison not only attacks the joints and other serous sti'uctures, 
 but at times may, in certain constitutions, expend its effects upon tlu! 
 skin. The following histoiy of a case of acute erythematous eczema is 
 an example of idios^aicratic dermatitis : — 
 
 Mr. D., set. 24, robust and healthy, consulted me in November 1887, 
 suffering from a first gonorrlia^a, and was ordered a mild alkaline mixture 
 and injection. About a week after its onset, he noticed round the pubes 
 a diffuse redness, not itchy, but weeping copiously, and extending up the
 
 NOTKS 0\ SOMK SKIX EKUPTION.S COMl'LICATIXCi UKKTHKI'l'l.S. 975 
 
 trunk to the level of the eusiform cartilage, and down the tVoiit and 
 inner surfaces of the thighs. He liad never sutiei-ed from skin disease 
 before. There was no trace of scaljies or pediculi, noi- any histoiy of 
 gout or rheumatism. The extent of the eruption and its position for- 
 bade one to attribute it to the irritating etiect of the discharoes. 
 Under exclusively local treatment, as recommended by Balmanno 
 Squire, the disease disappeared, after lasting about ten days, the treat- 
 ment for the urethral trouble being continued at the same time. 
 
 In October of this year (1888) he again contracted a discharge, and 
 within a few hours of its advent, another attack of eczema, Avhich was 
 much moi'e prolonged and extensive than before. 
 
 Cases of fugitive erythema are not infrecpiently met with in those 
 wlio have been treated fi-om the tirst l)y injections. They have one 
 
 distinguishing feature from the dietetic and medicinal rashes in this 
 
 that they occur in success! \e crops. P;i]Hilar eruptions clustered 
 together upon a very slightly iiiHamed portion of the skin, and due 
 possibly to the depressing influence of the disease upon the nervous 
 system ; for in the cases noted, 1 have rema)'ked that the persons were 
 of a highly neurotic temperament. (Tonori'hd'al lichen is distino-uished 
 from the ordinary disease by the itching being much less severe, and by 
 being circumscribed, with well-detined outlines. It is, perhaps, most 
 often found in tho.se sutlering from a chronic gleet, and l^roken down in 
 constitution ; and a very favourite seat is the front of the abdomen 
 and chest. These eruptions are not to be mistaken for those pi-oduced 
 by woollen clothing, from which they are quite distinct, as I have at 
 times found them on the forehead and limbs. 
 
 Finally, T may di-aw attention to the veiy rare but occasionally 
 
 undoubted cases of gonorrhcca-syphilis, tirst described by Hutchinson 
 
 cases where, without urethral chancre, or any evidence of chancre else- 
 Avhere, but with merely a nmcous or muco-purulent blenorrlw^a • where 
 even with minute endoscopic examination, notliing in the shape of a 
 specific lesion can be discovei'ed, and in which, unattended by bubo or 
 other adenopathy, the disease runs the ordinary course, attended with 
 cutaneous manifestations not distinguishable from the well-known 
 syphilides. 
 
 Since writing the above, I find tJiat ^I. Mallet, in the Revue de 
 2Inlicine (1886), has written an able article on the subject of cutaneous 
 diseases in gonorrhoea. He rejects the pyjemic and reflex theories of 
 the origin of gonorrheal rheumatism and skin eruptions, and aroues 
 strongly in favour of the absorption of a specific gonorrlueal virus 
 which, in the light of the discovery of the gonococcus — not only in the 
 urethra and its discharges, Vjut also in the synovial meml)rane of 
 inflamed joints — seems to be the most likely explanation. Mallet 
 classifies three groups — 
 
 (1) Eruptions clo.sely resembling scarlet fever or measles, comin^ on 
 late in the decline of the disease. 
 
 (2) Rashes described as those of polymorphic erythema. 
 
 (3) Purpuric patches.
 
 976 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 N0TE8 ON A CASE OF LEPROSY. 
 By F. Peipers, M.D. 
 
 M. A., fet. 30, native of Sydney, of Jewish descent ; no hereditary 
 taint of skin disease known. Five sisters and two brothers living, 
 who have not evidenced any disease of the skin. From his eighth 
 until his fifteenth year he lived in New Zealand, and then left for 
 Melbourne. In 1878, he acquired gonoi'rhtea. In 1879, after sus- 
 picious connection, he had a feverish disease for three weeks, which 
 was called typhoid. Soon afterwards, there was fever and pains all 
 OA"er the body, swelling of the face, nose, ears, feet, &c. There were 
 red inflamed spots on the dorsum pedis. At no time had he ulceration 
 on the penis, or parts tliereabouts. At that time his disease was 
 pronounced to be sy[)hilis. After that he was under specific treatment 
 of every kind by several practitioners, including mercury on seven 
 occasions. "When iodide of potash was given, the symptoms were 
 exaggerated. Arsenic, iodoform and sarsaparilla were given in large 
 quantities. The local lesions in the throat and tongue were treated by 
 ai'gent. nit. and hydrarg. nit. 
 
 On examination, I found the hair on the head black, strong, with 
 scalp visible at vei'tex. On tlie forehead, particularly on the right side, 
 there were a number of swellings, large and small, varying from the 
 size of a three-penny bit to a florin. The swellings did not penetrate 
 to the osseous structures beneath. The elevations presented an 
 umbilicated appearance, and were liaised somewhat distinctly at the 
 edges. Tlie epidermis between the swellings was apparently healthy. 
 There was no ulceration about the forehead, but a peculiar oily 
 brownish appearance of the diseased parts was oliservable. Similar 
 tumours existed on the ears, cheeks, lips and nose, forming together 
 a general enlargement and disfigurement of the face — in fact, constitu- 
 ting the true typical facies leontina. Some of the masses were 
 idcei'ated. On the arms, wrists, legs and hands particulai'ly, the same 
 state of things was to be seen. The skin on the Angers and toes was 
 veiy much ulcerated, in parts laying bare the tendons. Remarkable 
 symmetiy was exhibited by the disease in both hands, and in the feet 
 too. A deep brownish discolouration, sharply defined from the healthy 
 skin, was to be observed on both sides of the sternum, extending to a 
 line corresponding with the umbilicus. 
 
 The tongue showed at the tip a flat ulcerated surface, in size about 
 tliat of a sixpence. Deep fissures, intersecting, covered the tongue. 
 Tlie uvula was ahnost entirely obliterated. A deep fissure extending 
 into the pharynx on the left side of the uvula was clearly distinct. A 
 localised anaesthesia seemed to be present in the left thumb. The 
 internal organs, as far as is known and could be traced, were 
 apj)arently healthy. 
 
 Since 1885, and up to the present, his appearance has greatly 
 changed, the swellings in most parts having entirely gone. Lar^e 
 cicatrices now cover the forehead, cheeks, ears and nose, some of them 
 contracting to sucli an extent that difficulty is found in opening the 
 nioutli. Part of the nasal sei^tum has been destroyed. Anchylosis 
 is taking place in some of the finger-joints. An alteration in the 
 
 I
 
 A CASE OF ICHTHYOSIS. 977 
 
 cliaracter of tlie skin on the chest and abdomen has taken place. 
 However, on the back a similar discolouration is now e\'incinf>- itself. 
 Unfor-tunately, the condition of things in the throat appears to be 
 tending towards a worse state. It may be mentioned that an 
 amesthetic state is being developed in the inferior extremities. 
 
 The diagnosis is somewhat open to discussion ; but considering th.at, 
 firstly, the bones have not at any time been affected, excepting the 
 nasal septum ; secondly, the absence of improvement under strong and 
 repeated anti-syphilitic treatment ; and thirdly, the decided cliange for 
 the better from the exhibitioji of other remedies, we are precluded from 
 considering the case as one of syphilis in any form. What is the 
 disease then? The appearance of the patient, allied with the changing 
 symptoms, indicate le})rosy. 
 
 He was put uiider arsenic and (|uinine, combined with chaulmoogra 
 oil. No improvement following, lie was then put on ichthyol, with 
 almost immediate effect. Soon after-, the supply of this remedy 
 ran out, and at once it was noticed that the symptoms became worse. 
 He is now under the influence of ichthyol for tAvo years, on and off. A 
 singular feature about the drug is the disagreeable symptoms suffered 
 by tlie patient should it be suspended for a few days, a distinct 
 exaggeration of the disease, occurring. 
 
 The markedness of the symptoms in this case, peculiar as they are to 
 a disease so far unknown amongst any but Orientals in Australia, 
 renders it one of a highly interesting nature. The success that has 
 attended the use of ichthyol in this case is very suggestive, however 
 incomplete in its results, in a disease which at all times has presented 
 such intractability to any and e\-ery form of medication. 
 
 A CASE OF ICHTHYOSIS. 
 
 By J. P. Hyax. 
 
 Chevalier of the Legion of Honour. 
 
 Surgeon to the Skiu Department of the Melbourne Hospital. 
 
 Surgeon to the Victorian Eye and Ear Hospital. 
 
 Lesser, in " Ziemssen's Cyclopaedia of Medicine," defines ichthyosis 
 as a disease characterised by hypertrophy of the epithelium, with 
 deposit of pigment between the lamella; and elongated papilke, and 
 without change in the corium, beyond pigmentation of its superficial 
 layers. Malcolm Morris defines it as a congenital hypertrophic disease 
 of the skin, characterised by increased growth of the papillary layer, 
 with thickening of the true skin, and the production of masses of 
 epidermic scales. I think a majority of dermatologists will differ with 
 him about thickening of the true skin. Most generally it makes its 
 first appearance within a year of the child's birth, though it may 
 
 2k
 
 978 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 be delayed to the third or fourth year. It is frequently hereditary, 
 and by most authors it is looked upon as incurable. Tilbury Fox 
 makes out four degrees of it : — • 
 
 (1) Xeroderma, its least expressed foi-m, where the skin is rough, 
 hard, and dry, with a tendency to furfuraeeous desquamation. 
 
 (2) I. nacree, or nitida, in which the scales are large (mother-of-pearl 
 like), and arranged in little polygonal patches — the true fish-skin. 
 
 (3) In this variety, the epithelial accumulations form little square 
 masses, somewhat dark in colour, from exposure to dirt, or from 
 pigmentation. 
 
 (4) I. hystrix, or spinosa, the papillary ichthyosis of Dr. Copeland, 
 in which the epidermis is greatly hypertrophied, and forms a " series of 
 closely packed horny mobile excrescences, which are usually of a dark 
 olive-brown colour" (B. Squire), the discoloration being partly due to 
 increased pigmentation, and partly to dirt. The so-called "porcupine 
 men " were aftected with this variety. 
 
 The disease may be local or general. In either case there are parts, 
 as the front of the knees, back of the elbows, ankles and axillje, which 
 it favours. Even when general, according to Balmanno Squire and 
 Tilbury Fox, it avoids the palms, soles, eyelids, flexures of the joints 
 and genitals. 
 
 In the case which I am about to bring under your notice, the disease 
 displays itself mainly as ichthyosis hystrix, though some of the patches, 
 such as those which occur about the elbows, wrists and ankles, belong 
 to the third variety described above. 
 
 H. F., 5 years old, is a fairly well nourished, and, excepting for the 
 skin disease, a healthy boy. At birth he was clean skinned, like the 
 other children of the family, and there are ten of them. He was 
 vaccinated when 4 months old, and it was only towards the end of the 
 first year that his mother noticed what appeared to be a patch of dirt 
 on the back of his neck. It began to thicken and grow, other patches 
 came out on various parts of the body, and in a few months the con- 
 dition of the eruption, and its arrangement, were almost the same as 
 they now are. 
 
 The family history is good. The fatlier and mother and the other 
 children are healthy; the grandparents on either side have not suffered 
 from any chronic skin complaint, nor is there any history of syphilis. 
 The boy's hair, nails and skin, excepting only the affected localities, 
 are normal in appearance, but behind both ears are scars, which 
 his mother states wei'e caused by kimps, which he had there when he 
 was two years old, having been lanced by a medical man. The disease 
 for the most pai-t affects the left half of the body, for on the I'ight side 
 are found only a few brownish stains on the ribs, and some thick 
 scaliness about the elbow, back of hand, below the knee, and about the 
 ankle .;ind instep. 
 
 The distribution of the disease on the left side is as follows : — On 
 the back of the neck, touching the mesial line, is a patch of I. hystrix, 
 al)out two inches square, connected by lines of dull coloration, and 
 some roughness on the side of the neck, with two smaller patches of the 
 same in front just above the sternum. A mild form of the same affects 
 the front part of the shoulder and axilla. There are some streaks of
 
 4 
 
 i 
 
 II 
 
 i I 
 
 ^s^ 
 
 CASE OF ICHTHYOSIS 
 (Dr. J. P. Ryans Paper.)
 
 A CASE OP ICHTHYOSIS. 979 
 
 (lull brown colour on the IjaL-k ; a series of curved streaks on tlie lower 
 ribs, the convexities directed downwards, and some vertical streaks on 
 the tlank, groin, and side of scrotum, where the roughness and papillary 
 hypertrophy are more apparent. This is continued along the perin;eum 
 and between the buttocks. Then occupying the lower pai-t of the left 
 buttock is a large irreijular patch of Aery pronounced T. hystrix, ending 
 in the upper third of tliigli, but joined by a streak of discoloration to 
 another elongated patch of the same kind crossing the popliteal space, 
 and terminating near tlie middle of the calf. There is also a little 
 roughness and discoloration on the front of the knee, on one shin, and 
 about the ankle. There is not, nor has there ever been, heat, itching, 
 or other local irritation. 
 
 Ft will tlius be seen that, in the subject under notice, the disease 
 presents itself under three aspects, viz., (I) as dark brownish staining, 
 undoubtedly due to deposit of pigment ; (2) as little squarish slightly 
 raised scaly masses : and (3) as ichthyosis hystrix or spinosa, so gi-apliic- 
 ally described Ijy Xeligan. He says : — " The affected sui'face prei^ents 
 a singular and remarkable aspect, being of a greenish-ljrown colour, and 
 so hard as to feel like horn, and to produce a grating noise when the 
 hand is passed quietly over it, yet more or less elastic and yielding 
 when pressed. The diseased epidermis is firmly adherent to the derma, 
 and if attempted to be torn off with the nail, the part on which it is 
 attached bleeds, and is painful. The spiny elevations may be separated 
 from each other, when it will he seen that they are of a greyish or 
 yellowish-white colour."' 
 
 He has lieen under the care of several medical men, but he lias 
 never received any benetit fi"om medication. T employed inunction 
 Avith chrysophanic acid ointment (gr. xx. to jj) on a few of the less 
 developed patches, but apparently without benetit. I therefore deter- 
 mined upon trying a more radical mode of procedure, and Dr. Lalor, of 
 Richmond, having administered chloroform to the boy, on December 20 
 I operated on the patch occupying the popliteal space. T tirst removed 
 with a curved scissors tlie spinous-looking outgrowths : then I removed 
 the skin in its entire thickness from the upper half, and with a 
 Volkman's spoon thoroughly scraped away the affected tissue from the 
 lower half of the patch. The result, so far, appeai-s to be favourable. 
 The wound, as you see, has healed, and the scar is not very fomuidable 
 looking. T propose to deal later on with the other patches Ijy erasion 
 alone, which I think will be sufficiently effecti\e, and the scarring from 
 which will be very .slight. 
 
 Dr. G. A. Syme, who kindly examined under the microscope some 
 of the affected tissue, reports of it : — " A vertical section shows great 
 hypertrophy of the horny layer of the epithelium ; tliere is hai'dly any 
 change in the papilhe or hair sacs, and no sebaceous or sweat-glands 
 Avere found." An examination of a horizontal section shoAved the same 
 appearances. 
 
 There are some points of exceptional interest about this case. First, 
 it is evidently not Iiereditary, none of the relations on either .side 
 having ever had anything similar to it. Then it is found for the most 
 part upon the left half of the body, and is closely associated Avith the 
 distribution of certain nerves, viz., cervical, intercostal, ilio-hypogastric, 
 ilio-inguinal, and lesser sciatic. The flexures of the joints and the 
 
 2k 2
 
 980 INTERCOLONIAL MEDICAL CONfiHKSS OF AUSTKALASIA. 
 
 genitals are affected, which is unusual ; and the skin, excepting only 
 where the disease is found, is perfectly normal in appearance and in 
 function. Pigmentation is a marked feature, and in some places foi'nis 
 the only factor of the disease. 
 
 Recovery is very rare. Only two cases are reported by Hebra, one of 
 which disappeared after an attack of measles, the other after var-iola. 
 Neligan records three cases in children under eight years, in whom 
 the disease was confined to the extremities, which recovered under the 
 use of alkaline baths, and the internal administration of iodine and 
 iodide of potassium. The record is unsatisfactory ; it leaves us in the 
 dark as to the phases under which the lesions presented themselves, 
 and therefore we do not know if the disease was mild or tlie reverse in 
 character. 
 
 I do not know if the treatment which T am pursuing has been 
 employed by others ; at all events, I have not seen any account of it.
 
 SECTION OF DISEASES OE 
 CHILDJiEN. 
 
 PRESIDENT'S ADDRESS. 
 F,y AV. Snowball, M.B. et Ch. B. Melb., L.R.C.S. Ed. 
 
 Surgeon to the :Melbounic Hospital for Sick Children. 
 
 On Intestinal Tuoublks in Ciiilduen. 
 
 Gentlemen, — In olioosing the title intestinal trouble in childhood, 
 as a subject for discussion at this meeting, I have been influenced by 
 the fact, that of all children's ti'oubles, abdominal ones are in this 
 country the most frequent, and I am sorry to say in many cases the 
 most unsatisfactory as regards the result of treatment. Of all children's 
 complaints at this period of the year, the most frequent and most fatal 
 is the gastro-intestinal. In fact, it may with justice be looked upon as 
 an epidemic, or rather if I may be allowed the expression, as an 
 epidemic of sporadic cases, for as yet there does not appear to be 
 evidence that the cases liave any direct power of contagion. In this, 
 our climate is more like that of the Amei'ican towns, where, in the hot 
 period of the year, the same condition seems to exist aanong the 
 children, specially in the cities, that we find here. 
 
 The principal factors in the pi'oduction of these complaints are 
 heat, hygiene (or ratlier tlie want of it), food, age. Certainly, high 
 temperatui'e plays the Diost important part in this direction, not only 
 tending to produce febrile disturljance in the child, but also tending to 
 cause fermentative changes in the food, in the case of an artilicially- 
 reared infant. Tliough in hot weather all places are more or less 
 subject to a visitation from the complaint, the crowded towns are 
 most subject, next come inland places, especially if flat and badly 
 drained. The mountainous parts, ;ind places close to the sea shore 
 escape the best, though some of our over-crowded seaside sul)U7'bs 
 are specially sul^ject to it. 
 
 Food.— As in the case of most other ailments, artiflcially-fed children 
 are more prone to be attacked, than are tliose who are reared on breast 
 milk. This is due to the facts, that these children appear to lia/e 
 weaker vitality than the nursed ones, and so ha\e less resisting power 
 against disease; and also that their food is more liable to fermentative 
 changes than is breast milk.
 
 982 INTERCOLONIAL MEDICAL CONGKESS OF AUSTRALASIA. 
 
 The age most affected is under two years, that being the period of 
 greatest activity in the intestinal glands, which, being in a state of 
 unstable equilibrium, are more likely to be disordered than at a later 
 period. 
 
 Any part of the alimentary tract may be affected. Genei'ally the 
 stomach is involved, and in some cases the disease does not appear 
 to extend further, the ease either recovering or dying from exhaustion 
 before the bowel is affected. Next comes the small intestine, and, in 
 the more protracted cases, the most definite lesions are situated in the 
 ileum, especially near the ileo-ca'cal valve. 
 
 The symptoms vary with the part of bowel affected and with the 
 stage of the disease ; one point of interest being that as in intussusception, 
 tlie higher up the lesion is, the more proliably will there be more or less 
 complete suppression of urine. 
 
 The terminations of the complaint, are in favourable cases, recovery 
 without any sequeUe, beyond intense weakness. In others, tlie 
 supervention of that condition of asthenia known as spurious hydi'o- 
 cephalus, or the hydrenceplialoid disease of Marsliall Hall, Avhere all 
 the symptoms of tubercular meningitis are present, except that the 
 heart is feeble and uncertain in its action, the extremities are cold, 
 the fontanelles depressed, and passive cerebral effusion may take place 
 from venous stasis, due to want of propelling power of the heart. 
 Another class of case terminates in ur;emia. Here you find the 
 diarrhoea and vomiting ceasing. Nourishment is taken eagerly, but 
 the urine is nearly suppressed ; generally, muscular twitchings set in, 
 sometimes violent convulsions, amidst which the patient sinks. One 
 of the most common of all terminations is that condition of ill-health 
 known as marasmus, popular! 3^ called consumption of tlie bowels ; 
 which, though widely difterent from tabes mesenterica, presents all the 
 symptoms of it, except that the mesenteric glands, instead of being 
 enlarged, are generally more or less atroj)hied. 
 
 As regards treatment, during the last twenty years it may be 
 divided into three difierent epochs, the first being the eliminative 
 period, when the endeavour was to e\'acuate the materies morbi by 
 means of purgatives ; the second, wlien sedati\'es played the most 
 important part, and wlien at all hazards it was sought to ari*est tlie 
 peristaltic action by means of sedatives and astringents ; and the third, 
 wliich exists at the present time, that of antisepsis, the materies morbi 
 being killed, if possible, by the introduction into the system of the 
 various germicides. Possibly all aie more or less right, and the 
 happiest results Avill l)e ol)tained by a scientific combination of all 
 three methods.
 
 president's address — SECTION OP DISEASES OF CIIILDRKN. 983 
 
 The method I usually adopt t'of a case of gastro-intestiual catarrh, if seen 
 in the early period, when the temperature is high, and gastric symptoms 
 are most prominent, is to put tlicciiild in the coolest and best ventilated 
 I'oom in the liouse ; if possible, keej) the temperature of the room down 
 to G5°. Wrap the child in cold lotion to lower the body heat, and stop 
 all food except icefl rice \\at('r, and iced brandy and water, in small 
 quantities, gi\-en frequently : if the child is at the breast, recommend 
 that the breast be emptied by })umi)ing before the child is put to it, so 
 that it may have the comfort of sucking the nipple, without the irritant 
 of the mother's milk, which in these cases is more than the stomach can 
 bear. As for drugs, I have most confidence in minute doses of calomel, say 
 gr. Jj, repeated ever hour till a grain has been taken ; if tliat fails, creasote 
 and hydrocyanic acid in hourly doses, for from six to ten hours, and my 
 experience is then that either the cliild is better, or else that the disease 
 has progressed, and that intestinal trouble has commenced, as sliown by 
 the frequent, watery, foul-smelling motions, with coiisiderable pain. I 
 then use one of the liquid bismuth preparations, with liquor hydrarg. 
 perchlor., and if there be any sign of heart failure, an occasional dose of 
 digitalis. If the symptoms do not then abate, but purposeless straining 
 comes on, with the passage of mucous stools streaked with blood and 
 great tenesmtts, I apply belladonna over the bowels, at the same time 
 giving one of the insoluble bismuth salts, such as the subnitrate, with full 
 doses of opium, at same time giving injections of various astringents 
 with sedatives, the diet at this time consisting of raw albumen, raw 
 meat juice, and brandy. If in spite of treatment the case goes on to 
 the hydrencephaloid state, J wrap the child in brandy and oil, apj)ly 
 nmstard to the heart, give stimulants, such as spirit, amnion, aromat. 
 and digitalis, and tether, oi" camphoi'. In the unemic cases, I have 
 nothing more useful than small doses of pilocarpine, say J-^ gr., with 
 digitalis and warm mustard bat) is. If the case goes on into marasmus, 
 the changes may be rung on all the various digested and soluble foods, 
 with varying amount of success. 
 
 But, in all stages of the com|)laint, the two main features for a suc- 
 cessful issue are — removal to a healthy locality, and the stoppage of all 
 food that requires any digestion. Milk, no matter of what kind and 
 how prepared, whether human, whether peptonised, does positive harm 
 in the early stages.
 
 984 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 GASTRO- ENTERITIS IN CHILDREN: SOME POINTS IN 
 PATHOLOGY AND THERAPEUTICS. 
 
 By D. COLLINGWOOD, M.D. 
 
 This name may be used to indicate a class of diseases, the wide- 
 spread prevalence and importance of which are my excuse for asking 
 your patience for a few minutes to-day. Those of us especially who 
 are connected with institutions where children are brought into the 
 world, reared, or where their diseases ai'e treated, must all feel that in 
 this section, more perhaps than in any other, the value of an inter- 
 change of ideas cannot be ovei'-estimated. 
 
 Classification. 
 
 Of diseases of the gastro-intestinal tract we may make a classification 
 as follows : — Acute gastric catarrh, chronic gastric catarrh, dyspepsia, 
 acute intestinal catarrh, chronic intestinal catarrh, cholera infantum, 
 dysentery or ulcerative colitis, tubercular enteritis, parasitic enteritis. 
 
 I do not propose to attempt to travel over so wide a range of 
 material as this classification otters, but selecting from it that which 
 appears to me to be the most prevalent form in these colonies, I wish 
 to offer a few remarks on what I may call gastro-enteritis. 
 
 Etiology. 
 
 Amongst predisposing causes we have season, age, locality, heredity 
 and social condition ; and undoubtedly here, as in England and America, 
 summer, especially the earlier and later months, is the period of the 
 year when the disease amounts almost to an epidemic. Hot damp 
 weather is certain to be followed by a large increase in the number of 
 our gastro-enteric patients ; and most of all so v/hen the nights are 
 muggy and hot — when even healthy children are broken in sleep. 
 
 High barometric pressure would seem to have some influence, 
 especially when associated with excessive moisture in the atmosphere, 
 more so than high thermometric indications. 
 
 Locality and social conditions may be taken together. Overcrowding, 
 inefficient hygienic surroundings, tilth, bad ventilation, etc., are the 
 outcomes of cities and po\ei'ty, and potent are their evil influences upon 
 the infant exposed to them, both as predisposing agents and as direct 
 exciting causes, because for similar i-easons the feeding of such infants 
 is as bad as the hygiene. 
 
 Heredity is not usually introduced liy the text ])ooks as a pre- 
 disposing cause, but apart from the inlluence of sun-ounding conditions 
 to which the children of such parents are exposed, the propagation of 
 their species by ill-nourished, strumous, dyspeptic parents, must 
 necessarily produce Ijeings with prejudiced alimentary mucous mem- 
 l)ianes, and ill-acting absorbent and glandular systems. 
 
 Of direct exciting causes, bad feeding comes first. Let me divide 
 this into two classes : (1) the character of the food, (2) the method 
 of feeding. No one who has taken tlie trouble to look over his case 
 book can have failed to notice how comjiaratively rare gastro-enteric 
 disease is in the nurslings of averagely-healthy parents, how enormously
 
 GASTRO-EXTKIUTIS I\ CIIILDUHN. 985 
 
 it preponderates in hand-fed children ; so tliat one is conipelhid to the 
 conviction that all hand-feeding-, however well-directed, is bad. 
 
 Next to hand-feeding as a direct cause, I should place too early and 
 too late weaning, and afterwards injudicious irregular nursing or the 
 insistence in nursing of mothers whose own condition of health unfits 
 them to produce healthy nourishment for their infants. 
 
 [n hand-feeding, amongst bad foods must be pbiced sour milk, an 
 undue preponderance of farinaceous st;irchy foods, excess of sugars, 
 meat at too early an age, excess of fats and butters, scraps of adult 
 food. 
 
 By faults in the method of feeding, T mean in nursing, that want 
 of regulaT-ity which it is so hard to persuade mothers to avoid — -the 
 yielding to the temptation to put the child to the breast whenever it 
 cries ; and in hand-feeding, the same irregularity, as well as the want 
 of scrupulous cleanliness. 
 
 Amongst other exciting causes, we have cold, thi-ough insufficient 
 clothing in weather when perspiration is constant ; acute diseases, 
 especially the exanthemata. 
 
 Symptomatology. 
 
 There are usually some premonitory symptoms of these complaints, 
 lasting over two oi" three days. They consist of restlessness, fretfulness, 
 disturbed sleep, the infant waking with short tits of crying, pallor of 
 the face, heat of the liead, impaired appetite, and obvious discomfort 
 after food. 
 
 The actual attack is ushered in with vomiting and purging, usually 
 in this order : — The vomited matters consist of the contents of the 
 stomach from the last meal at first, and bile afterwards, when the 
 stomach has been thoroughly emptied by repeated retching attempts. 
 If milk has been taken, it is rejected in sour, very acid masses, con- 
 sisting of cui'd, often in the shape of lumps as l^ig as a walnut, and of 
 ^■ery tough consistence. The stools are frequent from the first, and 
 painful or preceded by pain. Their number varies from half-a-dozen to 
 twenty or more per diem. In the early stages they are semi-solid, 
 homogeneous, yellow in colour, and neutral in reaction. 8oon they 
 become more liquid and green ; and later still, they ai'eacid in reaction. 
 They may then become heterogeneous, gi-eenish with admixture of particles 
 of yellow f;eces, and neutral in reaction ; or green and acid, with flakes 
 of yellowish-white caseine. Further, they may, and usually do, vary 
 from hour to hour, both in colour and consistence. Mucus or blood, 
 or both, are usually present in the later stages. Sometimes, and 
 this is in very severe cases, the character of the stools appi'oximates to 
 that of cholera infantum — liquid, watery, and almost colourless; in 
 such, these stools may Ije passed without any straining, but, in 
 moderate cases, tenesmus is a mai-ked synqjtom. 
 
 The tongue is dry, clean at the tip and edges, furred thinly over the 
 dorsum. The fur Ijecomes thicker as the case proceeds, and in severe 
 cases the tongue becomes dry and brown. There is great thirst, the 
 child obviously craving for cool diinks. Ai)petite for solid food is lost 
 more and more. 
 
 Tlie abdomen is at first distended with flatus, and eructations are 
 frequent and sour-smelling. There is often some tenderness on
 
 986 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 palpation from the first. In the hxter stages the belly is flat, sometimes 
 retracted, always flaccid. 
 
 The temperature is raised from the first— 102° to 103° F. on the 
 average, with slight morning remissions. As the case proceeds, these 
 remissions become more marked, and then perspirations take place. In 
 the last stages of some cases, great variations of temperature are noted. 
 
 The I'estlessness which was present from the first continues through- 
 out the case. It increases when there is a tendency to convulsions ; 
 the head is then rolled from side to side ; slight twitchings are noticed, 
 perhaps some strabismus and sluggishness of the pupils, culminating in 
 an attack of convulsions, unilateral or general. 
 
 The pulse always runs high, and early shows signs of weakness. 
 
 Respiration is affected, as in pyrexia from whatever cause. A short 
 sharp cough of peculiar character is a frequent accompaniment of the 
 attack from its earliest stages, especially in cases where the gastric 
 symptoms are the most prominent. 
 
 The urine is diminished in quantity, high-coloured, and irritating to 
 the skin. It is passed only two or three times daily. 
 
 The general tissues are speedily affected, the roundness of the face is 
 lost, the limbs become soft and flabby, the eyes sunken and surrounded 
 by dark rings, the conjunctiva; lose their brilliancy, and the '• nasal 
 line " is deepened. The position taken by the patient shows languor and 
 weakness, a disinclination to move or be moved, but the onset of 
 restlessness is an unfavourable sign. 
 
 The skin of the buttocks and thighs soon become excoriated by the 
 acid stools and concentrated urine ; the skin of the bod}', esj)ecially the 
 abdomen, is dry and harsh. 
 
 The progress of the case towards i-ecovery is first marked by the 
 cessation of vomiting, by improvement in tlie colour, and diminution in 
 the frequency of the stools, increase in the quantity of urine passed, and 
 a re-gain, in cases of short duration, of flesh and strength, but little less 
 rapid than tlieir loss was. 
 
 When the symjitoms tend towards a fatal termination, convulsions 
 may occur ; at other times, drowsiness comes on, possibly ursemic in 
 character, persistence in refusal to take food, coldness creejnng up the 
 extremities, and sometimes the cessation of active symptoms, such as 
 vomiting and purging. 
 
 Morbid Axatomv and Pathology. 
 
 The primary lesions consist of hypersemia of the intestinal mucous 
 membrane. The position in which this hypera^niia is greatest varies in 
 different cases ; and as is usual in catarrhal diseases, the evidences after 
 death do not by any means correspond with the severity of the 
 sym})toms, especially if the duration of the case has been short. The lesions 
 occur in patches, frequently over the whole alimentary canal, but most 
 connnonly and intensely in the ileum and colon, and especially at the 
 ileo-caical valve, and in the sigmoid flexure. The mucous membrane is. 
 reddened, softened, and swollen, the hypertemia shows up in arborescent 
 patches about the follicles and patches of Peyer, which stand out above 
 the surface, and are marked with dark red spots. The arborescent 
 injection is very visible from the peritoneal surface.
 
 GASTKO-ENTERITIS I\ CHILDREN. 987 
 
 In cases which have gone beyond the acute stage, the mucous surface 
 is frequently abraded about the solitary gland and patches. 
 
 The lesions found in the stomach do not by any means always 
 correspond with the severity of the disease, as shown In' its symptoms 
 during life ; the exjtlanation of this fact may depend partly upon the 
 greater irritability of the gastric mucous membrane in children, and 
 jiartly upon irritability reflected through the sympathetic nei've plexus 
 from the intestines. it has been suggested also that the swollen con- 
 dition of the mucous membrane forming the ileo-c;ecal valve, frequently 
 so great as almost to occlude it, may have a direct agency in the 
 causation of the vomiting. 
 
 The morbid condition of the contents of the intestine is of interest. 
 An excess of secretion of mucus is of course present in all cases, and the 
 reaction of the contents of the small intestine, instead of being alkaline, 
 is found to be acid. The colour too of the contents of the healthy small 
 intestine is a bright rich yellow, or orange, but in this catari'hal con- 
 dition it becomes green. The explanation of this change of colour 
 depends upon alteration in the biliary colouring matters. We know that 
 these are the parents of the colours in healthy fieces, and it has been 
 shown that bile exposed to air, or to tlie action of an acid, changes 
 colour by the bilirubin becoming biliverdin. This is seen in the 
 ordinary so-called bilious vomiting, when bile regurgitates into the 
 stomach, and is exposed there before being rejected to the action of the 
 acid gastric juice. 
 
 Similar conditions are ])resent in these ca.ses : the intense acidity of the 
 material passed down into the intestine from the stomach — partly the 
 result of the increased acidity of the gastric secretion, and j)artly the 
 result of acid fermentation — proves too much for the alkalising powers of 
 the bile and pancreatic juices and succus entericus, so the action of the 
 acid contents changes all the bilirubin at once into biliverdin, and gives 
 the colour to the motion so characteristic of the disease. These green 
 motions must be cai-efully distinguished from the chopped spinach 
 motion of chronic entero-colitis, in which the colour is probably due to 
 altered blood-colouring matter. 
 
 The pathology of the central nervous system in this com|)laint is of 
 interest also, but I will touch uj)on one [loint only, and that is the 
 depression of the anterior fontanelle, which is so often seen in the later 
 stages of cases which are not improving. The explanation of this 
 phenomenon which has been offered, is that it is due to withdrawal of 
 the fluid elements from the brain by the flux from the bowels, so that an 
 actual loss of bulk of the cranial contents ensues. As the bony case is 
 not rigid in young children, atmospheric pressure from without leads to 
 depression of the softest and least resistant parts, so that dei)ression of 
 the fontanelle and even overlapping of the bones ensues. 
 
 In prolonged cases, this collapse of the cranial vault may not be 
 sufficient to compensate for the loss ; and a tidal wave of cerebro-spinal 
 fluid being for similar reasons impossible or insufficient, the cerebral 
 sinuses and large vessels become engorged with blood, the current 
 becomes sluggish, owing partly to the engorgement, and i)artly to the 
 enfeeblement of the heart's action, and so the conditions most favourable 
 to thrombosis result. The superior longitudinal sinus is chiefly affected
 
 988 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 in this way, and death results vvitli difficult respiration, stupor, dilata- 
 tion of pupils, and other nervous symptoms. 
 
 The diminution in the quantity of urine excreted depends apparently 
 in part upon the quantity of fluid lost from the bowel ; for although in 
 cases of moderate severity this quantity is not very great, it is sufficient 
 to cause a reduction of the blood pressure, and so to diminish the 
 urinary secretion. 
 
 In cases where death occurs with uraimic symjjtoms, probably acute 
 nephritis exists, the kidneys sharing in the inflammatory affection. 
 Further investigations on this point would be of great value. 
 
 The morbid processes, concerned in the formation of the large masses 
 of curd found in the intestines, deserve soiue attention. Doubtless, the 
 use of milk, containing too large a proportion of caseine for the digestive 
 power and age of the infant, has much to do with it. Certainly, too, 
 irregularity in feeding must have its influence, since it gives rise to a 
 catarrh of the mucous membrane of the stomach, with its consequent 
 excess of mucus secreted, which in its turn favours acid fermentation, 
 and also acts mechanically by preventing the access of the digestive 
 materials to the food. 
 
 The increased acidity of the gastric secretion has another influence, 
 in producing large masses of curd immediately upon the introduction of 
 milk into the stomach, instead of the small flakes of curd which are 
 formed in the healthy process. These masses are more liable to be 
 formed if fresh milk be introduced to a stomach already in over-action, 
 and containing a quantity of semi-digested milk, i.e., time not being 
 allowed for one meal to digest and pass into the duodenum, Viefore 
 another is given. 
 
 The masses of curd so formed are too large to be penetrated by the 
 digestive ferments, and so they react mechanically as irritants of the 
 intestinal nnicous membrane. Microscopic examination shows them to 
 be swarming with bacteria. 
 
 Treatment. 
 
 Treatment naturally divides itself into two headings — prophylactic 
 and direct. 
 
 The study of the causes of gastro-enteric troubles gives the key to 
 the ]->rophylaxis, and by insistence upon proper care in feeding, where 
 liand feeding is necessary, and upon an intelligent carj'ing out of the 
 directions in general hygiene, as well as in the choice of proper foods, 
 more can be done in prevention than medicine can do in cure. The 
 ignorance existing in these colonies amongst parents of even tlie better 
 classes, about infant management, is simply appalling, but is transcended 
 by the obstinacy, far woi'se than ignorance, of the large majority of 
 so-called nui-ses to whose tender mercies we are committing the 
 future men and women of Australia. 
 
 In tlie direct treatment, there are two points specially to be considered 
 in I'egaid to food — (1) The food itself, (2) The method of its administra- 
 tion. If the child be hand fed, milk being the chief aliment, to it must 
 first be directed our attention in all cases of the disease which we are 
 considering, and its j)ossible faults and the harm they may do must be 
 borne in mind. (J)ur flrst aim must be to [)revent or to cure the
 
 GASTRO-KXTKl;niS IX CIIILDKKX. D89 
 
 formation of too large masses of curd, and to this end the exhilntion of 
 lime water or other alkalies, or the process of enzymising befoie 
 administration should be resorted to in all cases. 
 
 The use of such i)reparations as nenicasei, which have for their 
 <)bject the approximation of cow's to mother's milk, may be sufficient. 
 In a large number of cases, the condition of things l)efore the ))ati(nt 
 comes under ti-eatment is such, that success can only be obtained hy 
 l)oldly cutting of!" milk altogether for a time — if not at first, at any rate 
 when att(Mnpts to render it more digestible have failed ; barley water 
 or rice water, and broth (carefully freed from fats), should be substituted, 
 or one of the jirepared foods, such as Mellor's or Allen and Hanbury's, 
 made with barley water in place of milk, may be found suitable. As 
 soon as the ci;rds have disappeai-ed from the motion, an attemjjt may lie 
 made to restore milk to the diet, the stools being carefully watched, and 
 the milk cut ofT again if it passes undigested. A very convenient way 
 of re-introducing milk, is to add it in increasing quantities to the barley 
 water, given alone, or used in the preparation of artificial food. 
 
 I think I have given sufficient reasons for urging a greater attention 
 to regularity in feeding infants, both as a preventive of disease and iii 
 the treatment of it. I need hardly allude to the quantity given excc-pfc 
 to say that, in all cases of gastro-enterie troubles, the quantity must be 
 strictly curtailed from the first, according to the age of the patient. 
 
 Medicixks. 
 
 I will not waste 3'our time by rei)eating the usual routine of medicinal 
 treatment. One or two points, however, are of interest. If the child 
 has l)een hand fed on cow's milk in any comVjination, alkalies come first 
 in the list of useful drugs. Their action consists chiefly in neutralising 
 the natural acidity of cow's milk, and so approximating it more nearly 
 to mother's, and rendering it more digestible. If there be much acid 
 fermentation going on, the administration of alkalies after food must be 
 of use. 
 
 ►Sedatives, notably o[)ium, have probably been too little used hitherto. 
 Their use has been almost limited to the induction of sleep, and for this 
 they have been very properly condennied. There is very little doubt 
 that small doses of opium, judiciously given to relieve pain, must 
 save that nerve exhaustion, which tells more seriously upon an 
 infant than upon an adult. The best form is pulv. ipecac, co. in doses 
 of },-'2 grains, according to age. In profuse watery diarrhoea, as an 
 astringent combined with sulphuric acid, tincture of opium is very 
 valuable. 
 
 Mercurials have been our stock remedy from time immemorial, and 
 yet the therapeutics of tlie drug have been very imperfectly worked 
 out. From clinical observation, the following would seem to be the 
 indications : — 
 
 (1) That vomiting is often best controlled by small doses of the per- 
 chloride in solution, and this form has the advantage of being very easy 
 of administration. 
 
 (2) That in diarrhcea of intestinal catarrh, small doses of l-ll grains 
 of grey powder, or jxj~1 gi'^'ii^ of calomel, act well. 
 
 (3) That the benefit from their exhibition may not be fully seen 
 until they have been pushed for one to three days.
 
 090 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 (4) Tliat during tlieir iulmiiiistration, the stools first regain tlieir 
 normal colour, ancl then gradnally diminish in frecjuency. 
 
 From these and other considerations, it would appear that the drug 
 in question is a direct sedative to the mucous membrane of the 
 alimentary canal, and esjiecially to the stomach, and that it tends to 
 control the acid fermentation which is so powerful a factor in the 
 disease. This effect is twofold. Under the influence of mercury, the 
 hiliary secretion is increased- — so experiment and clinical observation 
 ■would lead us to believe — and bile being the natural intestinal anti- 
 se])tic, this increase would tend to check acid fermentation ; also, as bile 
 and pancreatic fluid too (arguing from the analogy of the salivary glands) 
 are increased in quantit}', this increase in quantity of the alkaline fluids 
 poured out upon the already too acid material sent on to the intestines 
 from the stomach, will tend to neutralise it, and so bring it more nearly 
 to its natural condition. In addition to these results, the powerful 
 antiseptic jjroperties of the drug itself must be of great value. 
 
 Last of all, it appears certain, emj^irically, that mercury is a direct 
 sedative to the mucous membrane of the stomach ; it probably continues 
 a similar action u])on the intestinal mucous membrane — an additional 
 I'eason for its usefulness in catarrh. 
 
 In the treatment of the vomiting, creosote, especially in combination 
 with small quantities of iodine, is of great value, sometimes checking 
 the emesis where mercury lias failed to do so. Its therapeutics closely 
 resemble those of mercury in its antisejjtic properties, and it has special 
 value, which the mercury has not, in relieving the flatulence, which is a 
 distressing symptom in the earlier stages. The sulphate of aniline is 
 siuiilarly of particular value in distension from flatus. 
 
 DISCUSSION ON GASTRO-ENTEPJTIS. 
 
 Dr. Walsh (Kew) recommended the administration of hydrarg. 
 subchlor. gr. ij at the commencement of the attack ; he was not satisfied 
 with his experience of antiseptics in this form of diarrhwa. 
 
 Dr. DYRiNfi (Coburg) believed that there was a connection between 
 typhoid fever and the epidemic gastro-enteritis of children, often seeing 
 cases of both affections in the same family at the same time. 
 
 Dr. Davenport was dissatisfled with astringents in this form of septic 
 diarrhcea. He had found chloral very useful in these cases, giving as 
 much as gr. j every three hours to a child six months old. He considered 
 that it acted as an antiseptic, sedative, and antipyretic. It was very 
 beneflcial to send patient away for a change of climate, as .soon as the 
 septic character of the stools cleared up. He also had been frequently 
 struck by the apparent similarity between typhoid fever and gastro- 
 enteritis in children. 
 
 Dr. Henry believed that dentition played a large part in the etiology 
 of gastro-enteritis. He had found Brand's essence of chicken a useful 
 substitute for )nilk i)i these cases. 
 
 Dr. NiCKOLL (Hawthorn) thought that as the reflex irritability of 
 children was so great, the presence of the curds was a great factor in 
 the etiology of gastro-enteritis, and so believed in the old-fashioned
 
 AN ANOMALOUS CASE OF ACtiUlRKD INFANTILE SYPHILIS. 991 
 
 •castor oil. His Excellency the Govei'nor had drawn attention to the 
 very great infantile mortality in tiie colony; he thought it was due in 
 great measure to the bad feeding and hot climate. 
 
 Dr. Salmon (Ballarat) had found great benefit from minute doses of 
 calomel in cases of gastritis. Chloral was most useful in those cases 
 depending on dentition as a cause. Tee by the mouth, and ice to the 
 abdomen, he had found very useful in checking the symptoms. 
 
 Dr. CouPEK -Johnston said that the etiology was very indefinite. He 
 had found that improper food, sepsis, and arrest of secretions were three 
 very potent causes. Arrest of perspiration often precedes an attack of 
 gastro- enteritis, and the arrest of the same may often be procured Ijy 
 means of a hot bath, ;ind wrapping the child in a blanket for ten 
 minutes after the bath, giving six oi" eight drops of brandy if there is 
 much depression. llegularity of feeding is not sufficiently insisted 
 upon among the children of this colony. 
 
 Dr. Power thougiit that l)ad drainage, was a powerful factor in the 
 etiology of the disease. 
 
 Dr. James Robertson laid gieat stress on the diet l)eing regulated, 
 and rest in the recumbent posture. He also believed firmly in the use 
 of castor oil at the commencement of the attack. 
 
 Dr. Dawson said that the Ijowel was inflamed, and filled with ii-ritating 
 matter. The first indication was to clear away the ii-ritating matei-ial ; 
 and second, to rest the bowel by suitable nourishment. He liked 
 calomel better than oil, as it had a beneficial effect on the hepatic 
 congestion. 
 
 In reply, Dr. Sno\vi3ALL thought that the \isitors had been too polite 
 in not condemning the foul smells of Melliourne as a very potent cause 
 of our high infantile mortality. He i-egretted that he was unable to 
 shai'e in the hopefulness about drugs which seemed to be entertained 
 by most of the speakers. 
 
 Dr. CoLLiNfiWOOD, in reply, laid great stress on the necessity for 
 further investigating the pathology of gastro-enteritis in infants. He 
 considered that milk was usually the ^•ellicle for infection, and that the 
 sudden changes of temperature were very detrimental to the milk. He 
 did not consider the use of iced drinks rational in the treatment of 
 children. 
 
 AX ANOMALOUS CASE OF ACQUIK1:D INFANTILE 
 
 SYPHJLIS. 
 
 By R. A. Stirling M.B. et Ch. B. :\l.'ll)., L.R.C.P. et S. Ed. 
 
 In this case, the father, who acquii-ed syphilis three years before 
 marriage, after rigorous treatment was pronounced free of the disease. 
 A relapse occurred some six months after his child was born, and infection 
 of the child followed. 
 
 C. J., fet. 30, consulted me in LS82 with an infecting sore and a bubo. 
 Under treatment with mercury and iodide, no secondary symptoms 
 supervened. Not believing the true nature of the disease, he infected a
 
 992 IXTERCOLOXIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 woman with clianci-e, and in her tlie secondary symptoms followed 
 the usual course, lasting about a year, thus settling all doubt as to the 
 genuineness of the attack. 
 
 In 1885, having been treated more or less continuously the whole 
 time, and no sign — not even a blotch on the skin — appearing, he was 
 allowed to marry, on the advice of another physician and myself. His 
 son Avas born at full term, and was a healthy boy. Some weeks after 
 birth, the child developed a rash about the anus, which caused the 
 father much alarm ; but there were no snuffles. He .slept well, was in 
 good health, and ail signs of eruption disappeared with the application 
 of zinc ointment. The mother is now, and always has been, quite 
 healthy. 
 
 When six montlis old, a .small sore appeared on the lower lip of the 
 child, followed by induration of a gland at the angle of the jaw. 
 Simultaneously, there had been a breaking out of an old sore on the 
 angle of tlie mouth of the parent, and it was undoubtedly the contagious 
 secretion of this sore which had inoculated the infant. A macular 
 sypliilide, diftering in no wise from the cpmmon form of the adult, next 
 appeared on the front and sides of the chest, and a few moist papules 
 on the anus and between the toes. The throat was not affected, and no 
 other symptoms arose. The treatment consisted in inunction with blue 
 mass, and internally the hyd. c cretcu 
 
 Such, shortly, is a sketch of an unusual occurrence —the child 
 escaping infection during the latency of the di.sease in the father ; a 
 latency brought about probably by early and prolonged treatment by 
 hydrarg., and which goes to bear out the assumption of Zeissl and 
 others, that in some cases mercury given at the early stage merely 
 paralyses the activity of the syphilitic virus. 
 
 I should have before stated that the child was suckled by the mother 
 until ffve months old, and then bottle-fed A neai'ly parallel case is 
 infection of tlie mother by a hereditarily syphilitic child. 
 
 ON A CASE OF SYPHILITIC DACTYLITIS IN A CHILD. 
 By II. A. Stirling, M.B. et Ch. B. Melb., L.R.C.P. et S. Ed. 
 
 Dactylitis syphilitica is a rai'e affection, and as but few cases are on 
 record, T have thought the following woi^thy of production, especially 
 as I happened to be aware of the antecedents of one of the parents : — 
 
 Early in 1878 I circumcised, at the Melbourne Hospital, a young- 
 man who had an undoubted infecting sore on his prepuce, as well as 
 a congenital phimosis ; tlie wound rapidly healed, no further symptoms 
 of the disease became developed, and in three months from that time 
 he married. (I may mention that in this, as in many other instances 
 of .syphilis, neither tlu; inguinal nor any other glands were involved — 
 tlie disease probably missing the lymphatics and entering the blood 
 direct.) Two children were born of the marriage — a boy in April 1879, 
 and a girl in August 1880. In 1885, the father consulted me for nodes
 
 A CASE OF SVPJIIMTIC DACTYLITIS IX A CHILD. 99:3 
 
 on the tibia, for which he had been some time under treatment Ijy a 
 Chinese doctor, and which he of course thought to have no connection 
 with his former disease. These nodes, which were symmetrically 
 placed, rapidly subsided under the tannate of mercury and potassium 
 iodide. He looked robust and well, and with this exception had 
 been free from any symptoms. In 1886, several gunuuatous ulcers 
 appeared on the outer and inner sides of the legs, and required a 
 renewed and prolonged course of medicine before healing. 
 
 He stated that all this time his wife was quite healthy, and had 
 never had a miscarriage. In January 1887 he returned with his .son, 
 now nearly eight years old, who was suffering from an affection of 
 the fingers. I found the terminal phalanges of the digits of the left 
 hand, excepting the thumb, the seat of periostitis and ostitis — the 
 swelling being situated more on the back than the front, and not 
 involving the nails. Each finger was more or less swollen along its 
 whole lengtli, but this seemed to be due to cedema and to joint effusion, 
 which mucii impeded movement. There was only slight redness and 
 mottling at the ends of the fingers and at the back, and the pain was 
 much less than in whitlow; although subsequently in the index finger 
 there were all the symptoms of whitlow, with caries and loss of the 
 bone — a true syphilitic onychia. The gummy deposit in the other 
 fingers rapidly disappeared under treatment, and showed no tendency to 
 break down. The fibrous sheaths of the tendons were not at all 
 affected. Pressure over the ends of the fingers caused severe pain, but 
 not at their bases. 
 
 The course of the disease was chronic, owing to the condition of the 
 first finger, which at one time looked as if amputation would be 
 required; but in the other fingers full doses of grey powder and the 
 iodide of potassium, with occasional inunctions of mercurial oleate 
 on the affected part, rapidly reduced the swelling, which had nearly 
 all disappeared in six weeks. During treatment, however, the ring 
 finger of the right hand showed signs at its initial joint of periosteal 
 trouble, but the symptoms passed away. 
 
 One curious effect of the disease was to leave elongation and 
 incurving of the nails. 
 
 Tliis boy showed no other signs of late hereditary .syphilis ; and 
 beyond a well-marked depression of the nasal bones, which was not 
 present in the fathei^ and se\ei'al suspicious-looking stri;e about the 
 angles of the mouth, I could get no history of early infection. 
 
 Taylor, who has written fully on this disease, states that in its 
 primaiy stage it is amenable to treatment ; and to this circumstance 
 of early ti-eatment, and the peculiar features of the hi.story, I think I 
 owe its recognition, as the swelling is not unlikely to be put down as 
 strumous, and treated with cod oil and tonics. 
 
 The points of intei'est are the innnunity for many years of the father 
 from .syphilitic symptoms, after excision of the primary lesion — an 
 immunity in my experience by no means unusual. The immunity of 
 the son in infancy — no snuffles, nor wasting, eruption, or mouth-sores ; 
 no deformity of the teeth. The tertiary character of the disease in the 
 father transmitted to the son, as shown in the former by the large size 
 and small number (two) of the swellings, and in the latter by the 
 disease itself. 
 
 2s
 
 994 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 ON A CASE OF ACQUIRED SYPHILIS IN A CHILD 
 
 THREE YEARS OLD. 
 
 By James P. Ryan, M.K.Q.C.P.I. 
 
 Chevalier of the Legion of Honour. 
 Surgeon to the Skin Department of the Melbourne Hospital. 
 
 Mrs. A. H., aged 25 years, first caine under my notice as an out- 
 patient at the Melbourne Hospital, on March 14, 1888. She was 
 sufferino' from secondaiy syphilis, and had mucous patches about her 
 lips, and on her tongue and pharynx, a dark coloured macular eruption 
 slit^htly visible on the forehead, but well marked and widely distributed 
 over the limbs and ti-unk, and condylomata about the vulva and anus. 
 She was living with her husband, who was affected in a somewhat 
 similar manner. She had been married for four years, and had 
 one child, a girl, nearly 3 years old, and healthy, whom she brought 
 with her when she visited the hospital. Her husband had an eruption 
 on his skin about Christmas time, and a fortnight or three weeks 
 later she also became affected. Previous to this, she had enjoyed good 
 health. The child was always healthy, and had never suffered from a 
 skin eruption. However, about the middle of May a pimple made its 
 ai)pearance on her forehead, above the left eyebrow. A week later it 
 had become a slightly raised flattened patch, about the size of a three- 
 penny piece, with a somewhat depressed centre, tending to scale. It 
 became gradually larger, until a month from the time it was first noticed, 
 it was as big as a shilling, nearly round, somewhat raised, with an in- 
 durated base, and the centre for a fouith of an inch was depressed and 
 eroded. It was a good typical example of the '-parchment" chancre, 
 the peculiarities of which, according to Jonathan Hutchinson, ai'e, " that 
 its area of induration is large, and its thickness very small, whilst there 
 is little or no inflammation." Two weeks later, a roseolar rash came out 
 on her l>ack, chest, abdomen, and thighs, a few spots showing on her 
 forehead, her arms and legs being iinatfected. 
 
 About the middle of August, absorption of the chancre had taken 
 place, and there was left only a red patch to mark its site ; the eruption 
 had assumed a coppery tint, the j^harynx was deeply congested, and 
 there were some small mucous patches on the tongue. Henceforward 
 there was gradual but steady inii»rovement, and when last seen by me 
 on November 21, the rash had entirely disappeared, the mucous patches 
 in the mouth nearly so, and there was only left a copper-coloured stain 
 to mark the spot where the chancre once had been. The child's general 
 health did not seem to suffer to any appreciable extent, and no treatment 
 was employed until the eruption was fully out, when the daily inunction 
 of mercurial ointment was begun, and continued until October 3, after 
 which she was put upon small doses of hydrarg. e cretii. 
 
 There can Ije little doubt in this case as to the mode of infection. She 
 was an only child, and the pet of both parents, who frequently fondled 
 and kissed her. One of them, the mother, if not both of them, had 
 syphilitic sores about the mouth, the child had probably some slight 
 abrasion on her forehead, and through this the syphilitic poison made its 
 entry.
 
 CORRELATION OP FOLLICULAR TOXSILLITIS IX CHILDKEN. 095 
 
 Such a mode of infection is certainly unconunon, tliough why it sliould 
 be SO is not very clear, for umlonbtedly a considerable number of women 
 having young children, amongst tlie liumlder classes in Melbourne, and 
 amongst hospital patients, ai'e the subjects of syphilitic disease. 
 
 THE CORRELATION OF F(JLLICULAR TONSILLITIS IN 
 CHILDREN, WITH OTHER ZYINIOTIC DISEASES. 
 
 By A. HoxMAN, M.R.C.S. 
 
 During the last four or li\e years, I have taken notes of a number of 
 cases of follicular tonsillitis, which have come under my care. Mv 
 attention has been arrested by the grave results which have frequently 
 followed those sutfering from this generally considered simple complaint. 
 It must be observed that the vast majority of these cases have occurred 
 amongst children and young people. The glandular activity prevailing 
 during childhood, the well estaVjlished functions of the tonsils, and their 
 relationship to other glands consisting of lymi)hoid tissues, such as the 
 .solitary and agminated glands of the intestine ; the numerous instances 
 where the disease has assumed the character of an epidemic, the per- 
 sistent way in which it retui-ns to a neighbourhood whei'e the surround- 
 ings are unhealthy, and the distinctive symi)toms of its course, all lead 
 me to believe that there is a distinct relationship between this disease 
 and others of a sej)tic character. 
 
 The symptoms in all the cases I have observed of this disease are as 
 follow :— The attack is generally sudden, and may be preceded by a 
 ]"igor, or in some cases, especially in younger children, V)y convulsions ; 
 in others, by wild delirium. Upon examination of the throat, there 
 will be no sign of exudation, but the tonsils and uvula will be a deep 
 cherry -red colour ; the temperature ranges from 10.3" to 10.5°, or higher; 
 the pulse is generally below 120. Twenty-four hours afterwards, the 
 tonsils present a deeply congested condition, and are often so enlarged 
 that they meet in the centre. The uvula is generally oedematous and 
 congested. 
 
 In the earliest stage of the disease, the exudation from the crypts mar 
 be so great as to form one large ))yramidal patch between the two pillars 
 of the fauces. This patch is of a whitish colour, but ])Osse.sses less 
 tenacity than that of di[)litheria, and has no inflammatory zone ; and 
 upon its removal, the orifices of the crypt will be found plugged with 
 exudation, showing the typical appearance of follicular tonsillitis. The 
 child may or may not complain of a sore throat, generally not ; bi;t 
 this is generally due to the soft character of the food. The patient, if 
 old enough, comjjlains of headache, pains in the limbs and back. There 
 is pain on pressure over the tonsils; these can be felt enlarged under the 
 angle of the jaw, Ijut there is no marked enlargement of the lymphatic 
 glands, as in diplitheria. The skin is dry, the face flushed, and there is 
 albuminuria in many of the cases. Within forty-eight hours, these 
 symptoms gradually subside, if the case is going to 1)e a favourable One. 
 
 2s 2
 
 996 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 If the patient is not exposed to any fresh infection, by being allowed out 
 of doors, con\alescence generally results by the fourth or fifth day. 
 
 These symptoms have been almost invariably the same in the 315 
 cases that I have observed, but some of them have been a cause of great 
 anxiety to me, owing to the supervention of other diseases due to other 
 septic causes, the chief one being that of diplitheria. In every case 
 where this has occurred, I have always traced it to the patient being 
 allowed out within the range of some particularly offensive gutters. 
 Amongst others, I would mention two cases in particular : — 
 
 A child of 10 years of age, who had had one or two attacks of 
 follicular tonsillitis, for which she had been under my care during the 
 prevalence of an epidemic of this disease, became exposed to septic 
 influence, and was laid up for two or three days suffering from the same. 
 There were none of the symptoms of diphtheria ; the case progressed 
 well, and all the exudations disappeared ; but before the tonsils resumed 
 their normal condition, she was permitted to go out in the evening. 
 Within a few hours a relapse occurred, but not being ill enough, as the 
 parents thought, to send for me, she was brought to my surgery. 1 
 found well marked diphtheritic patches on her tonsils. Twenty-four 
 hours after, the disease had attacked the larynx, and in spite of 
 tracheotomy being performed, she died. 
 
 Just three doors from where this pjatient lived, 1 have been repieatedly 
 called to a household, where every child is liable to attacks of follicular 
 tonsillitis. The symptoms have all l>een the same as those described, and 
 T never had any cause of anxiety with any of the cases ; but after the 
 death of this child, the cases there appeared to get more and more 
 obstinate (the gutters all the while becoming more objectionable), until 
 at last, three months after the death of this neighbour's child, one of the 
 patients in the house had an attack ushered in with violent convulsions ; 
 patches appeared on the throat of a more tenacious character than usual, 
 and finally, the symptoms became distinctly di[)htheritic. Two months 
 after this, another child in the same house was affected with diphtheria ; 
 l>oth these cases recovered. I may mention at the time, in connection 
 with this, that I removed the tonsils of a child in this last house, and 
 she was foolishly permitted to go to Sunday School the same afternoon. 
 The malignant character of our drainage system in Williamstown may 
 be guessed, when I state that this short walk, where she was exposed to 
 the exhalations arising from the gutters, resulted in the raw surface of 
 the tonsils being covered with a copious exudation within thirty-six 
 hours, with all the symptoms of follicular tonsillitis. 
 
 There is a fatal case of diphtheria quoted in the Lancet, where 
 tracheotomy was performed. On post-mortem examination, ulceration 
 of Peyer's patches was found. The case had an unusually high 
 temperature. 
 
 A similar case, where a youth aged 14 was attacked by follicular 
 tonsillitis, and where the patches disappeared within fortj^-eight hours, 
 his tem})erature gradually becoming normal, against my directions took 
 a walk before convalescence was established. On the next day, his 
 ienii)erature was 105'. In a day or two, the case assumed a typhoid 
 character, and on the eighteenth day, he died from i)erforation of the 
 bowels, having suffered for three days previous to his death from 
 uncontrollable luemorrliacre from the bowels.
 
 I 
 
 CORRELATION OF FOLLICULAR TONSILLITIS IN CHILDREN. 997 
 
 Witli respect to the association of follicular tonsillitis Mith scarlatina, 
 I may mention that in no cases have 1 seen an}- i)eeling of the skin 
 after an ordinary attack of th<> former, but I have seen tlie two diseases 
 attack dift'erent persons in the same household : — A young man, who had 
 suffered from repeated attacks of follicular tonsillitis, was once more 
 laid up with an attack of tliis disease. He recovered without any other 
 symptoms, and there was no peeling of the skin. His illness last<;d 
 four days. His sister, married, was also attacked, but in a mild form. 
 Her two childi-en, aged 8 and G years respectively, two days after the 
 first case was attacked, showed symptoms of scarlet fever, which after a 
 long and sevei'e illness, terminated in peeling, and in one case in 
 nephritis. This child recovered. 
 
 These cases I have mentioned, in order to show the association of 
 follicidar tonsillitis with other diseases of septic origin. The frequency 
 with which I have observed a series of cases, where there has been no 
 intercourse between the families attacked, led me to believe that there 
 must be some other cause for this illness than an ordinary chill, and I 
 believe that that cause is no other than the defective system of drainage 
 that prevails in Williamstown. I believe that follicular tonsillitis is 
 common elsewhere ; but the flat nature of the ground on which 
 the town is built, and the consequent stagnation of the sewage in the 
 open drains, seem to me to account for the lai-ge nund^ei- of cases 
 prevailing in this town. 
 
 I need not give a detailed account of our sanitary defects, because 
 they prevail alike in Melbourne and the other suburbs, but I should 
 like to point out what the condition of things must be in a town, where 
 the majority of the liquid manure finds its way into the open gutters ; 
 where the water supply is cut oti" for half the year for the whole of the 
 working day ; where twice a week the green deconqwsing material 
 fermenting in the gutter is removed by the town scavenger, and jjlaced 
 in the centre of the road, to be dried up by the first hot wind, and 
 distributed in generous projiortions to the unfortunate inhabitants of 
 our town. When added to these conditions, in the older ])arts of the 
 town, we have numerous sweltering lagoons of filth, caused by the 
 building of houses on land sold by syndicates during the late boom, 
 without the slightest attention being paid to the disposal of the drainage 
 from the houses, is it any wonder I ask, that sore throats prevail of 
 such malignant nature. In several districts of Williamstown, this 
 disease has assumed quite an epidemic character, and T have noticed 
 this more particularly after a shower or two, when the ground has 
 connnenced to dry : but during the last hot weather, eases have been 
 almost as numerous. In two districts of the town, when the gutters 
 liave been unusually foul, nearly every house had a case of follicular 
 tonsillitis, and in some cases there were two or thi'ee in one house, 
 ^lore particularly I would mention one street leading do\ni to the bay, 
 Avhere there is a row of houses having most offensive drains both at the 
 back of the houses and at the front. In one house, five cases of 
 this disease occurred — the fiist being a child of 3 or 4 years of age, liis 
 two sisters then became afiected, and finally the parents of the children. 
 At the back of their house I liad another case, wliich followed the usual 
 course. Their cousins who lived in the same house and who had been 
 away for a change, on returning, were all laid uj) with the same
 
 908 IXTEKCOLONIAL MEDICAL COXCiRESS OF AUSTHALASIA. 
 
 complaint. All these cases recovered very quickly. In another house, 
 I have seen every child in the house attacked most severely with 
 follicular tonsillitis. In the same house, there are now four severe cases 
 of typhoid fever, three of them having also sutiered from follicular 
 tonsillitis. In another house in the same locality, where a female was 
 laid up, she was visited by a young girl who lived at some little distance 
 where there were no cases at the time ; within a day or two, she also 
 had an attack, but much milder in character. I could go on for some- 
 time giving instances of its infectious character. 
 
 The treatment I adopt in these cases, has always been to reduce the 
 temperature as speedily as possible, in order to avoid complications, such 
 as pneumonia. Arc— not an unnecessary ]>recaution I have found, when 
 I have neglected to do so. I have found that I could in most cases 
 accomplish this by means of salicylate of soda, together with an ordinary 
 saline niixture ; but lately I have found that in Phenacetin-Bayer, one 
 of the latest synthetical compounds introduced in antipyretics, I had a 
 most reliable remedy for this j^urpose. In a few hours pain is relieved,, 
 and the temperature becomes nearly normal. Indeed, in all cases in 
 children, as well as in adults, where a high temperature prevails, I have 
 lieen astonished at its antipyretic virtue and its sedative effect, and I 
 now invariably use it in ])reference to anti[)yrin or antifebrin, as I find 
 it is less dejiressing, and there is not the same tedious convalescence 
 after its prolonged use, as there is after the former named drugs. 
 
 I feel that this ])aper is deficient in many things that should make it 
 complete ; for instance, the microscopical character of the exudation, 
 and a complete series of tempeiatures, itc, but the little leisure 
 permitted Ijy a general ]}i-actice has not allowed me to render it more 
 complete. My object in writing is to draAv attention to a simple disease 
 very evident to the eyes, which I believe is solely due to our bad gutters 
 and system of drainage, and to endeavour to draw some analogy between 
 the causes of this disease and of typhoid fever and diphtheria, with a 
 view of showing the means of preventins; epidemics of such diseases by a 
 comj)lete and scientific system of drainage.
 
 PATHOLOGICAL MUSEUM. 
 
 CATALCXiUI-: OF SPECIMENS 
 Submitted hy 11. 15. Allen, M.D. 
 
 Professor of Anatomy and Patholojjy in the University of Melbourne. 
 
 1. Ai'terio- venous poi)lite;il aneurism, following a strain of the knee 
 which fractured the patella. (See Australian Medical Journal, 
 Septendjer 187t^.) 
 
 1'. Aneurism of sinus of ^'alsalva of aorta, almost tilled witli laminated 
 clot. 
 
 3. Aneurism of aortic arch oi^ening into the pulmonary artery, and 
 
 subsequently bursting into tlie trachea. 
 
 4. Dissecting aneurism of thoracic aorta, starting in a patch of 
 
 atheroma in the third part of the arch, and extending 
 
 upwards to the pericardial reflexion, and downwards to the 
 
 diapliragm. 
 •>. Pyriform aneurism, arising from the junction of the ascending and 
 
 transverse portions of the aortic arch, comj^letely occluded 
 
 l)y laminated fibrin by unassisted natural processes, 
 (i. Huge aneurism of aortic arch, rising into the neck in front of the 
 
 I'ight carotid sheath, distorting the origin of the innominate 
 
 artery, and simulating innominate aneurism. 
 
 7. Aneurism of upper aspect of transverse portion of aortic arch, with 
 
 enormous deposit of pale clot, occluding the orifices of the 
 great arteries. Consciousness was retained twenty-four hours 
 before death. 
 
 8. Pulmonary stenosis, w itii patent foramen ovale. Tlie segments of 
 
 the pulmonary ^■alve are fused together. The orifice is 
 reduced to a small chink. The foi'amen o\ale is patent, 
 almost circular, an inch in diameter. The patient, a married 
 woman aged 29, died greatly emaciated, with pulmonary tuber- 
 culosis and bronchi-ectatic cavities. There was no dropsy. 
 
 9. jMalfoi-mation of pulmonary valves. The valve consists of a single 
 
 annular segment, tliick and opaque, Avith narrow orifice and 
 beaded edge. There is one sinus of Valsalva, anteriorly and 
 to the right. The valve is bound down to tlie arterial wall 
 ])Osteriorly. The })ulmonary artery is very narrow. The 
 light ventricle hypertrophied, but not notably dilated. The 
 ])atient was more or less cyanotic from birth. She died at 
 the age of 27, with e.xtensive caseous pei-i-bronchitis. There 
 was no dropsy. A loud bruit was heard o^er the sternum, 
 especially opposite the second interchondral space. 
 
 10. Aorta and pulmonary artery combined, arising by one trunk from 
 two ventricles. 
 
 11 and 12. Tricuspid vegetations. No other \alves affected. Two 
 specimens.
 
 1000 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 13. Recent mitral and aortic endocarditis from a case o£ typhoid fever. 
 
 14. Aneurism of trmik of pulmonary artery. 
 
 15. Sudden extensive rupture of inner coats of a tiabby friable aorta, 
 
 apart from advanced atheroma. 
 
 16. Embolisms of cerebral arteries with consecutive arteritis and 
 
 aneurisms. 
 
 17. Cirrhosis of lung. 
 
 18. Fibro-pigmentary consolidation of lung with basal cavity, from a 
 
 miner aged 55. 
 
 19. Acute typhlitis, the walls of the ca-cum being greatly swollen, soft, 
 
 pale, but not yet absolutely sloughing. 
 
 20. Acute dysentery, with sloughing false )nembranes. 
 
 21. Colitis and proctitis, with large pale oval ulcers having thin under- 
 
 mined edges. 
 
 "22. Clironic dysentery, with thickening of the muscular coat, and 
 irregular ulceration and granularity of the mucous membrane. 
 
 23. Chronic dysentery, with atrophy of the coats of the intestine, and 
 ragged paie ulcers of the mucous membrane. 
 
 '2i. Chronic dysentery, with papillose ulceration of the mucous 
 membrane. 
 
 25. Syphilitic rectum from a woman. Immense thickening of the 
 coats; extensive cicatricial stricture just above anus; irregular 
 pitting of the intestine above the stricture ; and chronic 
 serpiginous ulceration for several inches higher up. 
 
 2(5 and 27. Two cases of multiple intussusception of the small intestine 
 obtained from children who died respectively of diphtheria 
 and of obstinate vomiting after lithotomy. In both, intus- 
 susception occurred in the death process. In one case there 
 were ten, in the other eleven, distinct intussusceptions. In 
 ■ the great majority of instances, the invagination was down- 
 wards, but in some it was upwards ; and occasionally a down- 
 ward and an upward invagination occurred in close proximity, 
 so that the two incarcerated parts came almost into immediate 
 relation. 
 
 28 and 29. Two specimens illustrating fatal intussusception ; one is a 
 case of slow intussusception at the ilio-cjecal valve ; the other 
 is a case of rapid intussusception in the ileum, the invaginated 
 portion being thickened by inflammation and hjemorrhage, 
 and rapidly sloughing. 
 
 30. Cystic kidneys, weighing together 68 ounces. The patient died of 
 
 tubercular epididymis and general tuberculosis consequent 
 upon it. 
 
 31. Renal calculi (Anstraliau Medical Journal, November 1883). 
 
 32. Tubercular ulcers in ureters. 
 
 33. Tubercular epididymis. 
 
 34-38. Series of complicated hydroceles — 
 
 (a) Encysted hydrocele in the usual position, with an opening 
 
 below into the tunica vaginalis. 
 
 (b) Hydrocele of the tunica vaginalis, covering the front of 
 
 the testis, and overlapping in its upper part an encysted 
 hydrocele — (two specimens). 
 
 (c) Encysted hydrocele, with ha-matocele of the spermatic cord 
 
 I 

 
 PATHOLOGICAL MUSEUM — CATALOGUE OF SPECIMENS. 1001 
 
 (c/) Hydrocele of tunica \iiyiiuilis of a partly descended 
 
 testis. The testis had remained a short distance below 
 
 the external abdonunal rin<jf. The sac of the tunica 
 
 vaginalis liad closed at the internal ring; l)ut, by the 
 
 accumulation of fluid within it, had Ijulged up through the 
 
 internal ring, so as to form an external and an internal 
 
 cyst coimnunicating l)y a narrow constricted neck thi'ough 
 
 the internal ring. 
 
 59. Necrosis of shaft of tibia, showing a largi^ irregular central 
 
 secjuestrum, and also a large I'egular set[uestrum, which 
 
 involves almost the whole tliickness of the shaft, but is 
 
 retained by tlie capsule of new bone formed by the periosteum. 
 
 40. Abscess in the head of the tibia, with long curved sinus, opening 
 
 about four and a half inclies down the shaft of the bone. 
 Indurative ostitis around the abscess and the sinus. (8ee 
 AustraUan 2Iedical Joitrnal, June 1885.) 
 
 41. Degenerative changes in the lowei- end of the tibia and in the 
 
 tarsal bones, in a case of anchylosis of the knee, with long 
 standing ostitis of tlie upper part of the tibia. The bones 
 are tliin shells tilled with soft yellow fatty tissue. 
 
 42. Old librous anchylosis of the knee, a vertical median antero- 
 
 posterior section showing the epiphysial cartilage. The 
 articular cartilages are intact, except at a few points where 
 adhesions ha\e occurred. The spaces of the joint are tilled 
 with fatty tissue, developed in the synovial folds. 
 
 43. Advanced morbus coxa' from a child with necrosis of the acetabular 
 
 tloor. {Australian Medical Journal, November 1879). 
 
 44. Intense morbus coxje, originating in synovitis, the cartilage of the 
 
 head of the femur separating in large flakes. 
 
 45. Caries of the trochanter major of the femur, without joint disease. 
 
 46. Suppui'ation of tlie Inirsa between the great t)-oclianter and the 
 
 gluteus maximus. A granulating surface covers the part of 
 the trochanter involved. 
 
 47. Incipient necrosis of the outer surface of the trochanter major, 
 
 secondary to .suppuration of the gluteal bursa. 
 
 48. Chronic arthritis deformans of liip, .showing the eliurnated articular 
 
 surfaces, the elongation, flattening and lowering of the head of 
 the femur, and the corresponding changes in the section of 
 the femur, partly indurative, jDartly rarefying. 
 
 49. Senile changes in the upper end of the femur. Erosion of articular 
 
 cartilage. Formation of a marrow cavity in tJie neck, with 
 delicate trabecuhe in the wall of the cavity. 
 
 50. Symmetrical double dislocation of the knees. The I leads of both 
 
 tibiiv have been completely displaced Ijehind the lower ends of 
 the os.sa femoiis, and false anchylosis has occurred in this 
 po.sition. Neai-ly all the joints wei'e aflected. The sequence 
 of events was pain, eflusion, distortion, absorption, aiuliylo.sis. 
 {Australian Madical Journal, January 1880.) 
 
 51. Carie.s sicca of spine, the body of one of the lumbar vertebn« 
 
 having crumbled away without suppuration. The symptoms 
 resembled those of aneurisinal erosion. No evidence of 
 tubercle or .syphilis. {A ustralian Medical Journal, June 1879.)
 
 1002 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 52. Acute caries, with suppuration of two cervical bodies, and destruc- 
 
 tion of the tibro-cartilaginous disc between them. 
 
 53. Caries of spine, with double psoas abscess. The fir.st and second 
 
 lumbar vertebrse are affected. The destruction of bone is 
 much greater on the left side than on the right, so that 
 the lateral angular curvature is marked, while there is 
 scarcely any boss posteriorly (Aitstralian Medical Journal, 
 July 1879). 
 
 54. Bullet embedded in Ijody of a lumlmr vertebrte, with no perceptible 
 
 injury of the surrounding bone. 
 
 55. Pulpy swelling of the synovial membrane of the wrist, with 
 
 destruction of the joint. The changes in the cai"tilages are 
 largely proportionate to tlie degree in which they come into 
 direct contact with the inflamed synovial membi^ane. 
 
 56. Spondylolisthesis. 
 
 57. Comminuted fracture of shaft of humerus, with formation of a false 
 
 joint. 
 
 58. Patella fractured transversely, and united by l^ony union, without 
 
 any external callus. 
 
 59. Chronic inflammation of bursa patellpe. The sac has thickened 
 
 indurated walls and contains many melon seed bodies, partly 
 free, partly attached to the parietes. 
 GO. Chronic inflammation of bursa patelhe, with formation of a solid 
 fibroid tumour-like growth. 
 
 61. Hydatidiform mole. 
 
 62. Interstitial haemorrhage into uterine wall, opposite the placental 
 
 attachment at the fundus. Rupture of peritoneum and fatal 
 
 luvmorrhage into peritoneal cavity. 
 63-64. Hydrosalpynx. In both cases, there is decided stricture at the 
 
 ostium internum : and at the outer end, the tubes are firmly 
 
 bound to the OAaries by old adhesions. 
 65-69. Monsters— 
 
 (a) Ectopia cordis, with double hare-lip. 
 
 (b) Occipital encephalocele. 
 
 (c) Blighted fcetus, without head, neck, or upper limbs. 
 ((/) Anenceplialous fd^tus. 
 
 (f) Ectopia of liver and intestines, with malformation of spine 
 and lower extremities, and no external genitals. 
 70-80. Syphilitic, tubercular, and cancerous larynges. 
 
 81. Huge goitre, removed by Mr. FitzGerald, hypertrophic, solid ; the 
 
 section presenting a reticular structure consisting of enlarged 
 alveoli, with Arm membranous walls, containing grey Arm 
 colloid matter. 
 
 82. Unilateral luemorrhagic goitre, consisting of a dense-walled .sac, full 
 
 of tirm partly decolorised clotted blood. 
 
 83. Small cystic goitre, witli calciflcation of tlie walls between the cysts. 
 
 84. Huge unilateral cystic goitre, with lowly organised solid growths 
 
 sprouting from the interior. 
 
 85. Pei'ithyroid growths of various character. 
 86-88. Sypliilitic testes — 
 
 {(i) and (/>) from the same patient, (ri) Enlarged, somewiiat 
 uneven on the surface, densely fibre id, of .stony hardness^
 
 PATHOLOfilCAI. MUSEUM — CA'lAr.OfilK OK SPECIMENS. 1003 
 
 the testis and epiditlyinis fused together, but no gummata 
 present ; (b) still larger, also hard, I)ut less so than («), 
 smooth on the surface, and containing distinct opaque 
 dry yellow guuiniata, end)ed(led in fibroid tissue. 
 
 (c) showing small gummata lying in dense fibroid tissue. The 
 surface is irregular and knobbed, with severe ciironic 
 inHanunation of the tunica vaginalis. 
 89-90. Syphilitic lesions of liver - 
 
 (n) huge gununata, dry and tirm. 
 
 (h) irregular cicatrices. 
 
 91. (Syphiloma of tongue, superficially sinuUating ei)itiielioma, Ijut 
 
 deeply presenting a sharply defined oval infiltration, only 
 partly masking the normal structure. 
 
 92. Syphilomata of frontal lobe of brain, with central softening. 
 
 93. Syphilomata of dura mater, showing diffuse fleshy thickening, with 
 
 low lobulated growths on the cerebral surface. 
 
 94. Syphilomata of \w,i mater, forming ;dong the arteries at the base of 
 
 the brain [Aiistrrdian Medical J oirnial^ April 1S82). 
 
 95. Firm flljromata in both ovaries. 
 
 96. vSoft pedunculated fibroma of labium majus. with superficial 
 
 excoriation. 
 
 97. Huge uterine myoma, \\'\W\ a moderate degree of cystic de- 
 
 genei-ation. One quarter of the tumour is shown as a wet 
 specimen ; one half of the tumour is shown dried, being 
 shrivelled to extremely small dimensions and extremely 
 heavy. Query — Are the modifications of the size of uterine 
 fibroids under treatment, or in i-elation to the catamenia, 
 dependent on the varying amount of fluid inflltrating their 
 substance ? 
 
 98. Pedunculated myoma hanging from the cer\ ix uteri, and filling the 
 
 upper part of the vagina. 
 
 99. Fasciculated myoma of alxlominal wall. This tumour grew in the 
 
 skin of the abdomen of a Chinaman, and, having attained a 
 diameter of nearly four inches, is enucleating itself. The 
 skin is adhei'ent, thinned, and fit parts perfoi-ated, the firm 
 rounded dry lowly lobulated growth being completely exposed 
 in the perforated parts. As Sir J. Paget says, such enuclea- 
 tion is a natural tendency of myomata, and not dependent on 
 the contraction of the muscular tissue in which they arise. 
 {Auiftrailan Medical Journal, October 1S80). 
 
 100. Compound cauliflower condyloma of labium m.ijus. 
 
 101. Sarcoma of left testis spreading up the spermatic veins, infiltrat- 
 
 ing the left kidney, extending along the left renal vein into 
 the vena cava, and presenting into the right auricle. Fun- 
 gating sarcomata of lungs and sarcomata of li\ er. 
 
 102. Primary sarcoma of lung, forming a huge homogeneous fii'm grey 
 
 growth, comi>osed of small spindle cells. 
 
 103. Lympho-sarcoma of mediastinum o\('rlapping the heart {A ustraltan 
 
 Medical Journal, Octol)er 1880). 
 
 104. Melanotic sarcoma of lungs, liver, heart, breast, lympliatic glands 
 
 along the pancreas, itc. {Australian Medical Jovnad, No- 
 vendjer 1880.)
 
 1004 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 105. Sarcoma of peiiostevim of bodies of dorsal ^•ertebra% spreading 
 
 through the intervertebral foramina, and extending along the 
 dura mater. 
 
 106. Sarcoma of kidney of a child, containing striped muscular fibres. 
 
 (Australiaii Jledical Journal, ]March and April 1886.) 
 
 107. Central sarcoma of both humeri, jvist below the surgical necks. 
 
 108. Discoid carcinomata of the mesentery along the line of intestinal 
 
 attachment, spreading into the intestinal wall. Carcinoma of 
 the semilunar ganglion. (Australian Med icalJotiruaI,^lay 1883.) 
 
 109. Simple cyst of liver, five inches in diameter, containing simple 
 
 serum. (AHstralian J/edical Journal, May 1883.) 
 
 110. Small cystic growths from lining membrane of both ureters. 
 
 111. Congenital sacral cyst of large size, formed by a terminal spina 
 
 bifida. 
 
 112. Multilocular ovarian cyst, Avith papillomatous growths from the 
 
 external surface. 
 
 113. Multilocular ovarian cyst, with much solid growth at the base. 
 
 These growths consist of laminated de2D0sits of epithelium and 
 cholestearin, encapsuled in fibrous tissue, and vary in size up 
 to more than an inch in diameter. (Australian Medical 
 Journal, July 1880.) 
 
 114. Dermoid ovarian cyst, with gTowth of bone, teeth, and hair. 
 
 (Australian Medical Journal., August 1882.) 
 
 115. Dermoid ovarian cyst, with large growth of hair, and with large 
 
 steatomatous deposit. 
 
 116. Cholesteatoma growing from peritoneum at the fundus uteri. 
 
 (Australian Medical Journal, November 1879.) 
 
 117. Cystic kidneys, weighing sixty-nine and forty-one ounces, fi'om a 
 
 man aged 43, who died of ura-mia. 
 
 118. Seven-flukes (distoma hepaticum) removed from the bile ducts of 
 
 a man. There was a large foul abscess of the liver, and 
 dilatation and suppuration of the bile ducts within the liver. 
 yote. — In two other cases, Professor Allen has found a single fluke 
 in the bile ducts of human beings. 
 
 Specimens of Hydatid Disease. 
 
 1. Hydatid of liver, showing a thin shining perfectly organised 
 
 adventitia, resembling a flbro-serous membrane. 
 
 2. Hydatids embedded in right lobe of liver, with perfectly organised 
 
 adventitia. A second cyst growing from the lobulus Spigelii 
 is thin-walled and movable, and is inserting itself between 
 the layers of the small omentum. 
 
 •3. Hydatids of liver, several specimens, with thick opaque irregular 
 adventitia, imperfectly oi'ganised. Query — Does the charac- 
 ter of the adAentitia depend on the rate of development, or 
 on the situation in which the growth starts- — a thin, smooth- 
 walled sac being formed when the embryo lodges within a 
 portal capillary, and a less highly organised sac being 
 produced when the embryo developes among the hepatic cells? 
 
 4. Hydatid of the liver adherent to the diaphragm, and having a very 
 tough secondary adventitia, nearly an incli tliick, developed 
 between it and the diapliragm.
 
 PATHOr-OGICAL MUSEUM— CATALOOUE OF SPECIMEX.S. 1005 
 
 n. Multiple liydatids of li\er. One large cyst in the right lobe was 
 suppurating. Others were stufted full of collapsed cysts and 
 concreted biliary matter. Others were mature, containin<>- 
 limpid tiuid. The patient died of dislocation of the spine, 
 caused by a fall. 
 Xote. — A very narrow septum may di\'ide a suppurating hydatid 
 from one showing no signs of degeneration or inflammation. 
 
 6. Multiple hydatids of liver. One very large thin-walled cyst has 
 
 developed at the extreme right of the liver, and is l)ounded in 
 the greater part of its extent only by the thickened serous 
 coat. Another grew from the back of the left lobe, and 
 bulges into the fissure of the vena cava. A third, lying a 
 little further forward on the under surface of the left lobe, is 
 separated fi-om the foregoing only by the thin fused adven- 
 titial. A fourth is buried in the left lobe, at its ujsper aspect. 
 A fifth is embedded in the left lobe, and abuts on the serous 
 capsule at its anterior border. A sixth is thoroughly predun- 
 culated, and is attached to the anterior border of the left 
 lobe, just where the serous coat forms part of the ad\entitia 
 of the tifth. The first cyst was much the largest, and 
 evidently at one time was embedded in the right lobe, 
 abutting on the serous coat only to a limited extent. But its 
 subsequent increase in size caused it to be bounded by the 
 serous coat over the greater part of its surface. There is a 
 limited patch of thickening in the part of the adventitia nf>w 
 formed by the serous coat, sharply defined and circular, 
 indicating the original connection of the cyst with the serous 
 capsule. 
 
 7. A hydatid of the liver five inches \n diameter, with thin well- 
 
 organised adventitia, but containing, instead; of a single 
 mother-cyst and its progeny, a mass of small cysts loosely 
 adherent together in an oval mass, 
 y. Part of the adventitia of an old-standing hydatid, with flakes of 
 gelatinous membrane adherent to it. Tiie adventitia is- 
 uneven, and altered by inflammation into an imperfect granu- 
 lation tissue, partly organised. 
 Note. — Such true adhesion of the mother-cyst to the adventitia is 
 very rare, and is seen only in old-standing cysts. The adhesion is an 
 abnormal occurrence in the life of the hydatid, and probably never 
 occurs apart from degeneration and inflammation. 
 9. Hydatid of the liver opening into the hepatic duct. 
 
 10. Hydatid of the liver perforating the diaphragin, and forming a 
 
 cavity in the base of the lung, bounded by indurated lung- 
 substance, and opening into a bronchial tube. 
 
 11. Hydatid of the liver, treated by tapping and insertion of a drain- 
 
 age tube between the rilis. This specimen shows how the 
 contraction of the cyst interferes with drainage so conducted. 
 
 12. A series of specimens of old-standing hydatids of the liver, showing 
 
 changes in the adventitia, partly thickening, contraction and 
 puckering, partly calcification. In some, the earthy matter is 
 uniformly diffused, foi-ming a complete calcareous shell ; in 
 others, it is deposited in irregular nodules.
 
 1006 IXTERCOLOXIAL MEDICAL COXGRESS OF AUSTRALASIA. 
 
 13. A series of specimens, sIiowin<^ retrogressive changes in the 
 contents of hydatid sacs : — Collapse of the cysts, accumulation 
 of fatty smegma, deposit of biliary matter, which in some 
 cases forms large concretions. 
 
 14-. Primary carcinoma in the thick adventitia of a retrogressing hydatid 
 of the liver. 
 
 15. Secondary carcinoma in the ad\entitia of a hydatid of the liver. 
 
 The primary scii-rhus grew in the pancreas. The adventitia 
 
 of the hydatid was formed in part by the thickened serous 
 
 capsule ; and in this part of the adventitia, plates of scirrhous 
 
 carcinoma huve developed. 
 
 JVote. — Professor Allen has seen a case of primary carcinoma of the 
 
 liver, forming a huge mass in the left lobe, with smaller tumoui's 
 
 scattered tlii'ough the liver ; a hydatid as large as the mature fcetal 
 
 head lay in the centre of the liver, and was not involved in the 
 
 cancerous growth. In another case there was a carcinomatous growth, 
 
 3i inches in diameter in the liver, abutting on the anterior border ; 
 
 while two large hydatids were present in the posterior part of the liver, 
 
 one of them l)eing separated from the cancer by only half an inch of 
 
 liver tissue. 
 
 16. Small liydatid in the muscular wall of the left ventricle, bulging 
 
 under the pericardium. 
 
 17. Hydatid of spleen of huge size, forming an ovoid sac, with tough 
 
 thin adventitia, representing little more than the thickened 
 capsule. The inner surface of the adventitia is opaque, yellow, 
 and uneven. 
 
 18. Hydatid of the s[)leen, with ^■ery irregular adventitia, formed partly 
 
 by altered splenic substance projecting in great lumps into the 
 cavity, and partly of the indurated greatly thickened capsule. 
 
 19. Huge hydatid of spleen, showing the mature mother-cyst, and the 
 
 comparatively smooth adventitia, wliicli is formed chiefly from 
 
 the serous coat. 
 iVo^e. — Other hydatids of the spleen are on the shelves, but in none 
 is there that perfect organisation of the adventitia which is seen in 
 many liver hydatids. Cysts of the spleen do not readily collapse after 
 tapping, and special cai'e is necessary in their drainage. In one case, 
 however, in a man who was brought to the Melbourne Hospital in a 
 dying state, the autopsy revealed several small hydatids in the spleen, 
 with calcified adventitiie, easily shelled out of the tissues around. 
 
 20. ^Multiple hydatids of the omentum. 
 
 21. Hydatid of the omentum, bounded by tirm adventitia, and contain- 
 
 ing collapsed degenerating cysts closely crowded together. 
 
 22. Hydatid, with very thick adventitia, attached to the omentum. 
 
 Removed by Mr. FitzGerald by abdominal section. 
 ]\/'oie. — These movable omental hydatids are eminently adapted for 
 
 removal by abdominal section. Tapping seems to be attended with 
 
 special danger. 
 
 23. — Hydatid of pelvis. A cyst about four inches in diameter, con- 
 taining clear fluid and scolices, which was found lying- 
 destitute of adventitia in the vesico-uterine pouch. It was 
 adherent to the pex^itoneum only by a small tag of gelatinous 
 membrane {Auiitrallan Medical Journal, April 1882). 
 
 I
 
 PATHOLOGICAL MUSEUM CATALOGUK OF SPKCIMENS. 1007 
 
 24. Spherical liydatid, 4] inolie.s in diameter, attached to fundus ot 
 
 uterus and hhidder, and opening into the right Fallopian tube, 
 which is dilated and full of cysts (Anstndian Medical Journal, 
 October 1879). 
 
 25. Hydatid in the substance of the diaphragm. One large and 
 
 several small gelatinous cysts are packed together within one 
 
 adventitious sac. 
 '2Q. Mature hyd;itid of kidney, about four inches in diameter, projecting 
 
 boldly under the capsule. 
 Note.—V>v. C. Smith, of Casterton, exhibited hydatid cysts of the 
 kidney, which passed down the ureter and escaped by the urethra. 
 
 27. Multiple hydatids of livei', with complicated masses of hydatid cysts 
 
 growing in the pelvis, adherent to all the structui'es around. 
 
 28. Hydatid of the right ovary, of large size. 
 
 Xote. — This is the only case of ovarian echinococcus wliich has come 
 under Professor Allen's observation. Specimens 2(5, 1*7, and 28 were 
 obtained from the same case. 
 
 29. Hydatid encapsuled among coils of intestine, and opening into the 
 
 jejunum. The patient had obscure Habby swelling of the 
 abdomen, with chronic dyspeptic symptoms. The oriiice 
 between the cyst and the bowel was well defined, and of long 
 stjinding. Tlie sac contained a foul mixture of bilious 
 intestinal matters, and decaying gelatinous membranes. 
 
 30. Hydatid growing from under surface of the anterior part of the 
 
 liver, in the midline of the body, which closely resembled 
 aneurism of the cteliac axis. The bruit, pulsation, and thrill 
 were strongly marked; but the lateral pulsation was not 
 distinct, and the aneurismal signs were greatly diminished in 
 the knee-elljow position. 
 
 31. Retrogressing hydatid between the liver and diapln-agm. 
 
 Xote. — Several other instances of hydatid in this situation are recorded 
 in tlie pathological registers of the Melbourne Hospital. 
 
 32. Hydatid of limited size, with firm adventitia growing from the front 
 
 of the sacrum, extending through the anterior sacral foramina, 
 and up the spinal canal as far as the last lumbar vertebra. The 
 liydatid within the spinal canal was bounded only by the 
 mother-cyst. It contained great numbers of daughter-cysts. 
 There was partial paraplegia. Finally, the cyst ruptured into 
 the subdural space, and there was rapid ascending paralysis. 
 (See Australiaii Medical JournoA, ^lay 1879.) 
 
 33. Calvarium from a girl who had intracranial hydatid. Tlie skull 
 
 cap is expanded, greatly thinned, with immerous perforations, 
 closed only by membrane. 
 
 34. Hydatid cyst growing from the superior surface of the right orbital 
 
 plate of the frontal bone. 
 
 35. Large hydatid in the left frontal lolje of the cerebrum, presenting 
 
 at the orbital surface. Specimens 34 and 35 were removed 
 from a girl aged 13, who died after six months' illness. At 
 first, she suffered only from epileptic fits; but two montlis 
 before death, she lost power in the left leg, and gradually 
 became unable to stand; then unable to turn herself in bed. 
 Finally, she became unconscious, and died in convulsions.
 
 1008 IXTKRCOLOXIAL iMEDICAL CONGRESS OF AUSTRALASIA. 
 
 36. Hydatid of cerebrum in the right mid-convexity, occupying the 
 
 marginal convolution and the lower part of the ascending 
 painetal. Bulging sliglitly beneath the arachnoid, and abutting 
 deeply on the body of the lateral ventricle. There is only a 
 very slight induration of the brain tissue around. (See 
 Cobbokfon "Parasites," 1879, pp. 140-141.) 
 
 37. Huge hydatid following out of the upper pai't of the left cerebral 
 
 hemisphere, from the front of the occipital lobe forward into 
 the back of the frontal lobe. 
 
 38. Hydatid cyst in left occipital lobe of cerebrum, presenting at the 
 
 extreme posterior end of the hemisphere. 
 
 Notes of Cases of Hydatids from the Pathological Records of 
 THE ^Melbourne Hospital, added by Professor Allen. 
 
 1. A case of hydatid behind the peritoneum and in front of the right 
 
 psoas muscle, extending from the diaphragm under Poupart's 
 ligament into the thigh. The patient died of aneurism of the 
 aortic arch. 
 
 2. Large hydatid growing in and distending the gall-bladder. The 
 
 liver was cirrhosed. There was jaundice, with epistaxis and 
 intestinal lijemorrhage. 
 
 3. Huge cyst of right lobe of liver opening into the ascending colon. 
 
 4. Right lobe of liver completely occupied by a cyst which opened 
 
 freely into the cystic duct. There was slight jaundice. 
 
 5. Large cyst in centre of liver. A hepatic duct admitting a large 
 
 catheter opened into it. General jaundice. Contents of cyst 
 deeply bile-stained, but not purulent. 
 
 6. Two large hydatids in the same liver, sepai'ated only by the fused 
 
 adventiti;>? — one suppurating, the other infiltrated with bile, 
 but not suppui-ating. 
 
 7. Cyst between liver and spleen passing through the spleen to become 
 
 adherent to the diaphragm. 
 
 8. Right lobe of liver completely occupied by a cyst. A branch of 
 
 the hepatic artery close to the transverse fissure opened into 
 the cyst, which was tilled with partly decolorised clot. Death 
 was due to primary tuberculosis of the trachea with secondary 
 acute pulmonary tuberculosis. 
 
 9. Cyst occvipying the lower half of the abdominal cavity ; bounded 
 
 in front by the abdominal wall, and elsewhere by coherent 
 
 coils of slate-coloured intestine and mesentery. Full of clear 
 
 limpid fluid. No daughter-cysts. In the left iliac region, 
 
 there was a thick layer of honey-combed lymph, outside the 
 
 mother-cyst, adherent to the adventitia. Tliis cyst occurred 
 
 in the same patient as the foregoing. 
 
 Notes of eigliteen cases of hydatid disease within the chest, reported 
 
 by Professor Allen, will be found in the Aiistralian Medical Journal for 
 
 March and May 1881. The .specimens from several of these cases were 
 
 shown at the Congress.
 
 APPENDIX. 
 
 ANTISEPTIC SURGERY AND SOME OF ITS RESULTS. 
 By R. 13. DuxcAX, F.R.C.S. Ed. (Exam.) 
 
 Fellow of the Faculty of Surgeons, Glasgow. Hon. Surgeon to the Kyuetou 
 
 Hospital. 
 
 Antiseptic surgery, though occupying a somewhat difterent field to 
 aseptic surgery, has ahnost identical aims. By the one method we 
 preserve a wound perfectly pure ; by the other we render it so, when, 
 as in an accidental wound, it has been previously contaminated. To 
 those who, like myself, have watched its progress, and endeavoured 
 to carry its principles into every day practice, it is a matter fraught 
 with very great issues, and deserving of the most serious consideration. 
 Like many great discoveries in our profession, it has been subjected to 
 an immense amount of criticism, and an unlimited amount of abuse. It 
 has had innumerable imitators, who, in many extraordinary ways, have 
 tried to establish systems of their own, and who in many instances 
 would have us believe that antiseptic surgery is possible with "anti- 
 septics left out." Hence the phrase, that every careful surgeon is an 
 antiseptic surgeon, whatever means he may employ. Listerism presents, 
 to those who believe in it, a creed of no ordinary kind. There is 
 no room in it for any vacillation, hesitancy, and doubt. It compels 
 obedience to a certain line of action, from which there can be no 
 deviation. Details may vary, but the principles remain fixed and 
 immutable. Mr. Savory, in his celebrated address "On the Prevention 
 of Blood-poisoning in Surgical Practice," * says, speaking of Listerism, 
 " But the principle on which it rests is a sound one, the logical outcome 
 of established facts." What those principles are, their application to 
 wound treatment will show. What they should enable us to accom- 
 plish, may be inferred from the following statement by a recent 
 authority on the subject. He states : — " It cannot now be denied that 
 the surgeon's acts determine the fate of a fresh wound, and that its 
 infection and suppuration are due to his technical faults of omission and 
 commission." This is undoubtedly true ; and it is a matter for sincere 
 congratulation that, thanks to Listerism, we have reached something 
 like exactness in surgical therapeutics. And is it not a matter of daily 
 experience, that just in proportion as our antiseptic plans are carefully 
 and judiciously carried out, so will our results be favourable or other- 
 wise? The marvellous and rapid strides which operative surgery has 
 made within the last few years, have been largely due to the safety 
 which antiseptic measures confer. 
 
 Operations are now undertaken with comparative unconcern, which 
 were formerly a dread to the suigeon, and always a peril to the patient. 
 Regions have been invaded which were thought to be sacred from the 
 surgeon's knife, and wounds of the limbs are now recovered from, which 
 
 * Medical Timft and Gazette, August 1879. 
 
 2t
 
 1010 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 in pre-antiseptic days would have imperatively demanded amjiutation. 
 Hospitals, which before were almost untenable, hot-beds of blood- 
 poisoning, and on the point of being pulled down, have not only been 
 rendered habitable by antiseptic means, but some of the most brilliant 
 successes on record achieved within their walls. It has passed far 
 beyond the limits of general surgery, and not to particularise other 
 fields, in obstetric practice, most brilliant and lasting results hav^e been 
 attained. In this direction alone, had it had no other raison d'etre, the 
 immunity from disease, and the saving of life, which it is daily effecting, 
 would entitle it to the gratitude of mankind, and give it an imperishable 
 fame. The " germ theory," on which Listerism is based, has had 
 considerable influence in retarding its acceptance by many who are 
 otherwise inclined to view it favourably. This is not to be wondered at, 
 when we hear surgeons of eminence speak of so-called germs, and sneer 
 at their power of doing any harm whatever. Fortunately, however, 
 bacteriology is now so firmly established, and its conclusions so clearly 
 worked out, that no one can deny on scientific, or any other grounds, 
 the important part that they play in diseased processes most intimately 
 connected with surgery. It now supplies the proofs in abundance, 
 which were in a measure defective in the early investigations of Schwann, 
 Pa«teur, and Lister. On what a solid foundation the relation of micro- 
 organisms to sui-gery i-ests, will be a]){)arent when we consider the 
 means which have been adopted to prove the connection. " No micro- 
 organism is regarded as the cause of a disease, unless it is, in the first 
 place, found to be constantly present in that disease, either in the blood 
 or in the tissues ; secondly — unless, when carefully isolated and culti- 
 vated, it can, when introduced into the body of a healthy animal, give 
 rise to the original disease, and be again found in quantity in the body." * 
 
 If we bear in mind that even the " oil of turpentine injected under 
 the skin will not produce suppuration without the presence of a germ ; 
 and if some cultivated pus-producing micrococcus be rubbed on the 
 intact and healthy skin, it will occasion inflammation and a wide-spread 
 crop of boils," t the bearing of germ life on surgical processes is further 
 exemplified. Wound infection, and the various forms of blood-j)oisoning 
 which in many cases follow, are undoubtedly due to si)ecific micro- 
 organisms. Whence do they come ? Omitting for the present the more 
 obvious sources, such as the surgeon's hands, instruments, sponges, and 
 the various ai)[)liauces of an oj^eration, the question may be asked — How 
 far is the air res[)onsible for them 1 To those who use the spray, this is a 
 matter of much importance. Let us see what the air is capable of 
 4oing ; and first of all, I deny that there is surgically pure air, any 
 more than there is surgically pure water. 
 
 The micro-organisms of the air are capable of setting up decomposition 
 in every fluid and solid that possesses the elements of decomjiosition. 
 " tSome require an animal diet, others a vegetable one, and for some a 
 specially ]jrepared soil is necessary. They may be cultivated through 
 successive generations, and in different media, but they will retain their 
 characteristics in every case." % 
 
 * Power, "Bacteriology in Belation to Surgery," Bradshaw Lecture, British 
 Medical Journal, December 1886. 
 
 t Ibid. \ Coats' " Manual of Pathology. "
 
 AXTISEPTIC SDRGERY A\I> SUM K OF 1 rs IJKSULTS. 1011 
 
 The results oLtaineJ, in meat infusions and nuiuorous other ways, are 
 so constant and unvavying, that their aiiplication in regard to the all- 
 imjiortant question of wound treatment ought at once to meet with 
 universal recognition. 
 
 No sooner liad bacteriology 'u-ought to liglit these facts, apparently so 
 important in tlu? ])i'actioe of surgery, than means were taken to give 
 them an entirely difterent complexion, and an endeavour made to nullify 
 their practical application. In this attemj)t, the chemico-biological 
 process of the putrefaction of meat infusions is not questioned, but its 
 relationship to wound treatment is altogether denied, as will be seen 
 from the following statement of the case by a high authority : — " Animal 
 fluids exposed in open vessels to the air after some time become putrid, 
 the length of time varying v^ith the state of the air ; and so it is forth- 
 with concluded, and argued l)y many, that if fluid upon the surface of a 
 wound be exposed to the air, it must, while there, become jmtrid also. 
 But the fact is, any one who cares to witness it may see fluid at any 
 time on the surface of exposed wounds, which is not putrid. And the 
 explanation of this most familiar fact is simple enough, that the fluid in 
 the vessel has been kept until it has become foul, while the fluid on the 
 surface of a wound in process of repair, which is daily watched, ajid 
 properly managed, is ever being i-enewed. The same fluid ought not to 
 be allowed to remain long enough to midergo a mischievous change." — 
 Savory. 
 
 The feebleness of this reasoning, although it emanates from a high 
 authority', opposed to Listerism, will be appai'ent at a glance. The 
 whole argument turns on this — ^We are not to allow fluid to remain long 
 enough on a wound to undergo putrefactive changes. We see fluid on 
 the surface of wounds that is not putrid. Granted ; but in how many 
 wounds deliberately made are we able to watch the surface and remove 
 the constantly renewed fluid 1 Practically none. Take an amputation 
 wound for instance. Is not the whole wound surface shut out from our 
 view the moment the last stitch isinsertedl and is not the deconq)osition 
 or putrefaction of Ijlood and serous fluid, which may afterwards follow, 
 merely a question of whether the wound is aseptic or not ? There is no 
 reaching it to remove so-called constantly renewed fluid. If we did, the 
 proceeding would only be meddlesome and bad surgery. Even in many 
 surface wounds of large extent, and where there has been much 
 laceration, it may be, and generally is, impossible to keep them sweet 
 without antiseptics. 
 
 The great conservatism of operative surgery, aided by antiseptic means, 
 is well illustrated when applied to the fingers. A finger, say, is crushed 
 to the extreme limit that surgery will allow without resort to amputation. 
 What eftbrts will we make to save it? Although apparently a simjile 
 matter, it is in reality a crucial test between two methods. If rendered 
 aseptic, and " kept in pickle"* by constant mercurial dressings, success 
 will almost be assured in every instance. If treated wholly without 
 antiseptics, the results will be disastrous in a least two-thirds of the cases 
 treated. And why? In one method we keep the damaged tissues free 
 from micro-organisms, and consequently from decomposition, and allow 
 them to regain their impaired vitality ; in the other, we do exactly the 
 opposite. 
 
 " Cameron, GUugvw Medical JouiikiI. 
 
 2t 2
 
 1012 IXTEKCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 In the minor surgery of country practice, I liave liad frequent 
 opportunities of verifying this, especially in very hot weathei-, when 
 the difference is very conspicuous. By keeping the parts in continuous 
 contact with suhliniate solution, every vestige of tissue will be saved 
 that it is possible to save. Adopt any other ]»lan, even with the aid of 
 antiseptics, other than this particular one, and the result ^\ill be 
 extremely problematical. It is believed that irrigation of a wound 
 after an operation with antiseptic solutions is sufficient to destroy any 
 germs that may have lodged in it. But does it do so ? If any doubt 
 remains, why not jjrevent them in the first instance, as the spray is 
 callable of doing 1 Is there any other parallel in our sui-gical procedures 
 where we allow an admittedly dangerous condition to be established, 
 with the dubious belief that we may or may not be able to neutralise 
 it 1 AYound infection, by micro-organisms from the air, is undoubted, 
 and why not take means to prevent it. " The myriads of particles of 
 filth or dust filling the air in all inhabited localities, contain, according 
 to indubitable evidence, a very large proportion of spores or seeds, that 
 on falling on the wound promptly develop, and set up feruientative 
 processes known as decomposition." * 
 
 Take again the case of a fracture where the injuries are entirely 
 subcutaneous, while the splintering of lione and laceration of the soft 
 parts may be great and widespread. What is the consequence 1 
 Perfect recovery in practically every case. Allow germ-laden air to 
 gain admittance — which it does when the fracture is compound — and 
 what is the difference ? On the one hand perfect recovery, as already 
 stated; and on the other, in numei'ous cases (I am afraid to say how 
 many), some of the following evils, most of them of grave import, and 
 some of them absolutely fatal :^" Traumatic fever, inflammation, sup- 
 puration, waxy degeneration, hectic fever, formation of abscesses, slough- 
 ing, acute necrosis, gangrene, erysipelas, sejitic intoxication, septi- 
 caemia, and pyaemia. "t And is not the whole ftibric of subcutaneous 
 surger}" based on these considerations — air, or no air 1 The only effectual 
 remedy against air contamination, at least in purely aseptic surgery, is 
 the spray, or failing that, the thorough use of an irrigator. Unfortu- 
 nately, the spray has been almost abandoned ; and this is perhaps the 
 most important modification that antiseptic surgery has undergone in 
 recent times. Whether it is a wise one or not, remains to be seen. On 
 what grounds this has been done, I have never been able clearly to 
 comprehend. I am open to recognise the reason of its absence in 
 abdominal surgery. But in operations in hospital practice, where it 
 can be efficiently carried out, it is a positive gain. 
 
 I have on many occasions in cases of amputation (and excision of 
 the breast especially), never touched the dressings from the moment 
 they were first put on till the wound was perfectly healed. The 
 successes attained by this method, and the dressing of which it forms an 
 essential part, have been simply marvellous, and have been equalled 
 by no other plan. T would make an exception to this in the proper use 
 of the irrigator, to which I have just alluded. 
 
 * Gerster, " Aseptic aud Antiseptic Surgery." 
 t Clioyuc, " Antiseptic Treatment of Wouuds."
 
 ANTlbi:i'llC SUK-.KKY AND SOMK OF ITS UBSULTR. 1013 
 
 Wliile in Edinburgh a little over two years since, I had the privilege 
 of witnessing the practice of that eminent surgeon, Mr. Josepji Bell, 
 whose name is inseparably connected with Edinburgh surgery. Mr. 
 Bell used an irrigator, but so thoroughly and effectively, and apparently 
 with so little trouble, that I am forced to admit that the spray would 
 have been clumsy in comj)arison. When an irrigator is nsed as I saw it 
 used there, it is a matter of indifference what l)ecomes of the spray, the 
 former answering the same purpose. 
 
 Dr. A. C. Patterson, at a meeting of the Medical Society of GLisgow, 
 when various antiseptic appliances were under discussion — notably, 
 sublimate gauze, just then coming into notice — stated, " that he was still 
 old-fashioned enough to use the spray. His results for the last six 
 months had been 137 operations and one death." In a piivate com- 
 munication lately received from him, he informs me that, by the same 
 means, he has completed 100 consecutive cases of excision of the breast 
 without a single failure. This result requires no comment. On what- 
 ever grounds, then, the spray has been discarded by some, it is still doing 
 useful work. 
 
 In whatever way an operation may be conducted, I wish to emj»hasise 
 the fact, that no surgical cleanliness can be attained without the use of 
 antiseptics. The more modern term " surgical cleanliness " is synonym- 
 ous with Listerism, because the latter, properly carried out, means the 
 former in its highest sense. It is no unusual thing to tind sui'gical 
 contributions terminate with something like the following : — "Although 
 no antiseptics were used, every care was taken to obtain thf* greatest 
 degree of cleanliness." When pure water does not exist (not available, 
 at any rate, for surgical purposes), it is difficult to see how cleanliness of 
 any description can be attained without antiseptics. They are absolutely 
 indispensable. I do not mean to assert that they are the only important 
 matters connected with wound treatment, but they occupy the first ])lace. 
 
 The antiseptic surgery practised by myself, and which I will submit 
 for your consideration, is somewhat modified by circumstances. Living 
 as I do in the country, J cannot always command the use of the spray, 
 and since the introduction of sublimate gauze dressing, I use chiefiy the 
 irrigator. It is of this method that I will now speak. I am careful, in 
 wound treatment, to have a definite object in view. Stated briefly, that 
 object is the thorough protection of the wound from all sources of 
 infection, whether arising from the air or from solids or fluids. This, 
 carried out in its integrity, would ensure its speedy and successful 
 healing, without any local septic disturbance or constitutional risk to 
 the patient. It would necessitate a perfsctly aseptic wound, antiseptic 
 surroundings, and efficient drainage. The latter, to my mind, is, next 
 to the introduction of antiseptics, the greatest boon yet conferred on 
 oi)erative surgery. Tlie method J adopt has not the charm of novelty. 
 It is similar to that pursued by the generality of surgeons who practise 
 some form of Listerism on a definite system. Nor is it characterised by 
 extreme simplicity. I mention this, because it is often amusing to hear 
 the complaints against aseptic surgery generally, that it is wanting in 
 this feature. It is either continually forgotten, or altogether ignoied, 
 that the labour spent in a well-nlainied asei)tic operation, however great, 
 is in the end an enormous gain! Tliis is a matter of daily exjteiience, 
 and need not be dwelt upon.
 
 1014 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA 
 
 Selecting an excision of the breast to illustrate what I have to say 
 regarding -wound treatment, because it is one often performed in country 
 2)ractice, I would first say a word concerning the preliminary prepara- 
 tions, to which I attach supreme importance.* 
 
 The part to be operated upon is thoroughly washed with soap and 
 water, and with ether afterwards, if thought desirable. This is followed 
 by washing with carbolic acid solution. Lint, dipped in some of the 
 same, is laid upon the part for a few hours previous to the operation. 
 
 I cannot too strongly insist, that a vigorous use of the nail brush 
 should precede every operative measure, followed by a washing of the 
 hands in carbolic solution. The same remark applies to ever3-one who 
 may assist. In regard to the immersion of the instruments, carbolic 
 acid solution is the only suitable fluid. Corrosive sublimate, although 
 the antiseptic, is unsuitable from the chemical action it exercises on 
 instruments not nickel-plated. This chemical reaction is also said to 
 alter the quality of the fluid. It makes however, an excellent medicum 
 for the sponges. The strength I use for this and subsequent purposes, 
 is 1-2000. There is one matter apparently not of much moment, but 
 in reality, of very great importance. Nothing is more common at an 
 operation than to see instruments and sponges, when leaving the hands 
 of the operator, put in every conceivable place on the table — on the 
 patient even, instead of being returned to the solution by the hands of 
 an assistant.! Especially is this likely to take place during a protracted 
 and anxious operation. To obviate this, it is well to cover the patient 
 with some impermeable material, previously antisepticised. If this is 
 carefully adjusted, leaving the part to be operated on only visible, it 
 will serve the purpose in view admirably : but it is scarcely 
 necessary to remark, that no precautions for such a purpose ought to 
 be necessary. 
 
 The removal having been accomplished, how is the wound to be 
 treated l Fii'st, in regard to the htemorrhage. Will we torsion the 
 vessels, or ligature them with catgut 1 I confess that I have never 
 twisted a vessel of respectable size without considerable misgiving for 
 the result, although those continuously doing it speak of it as the 
 more eflectual method of the two. In the hands of the distinguished 
 President of this Congress, torsion has, I believe, attained a perfection 
 rarely equalled. Whatever plan is adopted, the importaiice of stopping 
 every bleeding point cannot be over-estimated. The disadvantages of 
 oozing after an operation, and the collection of blood in the wound, 
 ai*e obvious. It may give lise to tension, requiring the dressing to be 
 interfered with, and if not perfectly aseptic, will cei-tainly decompose. 
 Otherwise, its absorption along with other products will prove harmless, 
 only giving rise to what is known as Yolkmann's "aseptic fever." In 
 an operation of this magnitude, thorough and complete drainage is 
 indispensable. Draining, while imperatively necessary, has unfortunately 
 serious drawbacks. We have to introduce a foreign body into the 
 wound, which is a highly imdesirable |)roceeding. Many attempts have 
 be'Mi made to perfect our drainage material, but with only partial 
 
 * The preliminaries of wound treatment will be found at some length in Cheyno's- 
 little work. 
 
 t Gerster, oj). cit
 
 ANTISEPTIC SUKCiERY AND SOME OF ITS RESULTS. 1015 
 
 success. Ordinary tubing, esi)eciiilly the red variety, holds the first 
 place. Decalcified bone has not realised the anticipations regardinir it, 
 and drainage by horse-hair and catgut have never come into much 
 prominence. Of all kimis of draining material however, I prefer the 
 lattei', because it is fairly effective and perfectly harmless. Unfortunately, 
 it will not drain pus, but blood or .serum ])erfectly. But as the presence 
 of pus in asej)tic wounds is rare, it n)ight have a trial in the first 
 instance. Perfection in drainage will not be attained till we find some 
 sulistance capable of doing so, giving rise to no irritation, and disappear- 
 ing when its functions are fulfilled. In all wounds of the size we are 
 now dealing with, stitches of relaxation should form a feature, be not 
 too numerous, and firndy tied ; and in all aseptic wounds, the sutures 
 for accurately bringing the edges together should be numerous. For 
 both purposes I use chromicised catgut. Sup])Ose the deep and superficial 
 sutures inserted, the hajmorrhage stopped, and the drainage material in 
 position, the wound is then thoroughly irrigated with corrosive sublimate 
 solution ; it is then closed, and the sutures cut short. Finely powdered 
 iodoform, or a mixture of iodoform and bismuth is dusted over it, w hen 
 it is ready for the sublimate gauze dressings. A few layers varied 
 according to circumstances are applied, and ovei-lap the wound for 
 several inches. These, being fixed in position by bandages of the same 
 material, constitute the deep dressing. Over this is placed further 
 layers of gauze, extending widely in all directions, and over all, equable 
 elastic ])i-essure. This may be graduated with such nicety as to give 
 not only the most efficient support to the dressings, but positive comfort 
 to the patient. Pressure ajjplied by means of some elastic substance, 
 has much to do with the success of wound treatment, not only for the 
 reasons just stated, but for the jierfect rest and immobility which it 
 ensures, and which ordinary bandaging is incapable of accomplishing. 
 
 In a wound treated in the manner indicated, what is there to interfere 
 with its future progress? It is presumed to be thoi'oughly aseptic so 
 far, and protected from all sources of infection. The chief danger 
 undoubtedly lies in the first dressing, and this, other conditions being 
 favourable, should be delayed as long as possible. Possibly, one dressing 
 only will be needed, and that at a time so advanced that no contamination 
 need be feared. 
 
 Macewen, when discussing the value of antiseptics at a meeting of 
 the Glasgow Medical Society, .said, "that in his last forty consecutive 
 cases of primary amputations, excluding some who died within forty- 
 eight hours after admission, healing took place after one dre.ssing — ^tliat 
 put on at the time of operation. In excision of the knee, he had now 
 no occasion to u.se parafhne or plaster, as the wounds generally healed 
 under a single dre.ssing." 
 
 I am not aware of any rule as to when the second dressing of an 
 aseptic wound should take place. I would not touch it without some 
 very decided indication. The thermometer might be thought to give 
 some sign, and although a sharp rise is often pre.sent, it generally 
 depends on the absorption of wound products, which are harndcss, 
 because j)ure. This " a.septic fever" then, as it has been termed, is a 
 matter of no moment. "With the exception of pain or tension in the 
 wound itself, or the appearance of discharge external to the dressings, 
 I know of no condition that would justify us in interfering at all.
 
 1016 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Nothing can be more conducive to invite disaster under such circum- 
 stances, than freqvient and consequently meddlesome treatment. An 
 early dressing would require the same scrupulous care as the first. An 
 irrigator must be kept continually playing over the wound, from the 
 time the dressings are removed till their re-application. Should local 
 inflammatory conditions supervene, and whei-e the strict adherence to 
 this routine has to be abandoned, much may still be done to carry out 
 asepticism. This is particularly to be desired, as the disturbance 
 generally depends upon excessive tension, from fluid as yet perfectly 
 free from a trace of decomposition. If the application of heat is called 
 for, whicli it generally is, in addition perhaps to the removal of some 
 stitches, and attention to drainage, I am decidedly against the employment 
 of poultices, as generally understood, of which linseed meal may be 
 taken as the type. They are dirty, inelegant, and above all, fruitful 
 sources of contagion. A suitable number of folds of boracic, carbolised, 
 or sublimated lint apjilied frequently as a fomentation, and covered by 
 any material that will retain the moisture, fulfil every indication. Not 
 only so, but their application is leased on principles, while the former is 
 only the result of a past and present empiricism. 
 
 From this imperfect sketch, it will be seen that an efi'ort is made to 
 give ]U'actical eS"ect to the great princijjles of IJsterism, viz., the 
 exclusion of active ferments from a wound, or surgical cleanliness, if you 
 will. The diff'erence exists in name only. Anything less would not be 
 much in advance of the suigicai ^^ractice of fifty years ago; while in the 
 direction of more completeness, it is capable of much improvement. 
 
 The choice of antiseptics is a varied one, but may for all pui-poses be 
 reduced to four — carbolic acid, corrosive sublimate, iodoform, and boi'o- 
 salicylic solution, the latter being a most admirable agent where a large 
 extent of surface has to be dealt with. I would employ carbolic acid 
 almo.st exclusively for cleansing the hands, the parts to be operated on, a;nd 
 the immersion of instruments. Tn this respect it has always stood, and 
 stands now, without a rival. The choice is limited in number, for a 
 very sim})le reason. They are the best that experimental and clinical 
 evidence has yet furnished us. In limiting the ninuber, we become 
 thoroughly acquainted with their individuality, if I may use the term, 
 and attain a correct knowledge of what each is capable of accomplishing.* 
 In this connexion, a curious and to me inexplicable anomaly is far from 
 infrequent. Nothing can be more certain than that two of the substances 
 at least possess aV)Solute and definite powers in relation to micro-organic 
 life; and how constantly do we hear this called in question or denied, 
 l)ecause at times they fail 1 Is it so in medical therapeutics 1 Do we 
 question the specific action of colchicum in gout ? mercury in syphilis 'i 
 salicylate of soda in acute rheumatism 1 or digitalis in certain cardiac 
 conditions, l>ecause in some cases we find them useless and inert? Is it 
 always the fault of the drug, and iiot of the administrator? No 
 condemjiation can alter the fact, that corrosive sublimate and carbolic 
 acid have specific actions in wound tieatment. The truth of this, any one 
 can verify for himself. Comparisons of a like nature might be made in 
 answer to the charge, that they have been productive of fatal results. . 
 Unquestionably, they have. So has chloroform iidialation; so has the 
 
 * Gerstor, o;>. cit. 
 
 I 
 t
 
 ANTISEPTIC SUKGEKY AND SOME OF ITS KESULTS. 1017 
 
 insignificant operation of vaccination, but neitlier will be abandoned on 
 that account. 
 
 The introduction of corrosive sublimate marks a distinct era in our 
 progress. "Its discovery as an antiseptic, or the very higli order of its 
 j)0wers, are not due to Koch, as many suppose. Eighty years a'-^o, 
 Waterton, the celebrated naturalist, during his wanderings in Soutli 
 America, used it for preserving the skins of animals. A little later 
 Kyan used it for preserving wood for building war ships, from dry rot. 
 In 1865, its antisej)tic powers were tii-st compared with other bodies. 
 In that year. Dr. Angus Smith found that when it was mixed with 
 blood, the amount of imtrefying gases evolved were too minute to admit 
 of determining their quantities ; while, with many other antiseptics, 
 including carbolic, tested under identical conditions, these gases were 
 l)roduced in large quantities." — (McDougall, Glasgow M(^dical Jotirnal). 
 To Koch in Germany, and Lister in England, undoubtedly belont^s the 
 credit of being the means of practically making it available for oui- 
 surgical wants. At the present moment, it is jjre-eminently the 
 antiseptic in wound treatment, and in fact every condition where sepsis 
 lias to be guarded against. A single instance of its power will l)e 
 sufficient. In Huid suitable for the growth of micro-organisms, but 
 treated with sublimate solution, no organisms had aj)peared after it had 
 been kept 182 days. 
 
 Iodoform is mo.st valuable, either pure, oi- mixed with bismuth. In 
 the minor surgery of countiy practice, its use fultils an acknowledo-ed 
 want. In operations about the anus or genito-urinary organs, it has 
 reall}' no substitute. In cases of supra-pubic lithotomy and extensive 
 jierineal section lately, I used tins substance entirely. In the former 
 there was considerable necrosis of tissue, fiom the action of the urine. 
 Though both advanced in years, free livers, and with a suspicion of 
 kidney disorder, their recovery was j^erfect. The sublimate is quite 
 inadmissible, where there is any indication of kidney disease. 
 
 Boro-salicylic jtreparations may be used on all occasions, and in any 
 quantity. Although their antiseptic powers are not great, they are often 
 valuable and handy for very large surfaces, Avhere the use of those 
 already mentioned might be attended with risk. 
 
 Such are some of the means we take to prevent blood-poisonino- a 
 condition absolutely depending on the presence of bacteria in a wound. 
 Whether we regard the jioison as due to the result of their chemical 
 action, and the production of ptomaines, or the entrance of jmtrid 
 matter, of which they form a part, into the blood, matters little. Thev 
 originate in our operation wounds, and it is our duty to prevent theni^, 
 which is the cardinal principle of Listerism. Its chief value lies in its 
 precision, and the unanswerable reasons which can be given for eveiv 
 stage of its process. It seeks to bring surgical treatment into somethiii"- 
 like harmony and definiteness of purpose — a thing of which we must all fed 
 it stands much in need. Surgery is beginning to feel the influence of a 
 power that has raised it, and will continue to raise it, to a higher level. 
 Pre-antiseptic surgery was almost empirical — a gro]»ing in the dark. As 
 a consequence of this, its j)rofessors, even of the most brilliant talents 
 Avere quite unable to look ahead, for the sim])le leason, it was quite 
 impossible to predict how an operation, in the majority of instances at 
 least, would end. The act once committed, was beyond the reach of any
 
 1018 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 controlling power. At the present time, we cannot speak of the results 
 of operations with absolute certainty, it is true ; but we have come very 
 near it. So far as blood-poisoning is concerned (and that is the only 
 condition engaging our attention), with a patient in good health, and 
 surrounded by all the hygienic conditions that modern surgery justly 
 demands, we can now in many cases promise results. And why? 
 Because of the power we possess over septic processes. 
 
 The limits of this short paper will not allow me to allude to the 
 results which aseptic surgery has accomplished. This is scarcely to be 
 regretted, as they ai-e now matters of history. A study of surgical 
 statistics generally, and those of aseptic surgery in particular, will show 
 the conspicuous superiority of the latter. In a series of 295 opei-ations 
 by myself, the death-rate was only a fraction over 3 per cent. One case 
 alone died from blood-poisoning. 
 
 Even in spite of Listerism, with all its safeguards, minuteness of 
 detail, and the sustained attention it demands, we have still to face 
 a certain mortality from blood-poisoning. The age of '•' perfect surgical 
 cleanliness," has not yet arrived, nor will it, as long as this scoui-ge 
 of sui'gery follows in our track. That Listerism has stayed its ravages 
 in a remarkable manner, has robbed it of half its terrors, and even 
 shown a way by which it may be eradicated, are facts which do not 
 require to be insisted on, and which few will deny.
 
 INDEX. 
 
 Abdominal Section, Fifty Cases of— F. C. Batchelor 
 
 Abo (Finlaucl), Hygienic Conditions of — A. R. Spoof 
 
 Adam, G. R. — Modification of Sims' Operation of Metrotomy 
 
 Addresses of Presidents of Sections. Sec Presidents of Sections. 
 
 Allen, H. B. — Typhoid Fever Connected with Milk Supply 
 
 ^'ariations in Pathological Process in Typhoid Fever 
 Catalogue of Museum of Pathology 
 Specimens and Cases of Hydatid Diser.se . . 
 
 Alopecia Ai-eata — D. Colquhoun 
 
 Anesthetics during Labour. — S. Maberly Smith 
 
 Anatomy and Physiology, Address in — T. P. Anderson Stuart 
 „ ,, Demonstrations, &c. . . 
 
 Anderson, C. M. — Nasal Calculus from a Girl . . 
 
 Microscopic Sections of Glioma of Retina 
 
 Anderson, E. — Menstrual Function 
 
 Ankle, Compound Dislocation of — H. C. GaiNlc . . 
 
 Antiseptic Surgery — R. B. Duncan 
 
 Anthrax in Australia — W. M. Hamlet . . 
 
 Apostoli's Treatment of Uterine Fibroids — J. Foreman . . 
 
 Aortic Incompetence and Locomotor Ataxia — D. Colquhoun 
 
 Ai-mstroug, W. — Lunacy Legislation in Australia 
 
 Astles, H. E. — Chiau Turpentine in Cancer 
 
 Astragalus, Fracture of — H. C. Garde . . 
 
 Asylum Practice, Hospital Methods in — Eric Sinclair 
 
 Atrophy, Unilateral Renal — T. C. Fisher 
 
 Aural Disease and Epilepsy — C. L. M. Iredell . . 
 
 Australian Climates for Consumptives —J. Robertson 
 
 ,, ,, Discussion in Hygiene Section 
 
 Australian Lunatic Asylums, Management of — W. L. Clelaud 
 
 Batchelor, F. C. — Address in Section of Obstetrics and Gynaecology 
 Fifty Cases of Abdominal Section 
 
 Balls-Headley, W. — Removal of Ovaries and Tubes 
 
 Bancroft, J. — On Filaria 
 
 Bancroft, T. L. — Materia Medica of Queensland I'lant^ . . 
 
 Barrett, J. W. — Nature of Vision in Animals 
 
 Treatment of Chronic Catarrh of the Middle Ear . . 
 Danger of Eye Operations when Mucocele is Present 
 Value of Redness of the Handle of the Malleus as a Symptom 
 in Diseases of the Middle Ear 
 
 Bath, Treatment of Typhoid by Cold— F. E. Hare 
 
 Beri-beri in the Northern Tei-ritory — P. M. Wood 
 
 Bickle, L. W. — Phlyctenular Conjunctivitis in Erythema Nod<j.->um 
 
 Birch Itch, a Note on the New Zealand — D. Cohiuhoun . . 
 
 Bird, S. D.— Immediate Treatment of Pleurisy with Effusion 
 
 Bismuth, Therapeutic Position of — T. Dixson . . 
 
 PAOB-. 
 
 649 
 
 702. 
 
 159' 
 175 
 
 999 
 1004 
 972 
 691 
 569 
 585 
 797 
 798 
 704 
 300 
 1009' 
 522 
 717 
 135 • 
 877' 
 941 
 301 
 895 
 615 
 789 
 77 
 565- 
 S70 
 
 625. 
 
 649' 
 
 667 
 
 49' 
 
 927 
 588 
 756 
 777 
 
 794 
 179 
 
 54 
 796 
 970 
 
 99 
 933
 
 1020 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Blight and Granular Ophthalmia — T. A. Boweu 
 
 Bone Disease, Specimens of — H. B. Allen 
 
 Bone Inflammation, Subcutaneous Drilling in — T. N. FitzGerald . . 
 
 Bonnefin, F, H. — Notes on Typhoid 
 
 Bowe, F. — Diseases of Polynesians in Queensland 
 
 Bowen, T. A. — Sandy Blight and Granular Ophthalmia . . 
 
 Brain, Eemoval of Hydatid Cyst from — J. C. Verco 
 
 Brain, Injury to Frontal Kegion of the — D. Colquhoun . . 
 
 Breast, Cancer of. Table of 47 cases — F. Milford 
 
 Caesarian Section — F. C. Batehelor 
 
 Cancer of Breast — F. Milford . . 
 
 Carstairs, J. G. — Etiology of Typhoid . . 
 
 Catalogue of Museum of Pathology 
 
 Cerebellar Abscess Trephined — ^H. L. Ferguson 
 
 Cerebellar Cyst — J. C. Verco . . 
 
 Cerebellar Disease, Trephining for — H. Maudsley 
 
 Cerebro-Spinal Fever — W. Fiulay 
 
 Cerebrum, Evacuation of Abscess in — J. C. Verco and E. C. Stirling 
 
 Cerebrum, Functions of — Professor Anderson Stuart 
 
 Chambers, T. — Uterine Pregnancy supervening on Ectopic Gestation 
 
 Chancre, Resection of Hard — M. Crivelli 
 
 Cliest, Origin of Form of — Professor Stuart 
 
 Chian Turpentine in Cancer — H. E. Astles 
 
 Children, Sunstroke in — W. K. MacEoberts 
 
 ,, Intestinal Troubles in — W. Snowball . . 
 Cholera Quarantine — K. R. Kirtikar 
 
 „ ,, Discussion 
 
 Chyluria and Filarial — J. Bancroft 
 Cleft Palate, a Case of— T. N. FitzGerald 
 
 Cleland, W. L. — Australian Lunatic Asylums, Management of 
 Climate of New Zealand — D. Colquhoun 
 Climate, Treatment of Phthisis by — D. Turner . . 
 Climatology of Nelson (N.Z.) — J. Hudson 
 
 Colonies as a Health Resort for Consumptives — J. Carnegie MacMullen 
 Colquhoun, D. — Aortic Incompetence and Locomotor Ataxia 
 Injury to Frontal Region of Brain 
 Phthisis in New Zealand 
 A Note on the New Zealand Birch Itch . . 
 On some Cases of Alopecia Areata and its pi-obable causes 
 Collingwood, D. — Gastro-Enteritis in Children . . 
 Conjunctivitis, Granular — R. B. Duncan 
 
 Conjunctivitis, Phlyctenular, in Erythema Nodosum — L. W. Bickle 
 Constitutional Factor in Disease — J. Robertson . . 
 
 Consumptives, Colonies as a Health Resort for— J. Carnegie MacMullen 
 Convergence — M. J. Symons . . 
 Creed, J. M. — Leprosy in its relations to the European Population 
 
 Australia 
 Cretinism, Sporadic — F. N. Manning .. 
 
 ,, „ E. C. Stirling 
 
 •Crivelli, M. — A Note on Pasteur's Methods 
 
 of
 
 IXDEX. 
 
 1021 
 
 Crivelli, M. — Critical Keview of Resection of Hard Chancre 
 
 Microbe of GouorrlKea 
 Croup and Diphtheria— J. Janiicsou 
 Cystotomy — A. SlacCorruick . . 
 
 ,, Supra-pubic, twenty succossfnl eases — H. O'Hara 
 
 Diphtheria, nature and causes of, and rehxtion to Croup — J. Jamieson 
 
 „ Notes on— A. Jarvie Hood . . 
 
 ,, Discussion on 
 
 Disease, Constitutional Factor in — J. Eobertson 
 Dixson, T. — Druminc : Is there such a body ? .. 
 
 Probable Therapeutic position of Bismuth . . 
 Drilling, Subcutaneous, in Bone Inflammation — T. N. FitzCierald . . 
 Druminc: Is there such a body? — T. Dixson 
 Duncan, R. B. — Granular Conjunctivitis 
 
 Antiseptic Surgery and some of its Kesiilts 
 Dyson, T. S.— JIalarial Fevers in Tropical Queensland . . 
 
 Ear, Middle, Redness of Handle of Malleus in Inflammation of— J. W. Barrett 
 
 Ear, Middle. Treatment of Chronic Catan-h— J. W. Barrett 
 
 Ectopic Gestation followed by Uterine Pregnancy — T. Chambers . . 
 
 Electricity in Diseases of Women — J. Foreman 
 
 Elephantiasis in New Guinea — Sir W. MacGregor 
 
 Epilepsy and Aural Disease — C. L. M. Iredell . . 
 
 Erson, Leger— Sanitary State of New Zealand .. 
 
 Execntive Committee, Report of 
 
 Exercises, as an Aid to Siu-gical Treatment — R. E. Roth 
 
 Eye, Excision of, followed by Septic Meningitis — J. T. Rudall 
 
 „ Points in Structure of — Professor Stuart . . 
 
 ,, Physiological Model to show accommodation, A:c. 
 Eyes, Manifestations of late Hereditai-y Syphilis in — G. A. Syme . . 
 Eye Operations when Mucocele is present — J. W. Barrett 
 Eyelids, Congenital Cyst of — W. Odillo Maher . . 
 ,, Sarcoma of — W. Odillo Maher 
 
 Faithfirll, R. L.— Notes on the Treatment of some of the more frequently 
 
 met with Skin Diseases . , 
 Federal Inspection and Quarantine — A. E. Salter 
 Ferguson, H. Lindo.— Cerebellar Abscess treated by Trephining . . 
 Optic Neuritis after Exposure to Heat 
 Resection of Optic and Ciliary Nerves 
 Exhibits by 
 Fetherstou, R. H.— Pilocai-pine in Puerperal Eclampsia . . 
 Fever, Cerebro-Spinal— W. Fiulay 
 
 Malarial, in Tropical Queensland— T. S. Dyson . . 
 Filaria — Dr. Bancroft 
 Finlay, W.— Cerebro-Spinal Fever 
 Fisher, T. C. — Unilateral Renal Atrophy 
 FitzGerald, T. N. — Inaugural Address by 
 
 New Operation for Cure of Congenital Talipes Varus and 
 Eqnino-Varus . . 
 
 241 
 
 620 
 
 800 
 21G 
 '2()0 
 
 800 
 
 807 
 
 814 
 
 73 
 
 937 
 
 933 
 
 321 
 
 il37 
 
 743 
 
 1001) 
 
 (54 
 
 794 
 7yt> 
 
 (m 
 
 717 
 
 48 
 
 789 
 
 485 
 
 3 
 
 298 
 769 
 5«5 
 586 
 771 
 777 
 767 
 751 
 
 965 
 
 545 
 
 764 
 
 761 
 
 731 
 
 797 
 
 708 
 
 139 
 
 64 
 
 49 
 
 139 
 
 615 
 
 9 
 
 316
 
 1022 
 
 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Fitzgerald, T. N. — Subcutaneous Drilling in the Treatment of Bone paoi; 
 
 Inflammation . . . . , . . . , . 321 
 
 Cleft Palate .. .. .. .. ..326 
 
 Foreman, J.— Electricity in Diseases of Women . . . . . . 717 
 
 -Garde, H. C. — Compound Dislocation of Ankle . . . . . . . . 300 
 
 Gardner, W. — Loreta's Operation . . . . . . . . . . 301 
 
 Surgery of the Kidney . . . . . . . . . . 305 
 
 Surgical Treatment of Hydatid Disease , . . . . . 345 
 
 Twisting of Pedicle in Ovarian Tumours . . . . . . 674 
 
 ■Gastro-Euteritis in Children — D. Collingwood . . . . . . . . 984 
 
 ■Gastrolobium and Oxylobium, Poisonous Action of — J. C. Eosselloty . . 931 
 
 'Gastrotomy and Gastrostomy — Sydney Jones . . . . . . . . 223 
 
 Glaucoma Fulminans — G. Thon . . . . . . . . . . 781 
 
 Glaucoma, Not Believed by Iridectomy — J. T. Rudall . . . . . . 768 
 
 Glioma of Retina — C. M. Anderson . . . . . . . . . . 798 
 
 Goitre, Specimens of — H.B.Allen .. .. .. .. .. 1002 
 
 Gonorrhcea, Microbe of — M. V. Crivelli . . . . . . . . 020 
 
 •Gout — J. Robertson . . . , . . . . . . . . . . 77 
 
 Governor's Address — Sir H. B. Loch . . . . . . . . . . 2 
 
 Grant, D. — Raynaud's Disease . . . . . . . . , . 129 
 
 <Gyna3Cology, ObUgations to Obstetrics — Felix Meyer .. .. .. 711 
 
 Hamilton, T. K. — Ocular Symptoms due to Nasal Disease . . . . 779 
 
 Post-nasal Growths . . . . . . . . . . 782 
 
 Hamlet, W. M. — Anthrax in Australia, .Junee Experiments . . . . 522 
 
 Hare, F. E.— Cold Bath Treatment of Typhoid Fever . . . . . . 179 
 
 Head Cases, Management of Traumatic — A. J. W. Pettigrew . . . . 269 
 
 Headley, W. Balls — Removal of Ovaries and Tubes . . . . . . 667 
 
 Health Legislation — Resolutions concerning . . . . . . . . 31 
 
 Heart and Great Vessels, Want of Proportion of Signs and Symptoms in 
 
 Diseases of — J. Jamieson . . . . . . . . , . 106 
 
 Henderson, A. V. — History of a Typhoid Epidemic . . . . . . 169 
 
 Henderson, Colin — External Use of Sulphate of Iron .. .. ,. 943 
 
 Hepatic Element in Disease — J. W. Springthorpe . . . . . . 67 
 
 Herniotomy, Treatment of Sac in^K. R. Kirtikar . . . , . . 271 
 Hoiiman, A. — The Correlation of Follicular Tonsillitis in Children with other 
 
 Zymotic Diseases . . . . . . . . . . . , 995 
 
 Hood, A. Jarvie — Notes on Diphtheria . . . . . . . . 807 
 
 Hojxj, J. W. — Ophthalmic Work in Western Australia . . . . . . 752 
 
 Hospital Accommodation in Sydney — J. Ashburton Thompson . . . . 446 
 
 Hudson, J. — Climatology of Nelson (N.Z.) .. ., .. .. 504 
 
 Hydatid Disease, Geneeal Meeting concerning . . . . . . 328 
 
 Age in relation to — J. Davies Thomas . . . . . . , . 342 
 
 Bihrubin in Hydatid Cysts — J. Davies Thomas . . . . . . 391 
 
 Discussion concerning . . . . . . . . . . . . 392 
 
 Geographical Distribution — J. Davies Thomas . . . . . . 328 
 
 Hydatid of Brain, Removal of— J. C. Verco .. .. .. .. 377 
 
 Hydatid of Zygomatic Fossa— J. R. M. Thomson . . . . . . 385 
 
 Multiple Hydatids treated by Tlioracic Incisions — J. C. Verco and 
 
 . A. A. Lendon . . . . . . . . . . . . 386
 
 INDKX. 
 
 1023 
 
 -W. P. Whitcombe 
 
 Hydatid Disease (Continued) — 
 
 Operative Treatment of — J. Davies Thomas 
 
 Patliological Specimens — H. B. Alien 
 
 Sex in relation to — J. Davies Thomas 
 
 Surgical Treatment of — W. Gardner 
 
 Treatment by Injection of Permanganate of Potash- 
 Hydatid in site of Kidney and in Bladder — T. C. Fisher . 
 Hydroceles, Specimens of Complicated — H. B. Allen 
 Hygienic Conditions in Victoria — J. W. Springthorpe 
 Hysterectomy — F. C. Batchelor 
 „ Sydney Jones 
 
 „ Puerperal — H. W. Maunsell 
 
 Iclitbyosis, Notes of a case of— J. P. Ryan 
 Inaugural Addi-ess of President — T. N. FitzGerald 
 
 ,, Meeting . . 
 Indian Drugs, Notes on — K. R. Kirtikar 
 
 ,, Remedies, Notes on an Exhibit of — R. Temple Wright 
 ludican. Excess of, in Urine — R. H. Marten 
 Inebriety, Its Etiology and Treatment — Patrick Smith 
 
 ,, A Contribution to the Study of — C. M'Carthy . . 
 Infantile MortaUty— W. F. Taylor 
 
 Influenza, Nervous Substratum of — J. W. Springthorpe . . 
 Insane, Housing of, in Victoria — W. Beattie Smith 
 
 ,, Training of Nurses in Hospitals for the — W. C. WiUiamson 
 Insanity and Race in New South Wales — C.Ross 
 
 „ in Australian Aborigines — F. N. Manning 
 Intestinal Obstruction — Sydney Jones . . 
 Intestine, Resection of, by New Method — H. W. Maunsell 
 Iodide of Potassium, Dosage of — W. M. Stenhouse 
 Iredell, C. L. M. — Aural Disease and Epilepsy . . 
 lion, A new mode of administering Protoxide of — T. S. Ralph 
 
 Jackson, J. — Treatment of Inherited Specific Keratitis 
 Jakins, W. V. — Principles and Practice of Ventilation 
 Jamieson, J. — Want of proportion in the signs and symptoms of Diseases 
 of the Heart and great Vessels 
 Nature and causes of Diphtheria and its relation to Croup 
 Jones, Sydney — On Laparotomy 
 Joske, A. S.— Seven cases of Typhlitis 
 
 Keratitis, Inherited Siiecific — J. Jackson 
 
 Kidneys, Fatty, in Polynesians in Queensland— F. Bowe 
 
 Kidney, Removal of Tumours of the — Sydney Jones 
 
 „ Surgery of the — W. Gardner . . 
 Ku-tikai', K. R.— Is Cholera Quarantine scientifically sanctioned ? . . 
 
 Treatment of Sac in Herniotomy 
 
 Notes on some Indian Drugs 
 KjTnoscope— Professor Anderson Stuart 
 
 VAGE 
 
 352 
 
 1004 
 
 345 
 
 t;i8 
 
 1000 
 405 
 054 
 •J29 
 
 OKI 
 
 ',)77 
 !J 
 1 
 040 
 <)56 
 Oil 
 bOO 
 867 
 43 
 101 
 898 
 887 
 849 
 857 
 226 
 •236 
 939 
 789 
 958 
 
 773 
 
 558 
 
 106 
 
 800 
 
 216 
 
 71 
 
 773 
 62 
 227 
 305 
 539 
 271 
 946 
 586 
 
 Laparotomy — Sydney Jones 
 
 216
 
 1024 INTERCOLONIAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 PAGE 
 
 Legislation, Healtli, Resolutions concerning . . . . . . • • '^^ 
 
 Lendon, A. A. — Notes of a fatal case of Pemphigus . . . . « - 9''7 
 
 Lendon, A. A. and Vereo, J. C— Multiple Hydatid Cysts, treated by Thoracic 
 
 Incisions . . . . . . . . . . • . • • '^^^ 
 
 Leprosy in its relations to the European Population of Australia — J. M. Creed 49'j 
 
 Leprosy in New Guinea — Sir W. MacGregor . . . . . . . • 48 
 
 ,, Notes of a case of — F. Peipers .. ., .. .• 976 
 Lithotomy. See a ho Cystotomy. 
 
 ,, Supra-pubic — J. Tremearne .. .. .. .. 257 
 
 Liver, Abscess of — Sydney Jones . . . . . . . . . . 227 
 
 Liver, Abscess of, treatment by Free Incision— J. Davies Thomas . . 230 
 
 Localisation in Nervous Diseases — J. W. Springthorpe .. .. •■ 121 
 
 Locomotor Ataxia and Aortic Incompetence — D. Colquhouu . . . . 13-5 
 
 Loreta's Operation for dilating the Pylorus — W. Gardner . . • • 301 
 
 Lunacy Legislation in Australia — W. Armstrong . . . . . . 877 
 
 Lunatic Asj'lums, Management of Australian — W. L. Clelaud . . . . 870 
 
 Lymph Scrotum and Filarife — J. Bancroft . . . . . . • • 53 
 
 McCarthy, C. — A Contribution to the Study of Inebriety . . . . 867 
 
 MacCormick, A. — Cystotomy . . . . . . . . . . . . 246 
 
 MacGregor, Sir W.— Diseases in British New Guinea . . . . . . 46 
 
 MacLaurin, Dr. — Elected President of Third Session . . . . . . 30 
 
 Comparative View of Mortality of the Different Colonies 
 
 from certain Diseases . . . . . . . . 401 
 
 MacMuUen, J. Carnegie — Colonies as a Health Resort for Consumptives . . 509 
 
 MacRoberts, W. K. — Sunstroke in Children .. .. .. .. 144 
 
 Maher, Odillo— Congenital Cyst of Eyehd . . . . . . . . 767 
 
 Sarcoma of Eyelids . . . . . . . . . . 751 
 
 Malarial Fevers of Tropical Queensland — T. S. Dyson . . . . . . 64 
 
 Malleus, Redness of Handle of— J. W. Barrett . . . . . . . . 794 
 
 Manning, F. N. — Address in Section of Psychology . . . . . . 816 
 
 Insanity in Australian Aborigines . . . . . . 857 
 
 Sporadic Cretinism . . . . . . . . . . 834 
 
 Marano, V. — On Pneumatic Therapeutics . . . . . . . . 93 
 
 Marten, R. H. — Excess of Indican in Urine .. .. .. .. 611 
 
 Materia Medica of Queensland Plants— T. L. Bancroft . . . . . . 927 
 
 Maudsley.'H. — Cerebellar Disease and Trephining . . . . . . 113 
 
 Maunsell, H. W. — Puerperal Hysterectomy . . . , . . . . 681 
 
 Resection of Intestine by New Method .. .. 236 
 
 Median Perineal Cystotomy — A. MacCormick . . . . . . . . 255 
 
 Medical Practitioner, an Officer of State— J. T. Mitchell . . . . 515 
 
 Menstrual Function — E. Anderson . . . . . . . . . . 704 
 
 Metrotomy, Modification of Sims' Method— G. R. Adam . . . . 702 
 
 Meyer, F. — Obligations of Gynsecology to Obstetrics . . . . . . 711 
 
 Microscopical Preparations, Instrument for Marking — T. P. Anderson Stuart 586 
 
 Milford, F.— Cancer of Breast, 47 cases .. .. .. ..288 
 
 Westerly Winds of Winter in their Influence on Disease . . 512 
 
 Milk Supply, Typhoid Fever connected with — H. B. Allen , . . . 159 
 
 H. T. Whittell . . . . 188 
 
 Mitchell,,J. T.— Should the Medical Practitioner be an Officer of State? . . 515 
 
 Morgan, C. W. — State Medicine in New South Wales . . . . . . 456
 
 TN'DRX. 1025 
 
 PACIE 
 
 Mortality, Infantile — W.F.Taylor .. .. .. .. .. 43 
 
 Mortality Eates and Expectation of Life in Australia . . , . . . 482 
 
 Mountain Climates in Australia — D. Turner . . . . . . . . 88 
 
 Mucocele, dangerous complication in eye operations . . . . . . 777 
 
 Mueller, Baron Ferd. von — Address in Pharmacology .. .. .. 909 
 
 Museum of Tathology, Catalogue of . . . . . . . . . . 999 
 
 Nasal Calculus from a girl aged ten — C. M. Anderson . . , . . . 797 
 
 Nelson (N.Z.), Cliraatologj' of— J. Hudson .. .. .. .. 504 
 
 Necrosis of Fingers and Toes — F. Bowe . . . . . . . . 63 
 
 Nephrotomy, Nepluectomy, &c. — W. Gardner , . . . . . . , 305 
 
 Nervous Diseases, Localisation in — J. W. Springthorpe . . . . . . 121 
 
 New Guinea, Diseases in British — Sir W. MacGregor . . . . . . 46 
 
 New South Wales, Present Sanitary State of — J. Ashbm-ton Thompson . . 434 
 
 ,, State Medicine in — C. W. Morgan . . . . . . 456 
 
 New Zealand, Sanitary Condition of — Leger Erson . . . . . . 485 
 
 Obstetrics and Gyna?cology, Address in — F. C. Batchelor . . . . 625 
 
 Ocular Symptoms due to Nasal Disease — T. K. Hamilton . . . . 779 
 
 O'Hara, H. — Twenty successful cases of Supra-pubic Cystotomy , . . . 260 
 
 Oophorectomy — F. C. Batchelor . . . . . . . . . . 652 
 
 Ophthalmia, Granular — T, A. Bowen . . . . . . . . . . 738 
 
 „ E. B. Duncan . . . . . . . . 743 
 
 Ophthalmic Work in AVestern Australia — J. W. Hope . . . . . . 752 
 
 Optic and CiUary Nerves, Eesection of — H. L. Ferguson . . . . . . 731 
 
 Optic Neuritis, after exposm-e to heat - H. L. Ferguson , . . . . . 761 
 
 Ovarian Disease and Pregnancy — T. Eowan . . . . . . . , 645 
 
 Ovarian Tumours, Twisting of Pedicle in — W. Gardner . . . . . . 674 
 
 Ovaries and Tubes, Eemoval of — W. Balls-Headley . . . . . . 667 
 
 Ovariotomy — F. C. Batchelor , . . . . . . . . . 649 
 
 Oxylobium and Gastrolobium, Poisonous Action of — J. C. Eosselloty . . 931 
 
 Palate, a case of Cleft— T. N. FitzGerald . . . , . . . . 326 
 
 Pasteur's Methods, a Note on — M. Crivelli . . . . . . . . 535 
 
 ,, Mode of Destroying Babbits . . . . . . . . . . 566 
 
 Pasteur's Vaccination for Anthrax — W. M. Hamlet . . . . . . 522 
 
 W.C.Wilkinson .. .. ..602 
 
 Pathology, President's Address in — W. C. Wilkinson . . . . . . 591 
 
 Peipers, F. — Notes of a case of Leprosy . . . . . . . . 976 
 
 Pelvic Cellulitis and Peritonitis— F. C. Batchelor . . . . . . 639 
 
 Pemphigus, Notes of a Fatal Case of — A. A. Lendon . . . . . . 967 
 
 Perm al Cystotomy — A. MacCormick , . . . . . . . . . 254 
 
 Periostitis, Suppmative, almost without Necrosis — J. C. Verco . . . . 277 
 
 Pettigrew, A. J. W.— Management of Traumatic Head Cases . . . , 269 
 
 Pharmacology, Address in— Baron F. von Mueller . . . . . . 909 
 
 Phimosis, Congenital— G. T. WooUey . . . . • . • • . . 234 
 
 Phthisis in Great Britain and Australasia— D. Colquhoun . . . . 81 
 
 Phthisis in New Zealand — D. Colquhoun . . . . . • . . 79 
 
 Phthisis, Open Air Treatment of— J. P. Eyan . . . . . . . . 90 
 
 Phthisis, Treatment of, by Chmate— D. Turner . . . . . . , . 87 
 
 Pilocarpine in Puerperal Eclampsia— E. H. Fetherston . . . . . . 708 
 
 Plenrisv \vith Effusion, Immediate Treatment of— S. D. Bird . . . . 99 
 
 2u
 
 1026 
 
 I>JTERCOLOyiAL MEDICAL CONGRESS OF AUSTRALASIA. 
 
 Pneumatic Therapeutics— V. Marano . . 
 
 Pneumonia attended with Mania in Polynesians — F. Bowe 
 
 Polynesians, Diseases of, in Queensland — F. Bowe 
 
 Post-nasal Growths — T. K. Hamilton . . 
 
 Poulton, Dr., Presentation to .. 
 
 Practitioners, Unqualified 
 
 ,, ,, Discussion concerning 
 
 Pregnancy, Complicated with or Associated with Ovarian Disease — T. Eowan 
 ,, Extra-Uterine, Two Cases Successfully Treated — R. Worrall 
 
 ,, Laparotomy during — F. C. Batchelor 
 
 ,, Uterine, Supervening on Ectopic Gestation — T. Chambers 
 
 Premier's Address of Welcome — Hon. D. Gillies 
 President of Next Session, Election of . . 
 President's Inaugural Address — T. N. FitzGerald 
 Presidents of Sections, Addresses of — 
 
 Anatomy and Physiology — T. P. Anderson Stuart 
 Diseases of Children— W. Snowball 
 Diseases of the Eye, &c. — M. J. Symons 
 Diseases of the Skin— J. P. Ryan . . 
 Hygiene— H. N. MacLauriu 
 Medicine— W. F. Taylor . . 
 Obstetrics and Gynaecology — F. C. Batchelor 
 Pathology— W. Camac Wilkinson . . 
 Psychological Medicine— F. N. Manning 
 Pharmacology— F. von Mueller 
 Surgery— E. C. Stirling .. 
 Psychology, Address in— F. N. Manning 
 Puerperal Eclampsia, Pilocarpine in— R. H. Fetherston . . 
 Puerperal Fever, in Relation to Midwifery Practice— J. C. Verco . . 
 
 ,, Discussion concerning 
 
 Pylorus, Dilatation of, Loreta's Operation— W. Gardner .. 
 „ Resection of, by New Method— H. W. Maunsell 
 
 Quarantine, Federal— A. E. Salter 
 
 Quarantine for Cholera— K. R. Kirtikar 
 
 Queensland, Malarial Fevers in Tropical— T. S. Dyson . . 
 
 Queensland Plants, Materia Medica of— T. L. Bancroft . . 
 
 Race and Insanity in New South Wales— C. Ross 
 
 Ralph, T. S. — A New Mode of Administering Protoxide of Iron 
 
 Raynaud's Disease — D. Grant 
 
 Receptions and Entertainments 
 
 Renal Atrophy, Unilateral- T. C. Fisher 
 
 Report of Executive (Committee 
 
 Robertson, J.— History of Typhoid Fever in Victoria and its Etiology 
 
 Importance of Constitiitional Factor in Disease 
 Ross, Chisholm — Race and Insanity in New South Wales 
 Rosselloty, J. C— Poisonous Actions of Gastrolobium and Oxylobium 
 Roth, E. E. — Instrument for Recording Lateral Curvature 
 
 Special Exercises as an Aid to Surgical Treatment . . 
 Rowan, T. — Pregnancy Complicated or Associated with Ovarian Disease 
 
 PACE 
 
 93 
 
 60 
 
 59 
 
 782 
 
 31 
 
 31 
 
 567 
 
 645 
 
 664 
 
 654 
 
 697 
 
 9 
 
 30 
 
 9 
 
 569 
 981 
 721 
 961 
 401 
 34 
 625 
 591 
 816 
 909 
 197 
 816 
 708 
 684 
 695 
 301 
 241 
 
 545 
 
 539 
 
 64 
 
 927 
 
 849 
 958 
 129 
 
 21 
 
 615 
 
 3 
 
 149 
 
 73 
 849 
 931 
 299 
 298 
 645
 
 102 
 
 PAfJi; 
 
 Rudall, J. T. — Glaucoma in whicli Iridectomy seemed Hurtful .. .. 7(58 
 
 Septic Meningitis after Excision of Suppurating Eyeball . . 769 
 
 Eyan, J. P.— Open-air Treatment of Phthisis . . . . . . . . 90 
 
 Address in the Section for Diseases of the Skin . . . . 961 
 
 A Case of Ichthyosis . . • • . . . . . . 977 
 
 On a Case of Acquired Syphilis in a Child Three Years Old . . 994 
 
 Salter, A. E.— Federal Quarantine . . . . . . . . . . r,i5 
 
 Sanitary Condition of Colonies. — Discussion .. .. .. .. o67 
 
 „ ,, New Zealand — Leger Erson .. .. .. 485 
 
 ,, State of New South Wales— J. Ashburton Thompson .. .. 434 
 
 Scott, G. A. — Notes on Lateral Spinal Curvature . . . . . . 264 
 
 Scrofula and Tubercle — J. Eobertson . . . . . . . . . . 75 
 
 Sectional Meetings of Section of Hygiene . . . . . . . . 565 
 
 Session, Date and Place of Thu-d, lixed . . . . . . . . 30 
 
 Sewage Disposal— W. F. Taylor . . . . . . . . . . 490 
 
 Sewage Farms, Typhoid Germs in — A. Shields . . . . . . . . 562 
 
 Shields, A. — Typhoid Germs in Sewage Farms . . . . . . . . 562 
 
 Sinclair, Eric — Extension of Hospital Methods to Asylum Practice . . 895 
 
 Skin, Diseases of — Presidential Address^ J. P. Ryan .. .. .. 961 
 
 „ ,, Notes on Treatment of some — E. L. Faithfull .. .. 965 
 
 Skin Eruptions complicating Urethritis — R. A. Stirling . . . . . . 974 
 
 Smith, Patrick — Inebriety, its Etiology and Treatment . . , . . . 860 
 
 Smith, S. Maberly—AniBsthetics during Labour .. .. .. 691 
 
 Smith, W. Beattie — Housing of Insane in Victoria, with special reference to 
 
 Boarding-out . . . . . . . . . . . . . . 898 
 
 Snake-bite, Notes on Two Cases of— J. S. Thwaites . . . . . . 945 
 
 Snowball, W. — Address in Section for Diseases of Children . . . . 981 
 
 SpeciaUsm, Benefits of — M. J. Symons . . . . . . . . 721 
 
 EvUs of —D. Turner .. ., .. .. ..551 
 
 Spinal Curvature, Notes on Lateral — G . A. Scott . . . . . . 264 
 
 ,, „ Instrument for Eecording Lateral — E. E. Eoth.. .. 299 
 
 Spoof, A. R.— Hygienic Conditions of Abo (Finland) . . . . . . 554 
 
 Springthorpe, J. W. — Hepatic Element in Disease , . . . . . 67 
 
 Hygienic Conditions in Victoria . . . . . . 465 
 
 Locahsation in Nervous Diseases .. •. .. 121 
 
 Nervous Substratum of Influenza . . . . . . 101 
 
 Notes on Typhoid Fever . . . . . . . . 173 
 
 State Medicine in New South Wales — C. W. Morgan . . . . . . 456 
 
 ,, ,, Western Australia— J. E. M. Thomson .. .. 489 
 
 State Medical Practitioners — J. T. Mitchell . . . . . . . . 515 
 
 Stenhouse, W. M. ^Dosage of Iodide of Potassium, with special reference to 
 
 Psoriasis . . . . , . . . . . . . . . 938 
 
 Stirling, E. C. — Address in Section of Surgery .. .. .. 197 
 
 On Sporadic Cretinism . . . . . . . . 840 
 
 Stu-ling, E. C, and Verco, J. C. — Abscess in Cerebrum . . .. 280 
 
 Stu-Ung, E. A. — Notes on some Skin Eruptions, complicating Urethritis . . 974 
 
 An anomalous case of acquired Infantile Syphilis . . 991 
 
 On a case of Syphilitic Dactyhtis in a Child . . . . 992 
 
 Stuart, Professor Anderson— Address in Section of Anatomy and Physiology 569 
 
 l)pmonstrationfi and Exhibits .. .. 585 
 
 2u 2
 
 1028 INTERCOLONIAL MEDICAL CONGRESS OP AUSTRALASIA. 
 
 I'AGE 
 
 Sulphate of Iron, External use of— Colin Henderson . . . . , . 943 
 
 Sunstroke in Children— W. K. MacRoberts . . . . . . , . 144 
 
 Supra-pubic Cystotomy — A. MacCormick . . . . . . . . 248 
 
 ,, Lithotomy — J. Tremearne .. .. .. .. 257 
 
 Syme, G. A. — Ocular Manifestations of late hereditary Syphilis .. .. 771 
 
 Symons, M. J. — Address in Section for Diseases of Eye . . . . . . 721 
 
 On Convergence . . . . , . . . . . 725 
 
 Syphilis among Polynesians in Queensland — F. Bowe . . . . . . 61 
 
 „ Ocular manifestations of late hereditary — G. A. Syme . . . . 771 
 
 „ Acquired in a Child three years old — J. P. Ryan . . . . 994 
 
 ,, an anomalous case of acquired Infantile — R. A. Stirling . . . . 991 
 
 Syphilitic Dactylitis in a Child— R. A. Stirling .. .. .. ..992 
 
 „ Keratitis (inherited) — J.Jackson .. .. .. .. 773 
 
 ,, Organs and Growths, Specimens of — H. B. Allen . . . . 1002 
 
 Tait's Operation — F. C. Batchelor . . . . . . . . . . 651 
 
 Talipes, New Operation for Congenital — T. N. FitzGerald . . . . 316 
 
 Taylor, W. F.— Address in Section of Medicine . . . . . . 35 
 
 Sewage Disposal . . . . . . . . . . 490 
 
 Thanks, Votes of .. .. .. .. .. ., .. 32 
 
 Thomas, J. Davies — Age and Sex in Hydatid Disease . . . . . . 342 
 
 Bilirubin in Hydatid Cysts . . . . . . 391 
 
 Geographical Distribution of Hydatid Disease . . 328 
 
 Operative Treatment of Echinococcus Cysts . . . . 352 
 
 Treatment of Liver Abscesses by Free Incision . . 230 
 Thompson, J. Ashburton — A Record of the Present Sanitary State of New 
 
 South Wales . . . . . . . . . . . . . . 434 
 
 Thomson, J. R. M— Hydatids in Zygomatic Fossa . , . . . . 385 
 
 State Medicine in Western Australia . . . . 489 
 
 Thon, G. — Glaucoma Fulminans .. .. .. .. .. 781 
 
 Thwaites, J. S. — Notes on two cases of Snake-bite . . . . . . 945 
 
 Tinea desquamans— Sir W. MacGregor . . . . . . . . 46 
 
 Tonsilhtis, Follicular, in Children, its correlation with other zymotic diseases 
 
 — A. Honman . . . . . . . . . . . . . . 995 
 
 Tremearne, J., Supra-pubic Lithotomy .. .. .. .. 257 
 
 Tubal Disease— F. C. Batchelor . . . . . . . . . . 633 
 
 Tumours, Pathological Specimens of— H. B. Allen .. .. .. 1003 
 
 Turner, D. — Evils of Specialism .. .. .. .. .. 551 
 
 Treatment of Phthisis by Climate . . . . . . . . 87 
 
 Twisting of Pedicle in Ovarian Tumours — W. Gardner . . . . . . 674 
 
 Typhlitis, Seven Cases of —A. S. Joske . . . . . . . . 71 
 
 Typhoid Fevkk, Meeting and Papers concerning . . . . . . 149 
 
 Cold Bath Treatment— F. E. Hare . . . . . . . . 179 
 
 Connection with Milk Supply— H. B. Allen . . . . . . 159 
 
 Discussion concerning . . . . . . . . . . • • 188 
 
 Etiology of Typhoid — J. G. Carstairs .. .. .. .. 155 
 
 History of an Epidemic — A. V. Henderson . . . . . . . . 169 
 
 History of Typhoid in Victoria and its Etiology— J. Robertson . . . . 149 
 
 Incubation Period — J. C. Verco . . . . . . . . . . 172 
 
 Notes on Typhoid and its Treatment — F. H. Bonncfin . . . . 185 
 
 Notes on Typhoid — J. W. Springthorpe . . . . . . . . 173
 
 INDEX. 1029 
 
 Typhoid Fever { Continued) — page 
 
 Resolutions concerning . . . . . . • • . . . . 15)5 
 
 Variations in Pathological Process — H.B.Allen .. .. .. 175 
 
 Typhoid Germs in Sewage Farms — A. Shields . . . . . . . . 562 
 
 Unqualified Practitioners, Resolutions concerning . . . . . . 31 
 
 Uterine Myomata, Removal of —Sydney Jones .. .. .. .. '2'2S 
 
 Ventilation, Principles and Practice of — W. V. Jakins . . . . . . 558 
 
 Verco, J. C— Case of Cerebellar Cyst . .. .. .. ..117 
 
 Diffuse Suppurative Periostitis almost without Necrosis . . 277 
 
 Hydatid of Brain, Removal .. .. .. .. 377 
 
 Incubation Period of Tyjihoid Fever . . . . . . 172 
 
 Puerperal Fever and Midwifery Practice . . . . . . 684 
 
 Verco, J. C. and Stii-ling, E. C. — Abscess in Left Middle Cerebral Lobe, 
 
 evacuation by operation . . . . . . . . . . . . 280 
 
 Verco, J. C. and Lendon, A. A. — Multiple Hydatid Cysts treated by Thoracic 
 
 Incisions . . . . . . . . . . . . • . 386 
 
 Victoria, Hygienic Conditions in — .T. W. Si)ringthorpe . . . . . . 465 
 
 Vision in Animals, Nature of — J. W. Barrett . . . . . . . . 588 
 
 Votes of Thanks . . . . . . . . . . . . . . 32 
 
 Westerly Winds of Winter in relation to Disease — F. Milford . . . . 512 
 
 Western Australia, State Medicine in — J. R. M. Thomson . . . . 48',( 
 
 ,, ,, Ophthalmic Work in— J. W. Hope .. .. .. 752 
 
 Whitcombe, W. P. — Treatment of Hydatids by Injection of Permanganate of 
 
 Potash . . . . . . . . . . . . . . 389 
 
 Whittell, H. T.— Typhoid and Milk Supply . . . . . . . . 188 
 
 Wilkinson, W. C. — Addi-ess in Section of Pathology . . . . , . 591 
 
 Williamson, W. C. — Training of Nurses and Attendants in Hospitals for the 
 
 Insane . . . . . . . . . . . . . . 887 
 
 Wood, P. M. — On Beri-beri in the Northern Territory . , . . . . 54 
 
 WooUey, G. T. — Congenital Phimosis and Adherent Prepuce . . . . 234 
 
 Worrall, R. — Two cases of Extra-uteiine Pregnancy . . . . . . 664 
 
 Yaws, in New Guinea — Sir W. MacGregor .. .. ,. .. 47 
 
 SllLLWtLL AND Co., I'lUSTtlW, lUJA CuLLINS STREET, MtLBULKNK.
 
 
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